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HB 1453 2026
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F L O R I D A H O U S E O F R E P R E S E N T A T I V E S
A bill to be entitled 1
An act relating to the state Medicaid program; 2
amending s. 409.904, F.S.; authorizing the Agency for 3
Health Care Administration to conduct retrospective 4
reviews and audits of certain claims under the state 5
Medicaid program for a specified purpose; creating s. 6
409.9041, F.S.; providing legislative findings; 7
requiring the agency, in coordination with the 8
Department of Children and Families, to implement 9
mandatory work and community engagement requirements 10
for able-bodied adults as a condition of obtaining and 11
maintaining Medicaid coverage; requiring the agency to 12
seek federal approval to implement such requirements 13
for certain populations; specifying populations that 14
are subject to such work and community engagement 15
requirements; providing exceptions; defining the term 16
"family caregiver"; specifying the types of activities 17
which may satisfy the work and community engagement 18
requirements; providing that a certain population is 19
required to engage in work or community engagement 20
activities only during standard school hours; 21
requiring persons eligible for Medicaid to demonstrate 22
compliance with the work and community engagement 23
requirements at specified times as a condition of 24
maintaining Medicaid coverage; requiring the agency to 25
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develop a process for ensuring compliance with the 26
work and community engagement requirements; requiring 27
that such process align, to the extent possible, with 28
certain existing processes; requiring the department 29
to verify compliance with the work and community 30
engagement requirements at specified intervals; 31
requiring the agency, in coordination with the 32
department, to conduct outreach regarding 33
implementation of the work and community engagement 34
requirements; specifying requirements for such 35
outreach; specifying procedures in the event of 36
noncompliance; requiring the agency, in coordination 37
with the department, to notify a Medicaid recipient of 38
a finding of noncompliance and the impact to 39
eligibility for continued receipt of services; 40
specifying requirements for such notice; amending s. 41
409.905, F.S.; requiring the agency to maintain cost-42
effective purchasing practices in its coverage of 43
hospital inpatient services rendered to Medicaid 44
recipients; amending 409.906, F.S.; requiring the 45
agency to seek federal approval to implement a program 46
for expanded coverage of home- and community-based 47
behavioral health services for a specified population; 48
specifying the goal of the program; requiring the 49
agency to work in coordination with the department to 50
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develop and implement the program upon federal 51
approval; amending s. 409.91195, F.S.; revising the 52
purpose of the Medicaid Pharmaceutical and 53
Therapeutics Committee to include creation of a 54
Medicaid preferred physician-administered drug list, a 55
Medicaid preferred product list, and a high-cost drug 56
list; requiring the agency to adopt such lists upon 57
recommendation of the committee; specifying the 58
frequency with which the committee must review such 59
lists for any recommended additions or deletions; 60
specifying parameters for such recommended additions 61
and deletions; providing that reimbursement for drugs 62
not included on such lists is subject to prior 63
authorization, with an exception; requiring the agency 64
to publish and disseminate such lists to all Medicaid 65
providers in the state by posting on the agency's 66
website or in other media; providing requirements for 67
public testimony related to proposed inclusions on or 68
exclusions from certain lists; requiring the committee 69
to consider certain factors when developing such 70
recommended additions and deletions; amending s. 71
409.912, F.S.; revising the components of the Medicaid 72
prescribed-drug spending-control program to include 73
the preferred physician-administered drug list, the 74
preferred product list, and the high-cost drug list; 75
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providing requirements for such lists; providing that 76
the agency does not need to follow rulemaking 77
procedures of ch. 120, F.S., when posting updates to 78
such lists; establishing an alternative reimbursement 79
methodology for long-acting injectables administered 80
in a hospital facility setting for severe mental 81
illness; requiring the agency to contract with a 82
vendor to perform a fiscal impact study of the federal 83
340B Drug Pricing Program; providing requirements for 84
the study; requiring specified entities to submit 85
certain data to the agency for purposes of the study; 86
providing that noncompliance with such requirement may 87
result in sanctions from the agency or the Board of 88
Pharmacy, as applicable; requiring the agency to 89
submit the results of the study to the Governor and 90
the Legislature by a specified date; providing 91
construction; amending s. 409.9122, F.S.; revising 92
requirements for managed care plan encounter data 93
submission and analysis under the Medicaid Encounter 94
Data System; amending s. 409.913, F.S.; revising the 95
definition of the term "overpayment"; providing that 96
determinations of an overpayment under the Medicaid 97
program may be based upon retrospective reviews, 98
investigations, analyses, or audits conducted by the 99
agency to determine possible fraud, abuse, 100
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overpayment, or recipient neglect; providing that 101
certain notices may be provided using other common 102
carriers, as well as through the United States Postal 103
Service; amending s. 409.962, F.S.; defining the term 104
"affiliate"; amending s. 409.967, F.S.; requiring that 105
managed care plan contracts require any third-party 106
administrative entity contracted with the plan to 107
adhere to specified requirements; specifying 108
additional types of payments which may not be included 109
in calculating income for purposes of the achieved 110
savings rebate; requiring the agency to ensure 111
oversight of affiliated entities and related parties 112
within the Statewide Medicaid Managed Care program; 113
requiring the agency to examine specified records and 114
data related to such entities and parties; requiring 115
the agency to consider certain data and findings when 116
determining its final medical loss ratio and during 117
the rate setting process under the program; creating 118
s. 409.9675, F.S.; defining the term "control"; 119
requiring managed care plans to report to the agency 120
and the Office of Insurance Regulation the existence 121
of and details relating to certain affiliations by a 122
specified date and annually thereafter; requiring 123
managed care plans to report any change in such 124
information to the agency and the office in writing 125
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within a specified timeframe; requiring the agency to 126
calculate, analyze, and publicly report on the 127
agency's website an assessment of affiliated entity 128
payment transactions in the Medicaid program and 129
certain administrative costs by a specified date and 130
annually thereafter; providing requirements for the 131
assessment; amending s. 409.973, F.S.; requiring the 132
agency to implement an Integrated Managed Care Pilot 133
Program in designated regions by a specified date; 134
requiring the agency to submit a request for federal 135
approval for the program by a specified date; 136
requiring the agency to implement the program in 137
specified regions by a specified date, contingent on 138
federal approval; providing requirements for 139
implementing the program, including requirements for 140
plan contracts, service delivery, and provider 141
credentialing; providing for the termination of plan 142
contracts under certain circumstances; requiring the 143
agency to establish measures for evaluating the 144
program; requiring the agency to contract with an 145
independent evaluator to conduct the evaluations; 146
specifying requirements for the evaluations; requiring 147
the agency to submit a report on the performance of 148
the pilot program to the Governor and the Legislature 149
beginning on a specified date and annually thereafter; 150
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F L O R I D A H O U S E O F R E P R E S E N T A T I V E S
amending ss. 409.91196 and 627.42392, F.S.; conforming 151
cross-references; providing an effective date. 152
153
Be It Enacted by the Legislature of the State of Florida: 154
155
Section 1. Subsection (4) of section 409.904, Florida 156
Statutes, is amended to read: 157
409.904 Optional payments for eligible persons.—The agency 158
may make payments for medical assistance and related services on 159
behalf of the following persons who are determined to be 160
eligible subject to the income, assets, and categorical 161
eligibility tests set forth in federal and state law. Payment on 162
behalf of these Medicaid eligible persons is subject to the 163
availability of moneys and any limitations established by the 164
General Appropriations Act or chapter 216. 165
(4) A low-income person who meets all other requirements 166
for Medicaid eligibility except citizenship and who is in need 167
of emergency medical services. The eligibility of such a 168
recipient is limited to the period of the emergency, in 169
accordance with federal regulations. The agency may conduct 170
retrospective reviews or audits of services rendered to the 171
individual and claims submitted by the provider to validate the 172
existence and duration of the emergency medical condition and 173
whether the services rendered were necessary to treat the 174
emergency medical condition regardless of whether the provider 175
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obtained prior authorization for the services. 176
Section 2. Section 409.9041, Florida Statutes, is created 177
to read: 178
409.9041 Medicaid work and community engagement 179
requirements.— 180
(1)(a) The Legislature finds that assisting able-bodied 181
adult Medicaid recipients in achieving self-sufficiency through 182
meaningful work and community engagement is essential to 183
ensuring that the state Medicaid program remains a sustainable 184
resource for residents who are most in need of such assistance. 185
(b) The agency, in coordination with the department, shall 186
implement mandatory work and community engagement requirements 187
for able-bodied adults as a condition of obtaining and 188
maintaining coverage under the state Medicaid program. 189
(2) The agency shall seek federal approval to implement 190
mandatory work and community engagement requirements for certain 191
populations, as specified in this section, as a condition of 192
obtaining and maintaining coverage under the state Medicaid 193
program. 194
(3)(a) Medicaid recipients between the ages of 18 and 64 195
years must meet the work or community engagement requirements of 196
this section, unless they are one of the following: 197
1. Indian as defined under 42 C.F.R. s. 438.14(a). 198
2. A parent, guardian, caretaker relative, or family 199
caregiver of a dependent child younger than 6 years of age or of 200
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a disabled individual. For purposes of this paragraph, the term 201
"family caregiver" means an adult family member or other 202
individual who has a significant relationship with, and who 203
provides a broad range of assistance to, an individual with a 204
chronic or other health condition, disability, or functional 205
limitation. 206
3. Former foster youth younger than 23 years of age. 207
4. A veteran with a total disability, as specified under 208
38 C.F.R. s. 3.340 or as specified by a Veteran Affairs 209
Disability Ratings Letter issued by the United States Department 210
of Veterans Affairs. 211
5. An individual classified as medically frail under the 212
Medicaid Institutionalized Care Program; categorized as aged, 213
blind, or disabled under the state Medicaid program; or who has 214
a developmental disability as defined in s. 393.063. 215
6. An individual living in a household that receives 216
Supplemental Nutrition Assistance Program benefits and who is 217
already in compliance with work requirements pursuant to s. 218
445.024. 219
7. An individual participating in a residential substance 220
use disorder treatment program. 221
8. An inmate of a public institution. 222
9. A woman eligible for Medicaid coverage in a pregnancy-223
related or postpartum care category. 224
(b) A person may satisfy the work or community engagement 225
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requirements of this section by participating in one or more of 226
the following activities for at least 80 hours per month: 227
1. Paid employment. 228
2. On-the-job-training. 229
3. Vocational educational training. 230
4. Job skills training directly related to employment. 231
5. Education directly related to employment. 232
6. Satisfactory attendance at a secondary school or in a 233
course of study leading to a high school equivalency diploma. 234
7. Enrollment at least half-time as defined in 34 C.F.R. 235
s. 668.2(b) in a postsecondary education program to obtain a 236
credential on the Master Credentials List as maintained pursuant 237
to s. 445.004(6)(e). 238
8. Any other work activity designated as such by the 239
Department of Commerce and provided by a local workforce 240
development board pursuant to s. 445.024. 241
(c) Parents with children ages 6 through 18 are required 242
to engage in work or community engagement activities only during 243
standard school hours. 244
(4)(a) Notwithstanding any other statutory provision, in 245
order to maintain Medicaid coverage, an eligible Medicaid 246
recipient must, before enrollment and upon any redetermination 247
for coverage, demonstrate compliance with the work or community 248
engagement requirements of this section. 249
(b) The agency shall develop a process for ensuring 250
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compliance with this section which aligns, to the extent 251
possible, with the processes currently in place relating to work 252
and community engagement requirements authorized under the 253
state's Supplemental Nutrition Assistance Program, including, 254
but not limited to, participant registration with a local 255
CareerSource center, employment and training programs, and 256
collaboration with the state's local workforce boards. 257
(c) The department shall verify, in accordance with its 258
procedures, that an individual subject to the work and community 259
engagement requirements of this section demonstrates compliance 260
during the individual's regularly scheduled redetermination of 261
eligibility, or more frequently as determined by the department. 262
(5) The agency, in coordination with the department, shall 263
conduct outreach regarding the implementation of the work and 264
community engagement requirements of this section. The outreach 265
much include, at a minimum, notification to impacted 266
individuals, including timelines for implementation, 267
requirements for compliance, penalties for noncompliance, and 268
information on how to request an exemption. 269
(6) If a recipient subject to the work and community 270
engagement requirements of this section is determined to be in 271
noncompliance with such requirements, the agency, in 272
coordination with the department, must notify the recipient of 273
the finding of noncompliance and the impact to his or her 274
eligibility for continued receipt of Medicaid services. The 275
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notice must include, at a minimum, notification of all of the 276
following: 277
(a) That the recipient is eligible for a grace period of 278
30 days to either come into compliance with the requirements or 279
request an exemption from the requirements and that Medicaid 280
coverage of services will continue during the grace period. 281
(b) That if, following the 30-day period, the individual 282
has not come into compliance with or requested an exemption from 283
the work and community engagement requirements, his or her 284
application for assistance will be denied and services 285
terminated at the end of the month following the month in which 286
such 30-calendar-day period ends. 287
(c) The right of the individual to request a fair hearing 288
if he or she is determined to be noncompliant with program 289
requirements and disenrolled from the state Medicaid program. 290
(d) How he or she can reapply for medical assistance under 291
the state Medicaid program. 292
Section 3. Paragraph (f) is added to subsection (5) of 293
section 409.905, Florida Statutes, to read: 294
409.905 Mandatory Medicaid services.—The agency may make 295
payments for the following services, which are required of the 296
state by Title XIX of the Social Security Act, furnished by 297
Medicaid providers to recipients who are determined to be 298
eligible on the dates on which the services were provided. Any 299
service under this section shall be provided only when medically 300
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necessary and in accordance with state and federal law. 301
Mandatory services rendered by providers in mobile units to 302
Medicaid recipients may be restricted by the agency. Nothing in 303
this section shall be construed to prevent or limit the agency 304
from adjusting fees, reimbursement rates, lengths of stay, 305
number of visits, number of services, or any other adjustments 306
necessary to comply with the availability of moneys and any 307
limitations or directions provided for in the General 308
Appropriations Act or chapter 216. 309
(5) HOSPITAL INPATIENT SERVICES.—The agency shall pay for 310
all covered services provided for the medical care and treatment 311
of a recipient who is admitted as an inpatient by a licensed 312
physician or dentist to a hospital licensed under part I of 313
chapter 395. However, the agency shall limit the payment for 314
inpatient hospital services for a Medicaid recipient 21 years of 315
age or older to 45 days or the number of days necessary to 316
comply with the General Appropriations Act. 317
(f) In its coverage of services under this subsection, the 318
agency shall maintain cost-effective purchasing practices as 319
required by s. 409.912. 320
Section 4. Present subsections (14) through (29) of 321
section 409.906, Florida Statutes, are redesignated as 322
subsections (15) through (30), respectively, and a new 323
subsection (14) is added to that section, to read: 324
409.906 Optional Medicaid services.—Subject to specific 325
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F L O R I D A H O U S E O F R E P R E S E N T A T I V E S
appropriations, the agency may make payments for services which 326
are optional to the state under Title XIX of the Social Security 327
Act and are furnished by Medicaid providers to recipients who 328
are determined to be eligible on the dates on which the services 329
were provided. Any optional service that is provided shall be 330
provided only when medically necessary and in accordance with 331
state and federal law. Optional services rendered by providers 332
in mobile units to Medicaid recipients may be restricted or 333
prohibited by the agency. Nothing in this section shall be 334
construed to prevent or limit the agency from adjusting fees, 335
reimbursement rates, lengths of stay, number of visits, or 336
number of services, or making any other adjustments necessary to 337
comply with the availability of moneys and any limitations or 338
directions provided for in the General Appropriations Act or 339
chapter 216. If necessary to safeguard the state's systems of 340
providing services to elderly and disabled persons and subject 341
to the notice and review provisions of s. 216.177, the Governor 342
may direct the Agency for Health Care Administration to amend 343
the Medicaid state plan to delete the optional Medicaid service 344
known as "Intermediate Care Facilities for the Developmentally 345
Disabled." Optional services may include: 346
(14) HOME- AND COMMUNITY-BASED BEHAVIORAL HEALTH 347
SERVICES.—The agency shall seek federal approval to implement a 348
program that covers an expanded array of home- and community-349
based services for adults 18 years of age and older diagnosed 350
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with a serious mental illness who are high utilizers of 351
behavioral health services in an institutional setting. The 352
program must be designed to reduce the need for institutional 353
levels of care for adults with a serious mental illness. The 354
agency shall work in coordination with the Department of 355
Children and Families to develop and implement the program upon 356
receiving federal approval. 357
Section 5. Section 409.91195, Florida Statutes, is amended 358
to read: 359
409.91195 Medicaid Pharmaceutical and Therapeutics 360
Committee.—There is created a Medicaid Pharmaceutical and 361
Therapeutics Committee within the agency for the purpose of 362
developing a Medicaid preferred drug list, a Medicaid preferred 363
physician-administered drug list, a Medicaid preferred product 364
list, and a high-cost drug list. 365
(1) The committee shall be composed of 11 members 366
appointed by the Governor. Four members shall be physicians, 367
licensed under chapter 458; one member licensed under chapter 368
459; five members shall be pharmacists licensed under chapter 369
465; and one member shall be a consumer representative. The 370
members shall be appointed to serve for terms of 2 years from 371
the date of their appointment. Members may be appointed to more 372
than one term. The agency shall serve as staff for the committee 373
and assist them with all ministerial duties. The Governor shall 374
ensure that at least some of the members of the committee 375
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represent Medicaid participating physicians and pharmacies 376
serving all segments and diversity of the Medicaid population, 377
and have experience in either developing or practicing under a 378
preferred drug list. At least one of the members shall represent 379
the interests of pharmaceutical manufacturers. 380
(2) Committee members shall select a chairperson and a 381
vice chairperson each year from the committee membership. 382
(3) The committee shall meet at least quarterly and may 383
meet at other times at the discretion of the chairperson and 384
members. The committee shall comply with rules adopted by the 385
agency, including notice of any meeting of the committee 386
pursuant to the requirements of the Administrative Procedure 387
Act. 388
(4) Upon recommendation of the committee, the agency shall 389
adopt a preferred drug list, a preferred physician-administered 390
drug list, a preferred product list, and a high-cost drug list 391
as described in s. 409.912(5). To the extent feasible, the 392
committee shall review all drug or product classes included on 393
the preferred drug list, the preferred physician-administered 394
drug list, and the preferred product list every 12 months, and 395
the high-cost drug list every 6 months. The committee may 396
recommend additions to and deletions from the lists preferred 397
drug list, such that the lists provide preferred drug list 398
provides for medically appropriate drug and product therapies 399
for Medicaid patients which achieve cost savings contained in 400
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F L O R I D A H O U S E O F R E P R E S E N T A T I V E S
the General Appropriations Act. 401
(5) Except for antiretroviral drugs, reimbursement of 402
drugs not included on the preferred drug list, preferred 403
physician-administered drug list, preferred product list, or 404
high-cost drug list is subject to prior authorization. 405
(6) The agency shall publish and disseminate the preferred 406
drug list, preferred physician-administered drug list, preferred 407
product list, and high-cost drug list to all Medicaid providers 408
in the state by Internet posting on the agency's website or in 409
other media. 410
(7) The committee shall ensure that interested parties, 411
including pharmaceutical manufacturers agreeing to provide a 412
supplemental rebate as outlined in this chapter, have an 413
opportunity to present public testimony to the committee with 414
information or evidence supporting inclusion of a drug or 415
product on the preferred drug list, preferred physician-416
administered drug list, or preferred product list. Such public 417
testimony shall occur before prior to any recommendations made 418
by the committee for inclusion or exclusion from the preferred 419
drug list, preferred physician-administered drug list, or 420
preferred product list. Upon timely notice, the agency shall 421
ensure that any drug that has been approved or had any of its 422
particular uses approved by the United States Food and Drug 423
Administration under a priority review classification will be 424
reviewed by the committee at the next regularly scheduled 425
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meeting following 3 months of distribution of the drug to the 426
general public. 427
(8) The committee shall develop its preferred drug list, 428
preferred physician-administered drug list, preferred product 429
list, and high-cost drug list recommendations by considering the 430
clinical efficacy, safety, and cost-effectiveness of a product. 431
(9) The Medicaid Pharmaceutical and Therapeutics Committee 432
may also make recommendations to the agency regarding the prior 433
authorization of any prescribed drug covered by Medicaid. 434
(10) Medicaid recipients may appeal agency preferred drug 435
formulary decisions using the Medicaid fair hearing process 436
administered by the Agency for Health Care Administration. 437
Section 6. Paragraph (a) of subsection (5) of section 438
409.912, Florida Statutes, is amended, and subsection (14) is 439
added to that section, to read: 440
409.912 Cost-effective purchasing of health care.—The 441
agency shall purchase goods and services for Medicaid recipients 442
in the most cost-effective manner consistent with the delivery 443
of quality medical care. To ensure that medical services are 444
effectively utilized, the agency may, in any case, require a 445
confirmation or second physician's opinion of the correct 446
diagnosis for purposes of authorizing future services under the 447
Medicaid program. This section does not restrict access to 448
emergency services or poststabilization care services as defined 449
in 42 C.F.R. s. 438.114. Such confirmation or second opinion 450
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shall be rendered in a manner approved by the agency. The agency 451
shall maximize the use of prepaid per capita and prepaid 452
aggregate fixed-sum basis services when appropriate and other 453
alternative service delivery and reimbursement methodologies, 454
including competitive bidding pursuant to s. 287.057, designed 455
to facilitate the cost-effective purchase of a case-managed 456
continuum of care. The agency shall also require providers to 457
minimize the exposure of recipients to the need for acute 458
inpatient, custodial, and other institutional care and the 459
inappropriate or unnecessary use of high-cost services. The 460
agency shall contract with a vendor to monitor and evaluate the 461
clinical practice patterns of providers in order to identify 462
trends that are outside the normal practice patterns of a 463
provider's professional peers or the national guidelines of a 464
provider's professional association. The vendor must be able to 465
provide information and counseling to a provider whose practice 466
patterns are outside the norms, in consultation with the agency, 467
to improve patient care and reduce inappropriate utilization. 468
The agency may mandate prior authorization, drug therapy 469
management, or disease management participation for certain 470
populations of Medicaid beneficiaries, certain drug classes, or 471
particular drugs to prevent fraud, abuse, overuse, and possible 472
dangerous drug interactions. The Pharmaceutical and Therapeutics 473
Committee shall make recommendations to the agency on drugs for 474
which prior authorization is required. The agency shall inform 475
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the Pharmaceutical and Therapeutics Committee of its decisions 476
regarding drugs subject to prior authorization. The agency is 477
authorized to limit the entities it contracts with or enrolls as 478
Medicaid providers by developing a provider network through 479
provider credentialing. The agency may competitively bid single-480
source-provider contracts if procurement of goods or services 481
results in demonstrated cost savings to the state without 482
limiting access to care. The agency may limit its network based 483
on the assessment of beneficiary access to care, provider 484
availability, provider quality standards, time and distance 485
standards for access to care, the cultural competence of the 486
provider network, demographic characteristics of Medicaid 487
beneficiaries, practice and provider-to-beneficiary standards, 488
appointment wait times, beneficiary use of services, provider 489
turnover, provider profiling, provider licensure history, 490
previous program integrity investigations and findings, peer 491
review, provider Medicaid policy and billing compliance records, 492
clinical and medical record audits, and other factors. Providers 493
are not entitled to enrollment in the Medicaid provider network. 494
The agency shall determine instances in which allowing Medicaid 495
beneficiaries to purchase durable medical equipment and other 496
goods is less expensive to the Medicaid program than long-term 497
rental of the equipment or goods. The agency may establish rules 498
to facilitate purchases in lieu of long-term rentals in order to 499
protect against fraud and abuse in the Medicaid program as 500
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defined in s. 409.913. The agency may seek federal waivers 501
necessary to administer these policies. 502
(5)(a) The agency shall implement a Medicaid prescribed-503
drug spending-control program that includes the following 504
components: 505
1. A Medicaid preferred drug list and a Medicaid 506
physician-administered drug list. The preferred drug list, which 507
shall be a listing of cost-effective therapeutic options 508
recommended by the Medicaid Pharmacy and Therapeutics Committee 509
established pursuant to s. 409.91195 and adopted by the agency 510
for each therapeutic class on the preferred drug list. At the 511
discretion of the committee, and when feasible, the preferred 512
drug list should include at least two products in a therapeutic 513
class. The physician-administered drug list shall be a listing 514
of physician-administered drugs covered by the state Medicaid 515
program, based on the United States Food and Drug 516
Administration's approved indications and compendia in 42 U.S.C. 517
s. 1396r-8(g)(1)(B). Within the preferred physician-administered 518
drug list, there must be a section containing a list of 519
preferred physician-administered drugs that are cost-effective 520
therapeutic options recommended by the Medicaid Pharmaceutical 521
and Therapeutics Committee established pursuant to s. 409.91195. 522
The physician-administered drug list must be updated at least 523
twice a year. The agency may post and update the preferred drug 524
list and the preferred physician-administered drug updates to 525
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the list on an Internet website without following the rulemaking 526
procedures of chapter 120. Antiretroviral agents are excluded 527
from the preferred drug list. The agency shall also limit the 528
amount of a prescribed drug dispensed to no more than a 34-day 529
supply unless the drug products' smallest marketed package is 530
greater than a 34-day supply, or the drug is determined by the 531
agency to be a maintenance drug in which case a 100-day maximum 532
supply may be authorized. The agency may seek any federal 533
waivers necessary to implement these cost-control programs and 534
to continue participation in the federal Medicaid rebate 535
program, or alternatively to negotiate state-only manufacturer 536
rebates. The agency may adopt rules to administer this 537
subparagraph. The agency shall continue to provide unlimited 538
contraceptive drugs and items. The agency must establish 539
procedures to ensure that: 540
a. There is a response to a request for prior 541
authorization by telephone or other telecommunication device 542
within 24 hours after receipt of a request for prior 543
authorization; and 544
b. A 72-hour supply of the drug prescribed is provided in 545
an emergency or when the agency does not provide a response 546
within 24 hours as required by sub-subparagraph a. 547
2. A Medicaid preferred product list, which shall be a 548
listing of cost-effective therapeutic supplies recommended by 549
the Medicaid Pharmaceutical and Therapeutics Committee 550
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established pursuant to s. 409.91195 and adopted by the agency 551
for each product class listed on the preferred product list and 552
reimbursed by the state Medicaid program through the pharmacy 553
point-of-sale. The agency may post the preferred product list 554
and updates to the list on the agency's website without 555
following the rulemaking procedures of chapter 120. 556
3. A list of high-cost drugs recommended by the Medicaid 557
Pharmaceutical and Therapeutics Committee established pursuant 558
to s. 409.91195 and adopted by the agency, for the purpose of 559
coverage, reimbursement, or billing guidance. The agency may 560
post the high-cost drug list and updates to the list on an 561
Internet website without following the rulemaking procedures of 562
chapter 120. 563
4. A provider of prescribed drugs is reimbursed in an 564
amount not to exceed the lesser of the actual acquisition cost 565
based on the Centers for Medicare and Medicaid Services National 566
Average Drug Acquisition Cost pricing files plus a professional 567
dispensing fee, the wholesale acquisition cost plus a 568
professional dispensing fee, the state maximum allowable cost 569
plus a professional dispensing fee, or the usual and customary 570
charge billed by the provider. 571
5. A hospital facility administering long-acting 572
injectables for severe mental illness shall be reimbursed 573
separately from the diagnosis-related group. Long-acting 574
injectables administered for severe mental illness in a hospital 575
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facility setting shall be reimbursed at no less than the actual 576
acquisition cost of the drug. 577
6. The agency shall contract with a vendor to perform a 578
detailed fiscal impact study to evaluate the 340B Drug Pricing 579
Program administered by the Health Resources and Services 580
Administration. The study must evaluate 340B compliance, 340B 581
drug purchases, and reimbursement methodologies within the fee-582
for-service program and Statewide Medicaid Managed Care program. 583
Statewide Medicaid Managed Care plans, pharmacy benefit 584
managers, and Medicaid providers shall submit to the agency all 585
data necessary for the completion of the study, including, but 586
not limited to, information related to drug purchasing, 587
reimbursement, billing and coding, and dispensing. Noncompliance 588
with the 340B data submission requirements of this subparagraph 589
may result in sanctions from the agency or the Board of 590
Pharmacy, as applicable. The agency shall submit the results of 591
the study to the Governor, the President of the Senate, and the 592
Speaker of the House of Representatives by June 30, 2027. 593
7.3. The agency shall develop and implement a process for 594
managing the drug therapies of Medicaid recipients who are using 595
significant numbers of prescribed drugs each month. The 596
management process may include, but is not limited to, 597
comprehensive, physician-directed medical-record reviews, claims 598
analyses, and case evaluations to determine the medical 599
necessity and appropriateness of a patient's treatment plan and 600
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drug therapies. The agency may contract with a private 601
organization to provide drug-program-management services. The 602
Medicaid drug benefit management program shall include 603
initiatives to manage drug therapies for HIV/AIDS patients, 604
patients using 20 or more unique prescriptions in a 180-day 605
period, and the top 1,000 patients in annual spending. The 606
agency shall enroll any Medicaid recipient in the drug benefit 607
management program if he or she meets the specifications of this 608
provision and is not enrolled in a Medicaid health maintenance 609
organization. 610
8.4. The agency may limit the size of its pharmacy network 611
based on need, competitive bidding, price negotiations, 612
credentialing, or similar criteria. The agency shall give 613
special consideration to rural areas in determining the size and 614
location of pharmacies included in the Medicaid pharmacy 615
network. A pharmacy credentialing process may include criteria 616
such as a pharmacy's full-service status, location, size, 617
patient educational programs, patient consultation, disease 618
management services, and other characteristics. The agency may 619
impose a moratorium on Medicaid pharmacy enrollment if it is 620
determined that it has a sufficient number of Medicaid-621
participating providers. The agency must allow dispensing 622
practitioners to participate as a part of the Medicaid pharmacy 623
network regardless of the practitioner's proximity to any other 624
entity that is dispensing prescription drugs under the Medicaid 625
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program. A dispensing practitioner must meet all credentialing 626
requirements applicable to his or her practice, as determined by 627
the agency. 628
9.5. The agency shall develop and implement a program that 629
requires Medicaid practitioners who issue written prescriptions 630
for medicinal drugs to use a counterfeit-proof prescription pad 631
for Medicaid prescriptions. The agency shall require the use of 632
standardized counterfeit-proof prescription pads by prescribers 633
who issue written prescriptions for Medicaid recipients. The 634
agency may implement the program in targeted geographic areas or 635
statewide. 636
10.6. The agency may enter into arrangements that require 637
manufacturers of generic drugs prescribed to Medicaid recipients 638
to provide rebates of at least 15.1 percent of the average 639
manufacturer price for the manufacturer's generic products. 640
These arrangements shall require that if a generic-drug 641
manufacturer pays federal rebates for Medicaid-reimbursed drugs 642
at a level below 15.1 percent, the manufacturer must provide a 643
supplemental rebate to the state in an amount necessary to 644
achieve a 15.1-percent rebate level. 645
11.7. The agency may establish a preferred drug list as 646
described in this subsection, and, pursuant to the establishment 647
of such preferred drug list, negotiate supplemental rebates from 648
manufacturers that are in addition to those required by Title 649
XIX of the Social Security Act and at no less than 14 percent of 650
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the average manufacturer price as defined in 42 U.S.C. s. 1936 651
on the last day of a quarter unless the federal or supplemental 652
rebate, or both, equals or exceeds 29 percent. There is no upper 653
limit on the supplemental rebates the agency may negotiate. The 654
agency may determine that specific products, brand-name or 655
generic, are competitive at lower rebate percentages. Agreement 656
to pay the minimum supplemental rebate percentage guarantees a 657
manufacturer that the Medicaid Pharmaceutical and Therapeutics 658
Committee will consider a product for inclusion on the preferred 659
drug list. However, a pharmaceutical manufacturer is not 660
guaranteed placement on the preferred drug list by simply paying 661
the minimum supplemental rebate. Agency decisions will be made 662
on the clinical efficacy of a drug and recommendations of the 663
Medicaid Pharmaceutical and Therapeutics Committee, as well as 664
the price of competing products minus federal and state rebates. 665
The agency may contract with an outside agency or contractor to 666
conduct negotiations for supplemental rebates. For the purposes 667
of this section, the term "supplemental rebates" means cash 668
rebates. Value-added programs as a substitution for supplemental 669
rebates are prohibited. The agency may seek any federal waivers 670
to implement this initiative. 671
12.a.8.a. The agency may implement a Medicaid behavioral 672
drug management system. The agency may contract with a vendor 673
that has experience in operating behavioral drug management 674
systems to implement this program. The agency may seek federal 675
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waivers to implement this program. 676
b. The agency, in conjunction with the Department of 677
Children and Families, may implement the Medicaid behavioral 678
drug management system that is designed to improve the quality 679
of care and behavioral health prescribing practices based on 680
best practice guidelines, improve patient adherence to 681
medication plans, reduce clinical risk, and lower prescribed 682
drug costs and the rate of inappropriate spending on Medicaid 683
behavioral drugs. The program may include the following 684
elements: 685
(I) Provide for the development and adoption of best 686
practice guidelines for behavioral health-related drugs such as 687
antipsychotics, antidepressants, and medications for treating 688
bipolar disorders and other behavioral conditions; translate 689
them into practice; review behavioral health prescribers and 690
compare their prescribing patterns to a number of indicators 691
that are based on national standards; and determine deviations 692
from best practice guidelines. 693
(II) Implement processes for providing feedback to and 694
educating prescribers using best practice educational materials 695
and peer-to-peer consultation. 696
(III) Assess Medicaid beneficiaries who are outliers in 697
their use of behavioral health drugs with regard to the numbers 698
and types of drugs taken, drug dosages, combination drug 699
therapies, and other indicators of improper use of behavioral 700
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health drugs. 701
(IV) Alert prescribers to patients who fail to refill 702
prescriptions in a timely fashion, are prescribed multiple same-703
class behavioral health drugs, and may have other potential 704
medication problems. 705
(V) Track spending trends for behavioral health drugs and 706
deviation from best practice guidelines. 707
(VI) Use educational and technological approaches to 708
promote best practices, educate consumers, and train prescribers 709
in the use of practice guidelines. 710
(VII) Disseminate electronic and published materials. 711
(VIII) Hold statewide and regional conferences. 712
(IX) Implement a disease management program with a model 713
quality-based medication component for severely mentally ill 714
individuals and emotionally disturbed children who are high 715
users of care. 716
13.9. The agency shall implement a Medicaid prescription 717
drug management system. 718
a. The agency may contract with a vendor that has 719
experience in operating prescription drug management systems in 720
order to implement this system. Any management system that is 721
implemented in accordance with this subparagraph must rely on 722
cooperation between physicians and pharmacists to determine 723
appropriate practice patterns and clinical guidelines to improve 724
the prescribing, dispensing, and use of drugs in the Medicaid 725
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program. The agency may seek federal waivers to implement this 726
program. 727
b. The drug management system must be designed to improve 728
the quality of care and prescribing practices based on best 729
practice guidelines, improve patient adherence to medication 730
plans, reduce clinical risk, and lower prescribed drug costs and 731
the rate of inappropriate spending on Medicaid prescription 732
drugs. The program must: 733
(I) Provide for the adoption of best practice guidelines 734
for the prescribing and use of drugs in the Medicaid program, 735
including translating best practice guidelines into practice; 736
reviewing prescriber patterns and comparing them to indicators 737
that are based on national standards and practice patterns of 738
clinical peers in their community, statewide, and nationally; 739
and determine deviations from best practice guidelines. 740
(II) Implement processes for providing feedback to and 741
educating prescribers using best practice educational materials 742
and peer-to-peer consultation. 743
(III) Assess Medicaid recipients who are outliers in their 744
use of a single or multiple prescription drugs with regard to 745
the numbers and types of drugs taken, drug dosages, combination 746
drug therapies, and other indicators of improper use of 747
prescription drugs. 748
(IV) Alert prescribers to recipients who fail to refill 749
prescriptions in a timely fashion, are prescribed multiple drugs 750
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that may be redundant or contraindicated, or may have other 751
potential medication problems. 752
14.10. The agency may contract for drug rebate 753
administration, including, but not limited to, calculating 754
rebate amounts, invoicing manufacturers, negotiating disputes 755
with manufacturers, and maintaining a database of rebate 756
collections. 757
15.11. The agency may specify the preferred daily dosing 758
form or strength for the purpose of promoting best practices 759
with regard to the prescribing of certain drugs as specified in 760
the General Appropriations Act and ensuring cost-effective 761
prescribing practices. 762
16.12. The agency may require prior authorization for 763
Medicaid-covered prescribed drugs. The agency may prior-764
authorize the use of a product: 765
a. For an indication not approved in labeling; 766
b. To comply with certain clinical guidelines; or 767
c. If the product has the potential for overuse, misuse, 768
or abuse. 769
770
The agency may require the prescribing professional to provide 771
information about the rationale and supporting medical evidence 772
for the use of a drug. The agency shall post prior 773
authorization, step-edit criteria and protocol, and updates to 774
the list of drugs that are subject to prior authorization on the 775
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agency's Internet website within 21 days after the prior 776
authorization and step-edit criteria and protocol and updates 777
are approved by the agency. For purposes of this subparagraph, 778
the term "step-edit" means an automatic electronic review of 779
certain medications subject to prior authorization. 780
17.13. The agency, in conjunction with the Pharmaceutical 781
and Therapeutics Committee, may require age-related prior 782
authorizations for certain prescribed drugs. The agency may 783
preauthorize the use of a drug for a recipient who may not meet 784
the age requirement or may exceed the length of therapy for use 785
of this product as recommended by the manufacturer and approved 786
by the Food and Drug Administration. Prior authorization may 787
require the prescribing professional to provide information 788
about the rationale and supporting medical evidence for the use 789
of a drug. 790
18.14. The agency shall implement a step-therapy prior 791
authorization approval process for medications excluded from the 792
preferred drug list. Medications listed on the preferred drug 793
list must be used within the previous 12 months before the 794
alternative medications that are not listed. The step-therapy 795
prior authorization may require the prescriber to use the 796
medications of a similar drug class or for a similar medical 797
indication unless contraindicated in the Food and Drug 798
Administration labeling. The trial period between the specified 799
steps may vary according to the medical indication. The step-800
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therapy approval process shall be developed in accordance with 801
the committee as stated in s. 409.91195(7) and (8). A drug 802
product may be approved without meeting the step-therapy prior 803
authorization criteria if the prescribing physician provides the 804
agency with additional written medical or clinical documentation 805
that the product is medically necessary because: 806
a. There is not a drug on the preferred drug list to treat 807
the disease or medical condition which is an acceptable clinical 808
alternative; 809
b. The alternatives have been ineffective in the treatment 810
of the beneficiary's disease; 811
c. The drug product or medication of a similar drug class 812
is prescribed for the treatment of schizophrenia or schizotypal 813
or delusional disorders; prior authorization has been granted 814
previously for the prescribed drug; and the medication was 815
dispensed to the patient during the previous 12 months; or 816
d. Based on historical evidence and known characteristics 817
of the patient and the drug, the drug is likely to be 818
ineffective, or the number of doses have been ineffective. 819
820
The agency shall work with the physician to determine the best 821
alternative for the patient. The agency may adopt rules waiving 822
the requirements for written clinical documentation for specific 823
drugs in limited clinical situations. 824
19.15. The agency shall implement a return and reuse 825
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program for drugs dispensed by pharmacies to institutional 826
recipients, which includes payment of a $5 restocking fee for 827
the implementation and operation of the program. The return and 828
reuse program shall be implemented electronically and in a 829
manner that promotes efficiency. The program must permit a 830
pharmacy to exclude drugs from the program if it is not 831
practical or cost-effective for the drug to be included and must 832
provide for the return to inventory of drugs that cannot be 833
credited or returned in a cost-effective manner. The agency 834
shall determine if the program has reduced the amount of 835
Medicaid prescription drugs which are destroyed on an annual 836
basis and if there are additional ways to ensure more 837
prescription drugs are not destroyed which could safely be 838
reused. 839
(14) Neither this section nor this chapter prevents the 840
agency from conducting retrospective reviews, investigations, 841
analyses, audits, or any combination thereof to determine 842
possible fraud, abuse, overpayment, or recipient neglect in the 843
state Medicaid program pursuant to s. 409.913, including, but 844
not limited to, reviews in which the services were the subject 845
of a utilization review or prior authorization process. 846
Section 7. Paragraph (a) of subsection (4) and paragraph 847
(b) of subsection (6) of section 409.9122, Florida Statutes, are 848
amended to read: 849
409.9122 Medicaid managed care enrollment; HIV/AIDS 850
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patients; procedures; data collection; accounting; information 851
system; medical loss ratio.— 852
(4) The agency shall maintain and operate the Medicaid 853
Encounter Data System to collect, process, store, and report on 854
covered services provided to all Florida Medicaid recipients 855
enrolled in prepaid managed care plans. 856
(a) Prepaid Managed care plans shall submit encounter 857
data, including denied encounters and encounters resulting from 858
a capitated arrangement, electronically in a format that 859
complies with the Health Insurance Portability and 860
Accountability Act provisions for electronic claims and in 861
accordance with deadlines established by the agency. Prepaid 862
Managed care plans must certify that the data reported is 863
accurate and complete. 864
(6) The agency shall establish, and managed care plans 865
shall use, a uniform method of accounting for and reporting 866
medical and nonmedical costs. 867
(b) The agency is responsible for validating the financial 868
data submitted by the plans. The agency shall develop methods 869
and protocols for ongoing analysis of data that adjusts for 870
differences in characteristics of plan enrollees to allow 871
comparison among plans and against expected levels of 872
expenditures. The analysis shall be used to identify possible 873
cases of overspending on administrative costs, payment amounts 874
in excess of market rates, or underspending on medical services, 875
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or potential managed care plan fraud, waste, and abuse. Such 876
analysis shall also be used in the rate setting process. 877
Section 8. Paragraph (e) of subsection (1) and subsections 878
(2) and (6) of section 409.913, Florida Statutes, are amended to 879
read: 880
409.913 Oversight of the integrity of the Medicaid 881
program.—The agency shall operate a program to oversee the 882
activities of Florida Medicaid recipients, and providers and 883
their representatives, to ensure that fraudulent and abusive 884
behavior and neglect of recipients occur to the minimum extent 885
possible, and to recover overpayments and impose sanctions as 886
appropriate. Each January 15, the agency and the Medicaid Fraud 887
Control Unit of the Department of Legal Affairs shall submit a 888
report to the Legislature documenting the effectiveness of the 889
state's efforts to control Medicaid fraud and abuse and to 890
recover Medicaid overpayments during the previous fiscal year. 891
The report must describe the number of cases opened and 892
investigated each year; the sources of the cases opened; the 893
disposition of the cases closed each year; the amount of 894
overpayments alleged in preliminary and final audit letters; the 895
number and amount of fines or penalties imposed; any reductions 896
in overpayment amounts negotiated in settlement agreements or by 897
other means; the amount of final agency determinations of 898
overpayments; the amount deducted from federal claiming as a 899
result of overpayments; the amount of overpayments recovered 900
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each year; the amount of cost of investigation recovered each 901
year; the average length of time to collect from the time the 902
case was opened until the overpayment is paid in full; the 903
amount determined as uncollectible and the portion of the 904
uncollectible amount subsequently reclaimed from the Federal 905
Government; the number of providers, by type, that are 906
terminated from participation in the Medicaid program as a 907
result of fraud and abuse; and all costs associated with 908
discovering and prosecuting cases of Medicaid overpayments and 909
making recoveries in such cases. The report must also document 910
actions taken to prevent overpayments and the number of 911
providers prevented from enrolling in or reenrolling in the 912
Medicaid program as a result of documented Medicaid fraud and 913
abuse and must include policy recommendations necessary to 914
prevent or recover overpayments and changes necessary to prevent 915
and detect Medicaid fraud. All policy recommendations in the 916
report must include a detailed fiscal analysis, including, but 917
not limited to, implementation costs, estimated savings to the 918
Medicaid program, and the return on investment. The agency must 919
submit the policy recommendations and fiscal analyses in the 920
report to the appropriate estimating conference, pursuant to s. 921
216.137, by February 15 of each year. The agency and the 922
Medicaid Fraud Control Unit of the Department of Legal Affairs 923
each must include detailed unit-specific performance standards, 924
benchmarks, and metrics in the report, including projected cost 925
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savings to the state Medicaid program during the following 926
fiscal year. 927
(1) For the purposes of this section, the term: 928
(e) "Overpayment" includes any amount that is not 929
authorized to be paid by the Medicaid program or that should not 930
have been paid, including payments made whether paid as a result 931
of inaccurate or improper cost reporting, improper claiming, 932
unacceptable practices, fraud, abuse, or mistake, and may 933
include amounts paid for goods or services that were the subject 934
of a utilization review or prior authorization process. 935
(2) The agency shall conduct, or cause to be conducted by 936
contract or otherwise, reviews, investigations, analyses, 937
audits, or any combination thereof, to determine possible fraud, 938
abuse, overpayment, or recipient neglect in the Medicaid program 939
and shall report the findings of any overpayments in audit 940
reports as appropriate. An overpayment determination may be 941
based upon retrospective reviews, investigations, analyses, 942
audits, or any combination thereof to determine possible fraud, 943
abuse, overpayment, or recipient neglect in the Medicaid 944
program. At least 5 percent of all audits shall be conducted on 945
a random basis. As part of its ongoing fraud detection 946
activities, the agency shall identify and monitor, by contract 947
or otherwise, patterns of overutilization of Medicaid services 948
based on state averages. The agency shall track Medicaid 949
provider prescription and billing patterns and evaluate them 950
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against Medicaid medical necessity criteria and coverage and 951
limitation guidelines adopted by rule. Medical necessity 952
determination requires that service be consistent with symptoms 953
or confirmed diagnosis of illness or injury under treatment and 954
not in excess of the patient's needs. The agency shall conduct 955
reviews of provider exceptions to peer group norms and shall, 956
using statistical methodologies, provider profiling, and 957
analysis of billing patterns, detect and investigate abnormal or 958
unusual increases in billing or payment of claims for Medicaid 959
services and medically unnecessary provision of services. 960
(6) Any notice required to be given to a provider under 961
this section is presumed to be sufficient notice if sent to the 962
mailing address last shown on the provider enrollment file. It 963
is the responsibility of the provider to furnish and keep the 964
agency informed of the provider's current mailing and service 965
addresses address. United States Postal Service or other common 966
carrier's proof of mailing or certified or registered mailing of 967
such notice to the provider at the address shown on the provider 968
enrollment file constitutes sufficient proof of notice. Any 969
notice required to be given to the agency by this section must 970
be sent to the agency at an address designated by rule. 971
Section 9. Present subsections (2) through (18) of section 972
409.962, Florida Statutes, are redesignated as subsections (3) 973
through (19), respectively, and a new subsection (2) is added to 974
that section, to read: 975
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409.962 Definitions.—As used in this part, except as 976
otherwise specifically provided, the term: 977
(2) "Affiliate," including the terms "affiliated with" and 978
"affiliation," means a person, as construed in s. 1.01(3), who: 979
(a) Directly or indirectly, through one or more 980
intermediaries, controls, is controlled by, or is under common 981
control with a specified entity or person. The term includes 982
parent and subsidiary entities; or 983
(b) Is deemed a "related party" according to the standards 984
adopted by the Financial Accounting Standards Board. 985
Section 10. Subsections (1) and (2) and paragraph (h) of 986
subsection (3) of section 409.967, Florida Statutes, are 987
amended, and subsection (5) is added to that section, to read: 988
409.967 Managed care plan accountability.— 989
(1) CONTRACT PROCUREMENT PROCESS.—Beginning with the 990
contract procurement process initiated during the 2023 calendar 991
year, the agency shall establish a 6-year contract with each 992
managed care plan selected through the procurement process 993
described in s. 409.966. A plan contract may not be renewed; 994
however, the agency may extend the term of a plan contract to 995
cover any delays during the transition to a new plan. The agency 996
shall extend until December 31, 2024, the term of existing plan 997
contracts awarded pursuant to the invitation to negotiate 998
published in July 2017. 999
(2) CONTRACT REQUIREMENTS.—The agency shall establish such 1000
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contract requirements as are necessary for the operation of the 1001
statewide managed care program. The contracts must require any 1002
third-party administrative entity contracted by a plan to adhere 1003
to all requirements specific to the state Medicaid program. In 1004
addition to any other provisions the agency may deem necessary, 1005
the contract must require: 1006
(a) Physician compensation.—Managed care plans are 1007
expected to coordinate care, manage chronic disease, and prevent 1008
the need for more costly services. Effective care management 1009
should enable plans to redirect available resources and increase 1010
compensation for physicians. Plans achieve this performance 1011
standard when physician payment rates equal or exceed Medicare 1012
rates for similar services. The agency may impose fines or other 1013
sanctions on a plan that fails to meet this performance standard 1014
after 2 years of continuous operation. 1015
(b) Emergency services.—Managed care plans shall pay for 1016
services required by ss. 395.1041 and 401.45 and rendered by a 1017
noncontracted provider. The plans must comply with s. 641.3155. 1018
Reimbursement for services under this paragraph is the lesser 1019
of: 1020
1. The provider's charges; 1021
2. The usual and customary provider charges for similar 1022
services in the community where the services were provided; 1023
3. The charge mutually agreed to by the entity and the 1024
provider within 60 days after submittal of the claim; or 1025
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4. The Medicaid rate, which, for the purposes of this 1026
paragraph, means the amount the provider would collect from the 1027
agency on a fee-for-service basis, less any amounts for the 1028
indirect costs of medical education and the direct costs of 1029
graduate medical education that are otherwise included in the 1030
agency's fee-for-service payment, as required under 42 U.S.C. s. 1031
1396u-2(b)(2)(D). For the purpose of establishing the amounts 1032
specified in this subparagraph, the agency shall publish on its 1033
website annually, or more frequently as needed, the applicable 1034
fee-for-service fee schedules and their effective dates, less 1035
any amounts for indirect costs of medical education and direct 1036
costs of graduate medical education that are otherwise included 1037
in the agency's fee-for-service payments. 1038
(c) Access.— 1039
1. The agency shall establish specific standards for the 1040
number, type, and regional distribution of providers in managed 1041
care plan networks to ensure access to care for both adults and 1042
children. Each plan must maintain a regionwide network of 1043
providers in sufficient numbers to meet the access standards for 1044
specific medical services for all recipients enrolled in the 1045
plan. The exclusive use of mail-order pharmacies may not be 1046
sufficient to meet network access standards. Consistent with the 1047
standards established by the agency, provider networks may 1048
include providers located outside the region. Each plan shall 1049
establish and maintain an accurate and complete electronic 1050
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database of contracted providers, including information about 1051
licensure or registration, locations and hours of operation, 1052
specialty credentials and other certifications, specific 1053
performance indicators, and such other information as the agency 1054
deems necessary. The database must be available online to both 1055
the agency and the public and have the capability to compare the 1056
availability of providers to network adequacy standards and to 1057
accept and display feedback from each provider's patients. Each 1058
plan shall submit quarterly reports to the agency identifying 1059
the number of enrollees assigned to each primary care provider. 1060
The agency shall conduct, or contract for, systematic and 1061
continuous testing of the provider network databases maintained 1062
by each plan to confirm accuracy, confirm that behavioral health 1063
providers are accepting enrollees, and confirm that enrollees 1064
have access to behavioral health services. 1065
2. Each managed care plan must publish any prescribed drug 1066
formulary or preferred drug list on the plan's website in a 1067
manner that is accessible to and searchable by enrollees and 1068
providers. The plan must update the list within 24 hours after 1069
making a change. Each plan must ensure that the prior 1070
authorization process for prescribed drugs is readily accessible 1071
to health care providers, including posting appropriate contact 1072
information on its website and providing timely responses to 1073
providers. For Medicaid recipients diagnosed with hemophilia who 1074
have been prescribed anti-hemophilic-factor replacement 1075
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products, the agency shall provide for those products and 1076
hemophilia overlay services through the agency's hemophilia 1077
disease management program. 1078
3. Managed care plans, and their fiscal agents or 1079
intermediaries, must accept prior authorization requests for any 1080
service electronically. 1081
4. Managed care plans serving children in the care and 1082
custody of the Department of Children and Families must maintain 1083
complete medical, dental, and behavioral health encounter 1084
information and participate in making such information available 1085
to the department or the applicable contracted community-based 1086
care lead agency for use in providing comprehensive and 1087
coordinated case management. The agency and the department shall 1088
establish an interagency agreement to provide guidance for the 1089
format, confidentiality, recipient, scope, and method of 1090
information to be made available and the deadlines for 1091
submission of the data. The scope of information available to 1092
the department shall be the data that managed care plans are 1093
required to submit to the agency. The agency shall determine the 1094
plan's compliance with standards for access to medical, dental, 1095
and behavioral health services; the use of medications; and 1096
followup on all medically necessary services recommended as a 1097
result of early and periodic screening, diagnosis, and 1098
treatment. 1099
(d) Quality care.—Managed care plans shall provide, or 1100
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contract for the provision of, care coordination to facilitate 1101
the appropriate delivery of behavioral health care services in 1102
the least restrictive setting with treatment and recovery 1103
capabilities that address the needs of the patient. Services 1104
shall be provided in a manner that integrates behavioral health 1105
services and primary care. Plans shall be required to achieve 1106
specific behavioral health outcome standards, established by the 1107
agency in consultation with the department. 1108
(e) Encounter data.—The agency shall maintain and operate 1109
a Medicaid Encounter Data System to collect, process, store, and 1110
report on covered services provided to all Medicaid recipients 1111
enrolled in prepaid plans. 1112
1. Each prepaid plan must comply with the agency's 1113
reporting requirements for the Medicaid Encounter Data System. 1114
Prepaid plans must submit encounter data electronically in a 1115
format that complies with the Health Insurance Portability and 1116
Accountability Act provisions for electronic claims and in 1117
accordance with deadlines established by the agency. Prepaid 1118
plans must certify that the data reported is accurate and 1119
complete. 1120
2. The agency is responsible for validating the data 1121
submitted by the plans. The agency shall develop methods and 1122
protocols for ongoing analysis of the encounter data that 1123
adjusts for differences in characteristics of prepaid plan 1124
enrollees to allow comparison of service utilization among plans 1125
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and against expected levels of use. The analysis shall be used 1126
to identify possible cases of systemic underutilization or 1127
denials of claims and inappropriate service utilization such as 1128
higher-than-expected emergency department encounters. The 1129
analysis shall provide periodic feedback to the plans and enable 1130
the agency to establish corrective action plans when necessary. 1131
One of the focus areas for the analysis shall be the use of 1132
prescription drugs. 1133
3. The agency shall make encounter data available to those 1134
plans accepting enrollees who are assigned to them from other 1135
plans leaving a region. 1136
4. The agency shall annually produce a report entitled 1137
"Analysis of Potentially Preventable Health Care Events of 1138
Florida Medicaid Enrollees." The report must include, but need 1139
not be limited to, an analysis of the potentially preventable 1140
hospital emergency department visits, hospital admissions, and 1141
hospital readmissions that occurred during the previous state 1142
fiscal year which may have been prevented with better access to 1143
primary care, improved medication management, or better 1144
coordination of care, reported by age, eligibility group, 1145
managed care plan, and region, including conditions contributing 1146
to each potentially preventable event or category of potentially 1147
preventable events. The agency may include any other data or 1148
analysis parameters to augment the report which it deems 1149
pertinent to the analysis. The report must demonstrate trends 1150
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using applicable historical data. The agency shall submit the 1151
report to the Governor, the President of the Senate, and the 1152
Speaker of the House of Representatives by October 1, 2024, and 1153
each October 1 thereafter. The agency may contract with a third-1154
party vendor to produce the report required under this 1155
subparagraph. 1156
(f) Continuous improvement.—The agency shall establish 1157
specific performance standards and expected milestones or 1158
timelines for improving performance over the term of the 1159
contract. 1160
1. Each managed care plan shall establish an internal 1161
health care quality improvement system, including enrollee 1162
satisfaction and disenrollment surveys. The quality improvement 1163
system must include incentives and disincentives for network 1164
providers. 1165
2. Each managed care plan must collect and report the 1166
Healthcare Effectiveness Data and Information Set (HEDIS) 1167
measures, the federal Core Set of Children's Health Care Quality 1168
measures, and the federal Core Set of Adult Health Care Quality 1169
Measures, as specified by the agency. Each plan must collect and 1170
report the Adult Core Set behavioral health measures beginning 1171
with data reports for the 2025 calendar year. Each plan must 1172
stratify reported measures by age, sex, race, ethnicity, primary 1173
language, and whether the enrollee received a Social Security 1174
Administration determination of disability for purposes of 1175
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Supplemental Security Income beginning with data reports for the 1176
2026 calendar year. A plan's performance on these measures must 1177
be published on the plan's website in a manner that allows 1178
recipients to reliably compare the performance of plans. The 1179
agency shall use the measures as a tool to monitor plan 1180
performance. 1181
3. Each managed care plan must be accredited by the 1182
National Committee for Quality Assurance, the Joint Commission, 1183
or another nationally recognized accrediting body, or have 1184
initiated the accreditation process, within 1 year after the 1185
contract is executed. For any plan not accredited within 18 1186
months after executing the contract, the agency shall suspend 1187
automatic assignment under ss. 409.977 and 409.984. 1188
(g) Program integrity.—Each managed care plan shall 1189
establish program integrity functions and activities to reduce 1190
the incidence of fraud and abuse, including, at a minimum: 1191
1. A provider credentialing system and ongoing provider 1192
monitoring, including maintenance of written provider 1193
credentialing policies and procedures which comply with federal 1194
and agency guidelines; 1195
2. An effective prepayment and postpayment review process 1196
including, but not limited to, data analysis, system editing, 1197
and auditing of network providers; 1198
3. Procedures for reporting instances of fraud and abuse 1199
pursuant to chapter 641; 1200
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4. Administrative and management arrangements or 1201
procedures, including a mandatory compliance plan, designed to 1202
prevent fraud and abuse; and 1203
5. Designation of a program integrity compliance officer. 1204
(h) Grievance resolution.—Consistent with federal law, 1205
each managed care plan shall establish and the agency shall 1206
approve an internal process for reviewing and responding to 1207
grievances from enrollees. Each plan shall submit quarterly 1208
reports on the number, description, and outcome of grievances 1209
filed by enrollees. 1210
(i) Penalties.— 1211
1. Withdrawal and enrollment reduction.—Managed care plans 1212
that reduce enrollment levels or leave a region before the end 1213
of the contract term must reimburse the agency for the cost of 1214
enrollment changes and other transition activities. If more than 1215
one plan leaves a region at the same time, costs must be shared 1216
by the departing plans proportionate to their enrollments. In 1217
addition to the payment of costs, departing provider services 1218
networks must pay a per-enrollee penalty of up to 3 months' 1219
payment and continue to provide services to the enrollee for 90 1220
days or until the enrollee is enrolled in another plan, 1221
whichever occurs first. In addition to payment of costs, all 1222
other departing plans must pay a penalty of 25 percent of that 1223
portion of the minimum surplus maintained pursuant to s. 1224
641.225(1) which is attributable to the provision of coverage to 1225
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Medicaid enrollees. Plans shall provide at least 180 days' 1226
notice to the agency before withdrawing from a region. If a 1227
managed care plan leaves a region before the end of the contract 1228
term, the agency shall terminate all contracts with that plan in 1229
other regions pursuant to the termination procedures in 1230
subparagraph 3. 1231
2. Encounter data.—If a plan fails to comply with the 1232
encounter data reporting requirements of this section for 30 1233
days, the agency must assess a fine of $5,000 per day for each 1234
day of noncompliance beginning on the 31st day. On the 31st day, 1235
the agency must notify the plan that the agency will initiate 1236
contract termination procedures on the 90th day unless the plan 1237
comes into compliance before that date. 1238
3. Termination.—If the agency terminates more than one 1239
regional contract with the same managed care plan due to 1240
noncompliance with the requirements of this section, the agency 1241
shall terminate all the regional contracts held by that plan. 1242
When terminating multiple contracts, the agency must develop a 1243
plan to provide for the transition of enrollees to other plans, 1244
and phase in the terminations over a time period sufficient to 1245
ensure a smooth transition. 1246
(j) Prompt payment.—Managed care plans shall comply with 1247
ss. 641.315, 641.3155, and 641.513. 1248
(k) Electronic claims.—Managed care plans, and their 1249
fiscal agents or intermediaries, shall accept electronic claims 1250
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in compliance with federal standards. 1251
(l) Fair payment.—Provider service networks must ensure 1252
that no entity licensed under chapter 395 with a controlling 1253
interest in the network charges a Medicaid managed care plan 1254
more than the amount paid to that provider by the provider 1255
service network for the same service. 1256
(m) Itemized payment.—Any claims payment to a provider by 1257
a managed care plan, or by a fiscal agent or intermediary of the 1258
plan, must be accompanied by an itemized accounting of the 1259
individual claims included in the payment including, but not 1260
limited to, the enrollee's name, the date of service, the 1261
procedure code, the amount of reimbursement, and the 1262
identification of the plan on whose behalf the payment is made. 1263
(n) Provider dispute resolution.—Disputes between a plan 1264
and a provider may be resolved as described in s. 408.7057. 1265
(o) Transparency.—Managed care plans shall comply with ss. 1266
627.6385(3) and 641.54(7). 1267
(3) ACHIEVED SAVINGS REBATE.— 1268
(h) The following may not be included as allowable 1269
expenses in calculating income for determining the achieved 1270
savings rebate: 1271
1. Payment of achieved savings rebates. 1272
2. Any financial incentive payments made to the plan 1273
outside of the capitation rate. 1274
3. Any financial disincentive payments levied by the state 1275
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or Federal Government. 1276
4. Expenses associated with any lobbying or political 1277
activities. 1278
5. The cash value or equivalent cash value of bonuses of 1279
any type paid or awarded to the plan's executive staff, other 1280
than base salary. 1281
6. Reserves and reserve accounts. 1282
7. Administrative costs, including, but not limited to, 1283
reinsurance expenses, interest payments, depreciation expenses, 1284
bad debt expenses, and outstanding claims expenses in excess of 1285
actuarially sound maximum amounts set by the agency. 1286
8. Payments to affiliated entities as defined in s. 1287
409.962 in excess of market rates, as determined by the agency. 1288
1289
The agency shall consider these and other factors in developing 1290
contracts that establish shared savings arrangements. 1291
(5) AFFILIATED ENTITIES AND RELATED PARTIES.— 1292
(a) The agency shall ensure oversight of affiliated 1293
entities and related parties as defined in s. 409.962 within the 1294
Statewide Medicaid Managed Care program. This includes, but is 1295
not limited to, examining financial records and self-referral 1296
data for any managed care plan providing services within the 1297
Statewide Medicaid Managed Care program utilizing affiliated 1298
entities and related parties within their business model. 1299
(b) The agency shall consider data obtained pursuant to 1300
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paragraph (a) and the findings of the annual assessment required 1301
under s. 409.9675(3) when determining the final medical loss 1302
ratio as specified in subsection (4) and during the rate setting 1303
process. 1304
Section 11. Section 409.9675, Florida Statutes, is created 1305
to read: 1306
409.9675 Affiliated entities and controlling interest; 1307
reports required.— 1308
(1) As used in this part, the term "control," including 1309
the terms "controlling," "controlled by," and "under common 1310
control with," means the possession, direct or indirect, of the 1311
power to direct or cause the direction of the management and 1312
policies of a person, whether through the ownership or voting 1313
securities, by contract other than a commercial contract for 1314
goods or nonmanagement services, or otherwise, unless the power 1315
is the result of an official position with or corporate office 1316
held by the person. This definition applies regardless of 1317
whether such power is affirmative or negative or whether such 1318
power is actually used. Control is presumed to exist, but is not 1319
limited to, when any affiliate or person, as construed in s. 1320
1.01(3): 1321
(a) Directly or indirectly owns, controls, holds the power 1322
to vote, or holds proxies representing 10 percent or more of any 1323
class of the voting securities of any other person. 1324
(b) Shares common ownership with any person, has an 1325
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investor or is a holder of an ownership interest in any person, 1326
exercises control in any manner over the election of a majority 1327
of the directors or of individuals exercising similar functions 1328
of any person, has the power to exercise controlling influence 1329
over the management of any person, or serves as a working 1330
majority of the board of directors, managers, or the officers of 1331
a person, who is: 1332
1. A provider or a member of a provider group or group 1333
practice as defined in s. 456.053 under the managed care plan; 1334
or 1335
2. A person responsible for providing any pharmacy 1336
services, pharmaceuticals, diagnostics, care coordination, care 1337
delivery, health care services, medical equipment, 1338
administrative services, or financial services under the managed 1339
care plan. 1340
(2) By March 31, 2027, and annually thereafter, each 1341
managed care plan shall report to the agency and the Office of 1342
Insurance Regulation, in the manner prescribed by the agency, 1343
all of the following: 1344
(a) Any person, as construed in s. 1.01(3), controlled by 1345
or affiliated with the managed care plan, including, but not 1346
limited to, any provider, provider group, group practice as 1347
defined in s. 456.053(3), or person responsible for providing 1348
any pharmacy services, pharmaceuticals, diagnostics, care 1349
coordination, care delivery, health care services, medical 1350
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equipment, administrative services, or financial services for, 1351
to, or on behalf of the managed care plan. 1352
(b) Any affiliation of any kind or nature with any person, 1353
as construed in s. 1.01(3), which, either directly or 1354
indirectly, through one or more intermediaries has an investment 1355
or ownership interest representing 10 percent or more, shares 1356
common ownership, or has an investor or a holder of an ownership 1357
interest representing 10 percent or more, with any person 1358
providing pharmacy services, diagnostics, care coordination, 1359
care delivery, health care services, medical equipment, 1360
administrative services, or financial services for, to, or on 1361
behalf of the managed care plan. 1362
(c) For any affiliation reported under paragraph (a) or 1363
paragraph (b), the report must include all of the following: 1364
1. The percentage of ownership or control of any person or 1365
affiliate with whom the managed care plan or prepaid plan has 1366
had business transactions during the 12-month period in the 1367
annual achieved savings rebate financial reporting required 1368
under s. 409.967(3) and identification of the services provided 1369
under the contract or contracts involved in such business 1370
transactions; and 1371
2. Any significant business transactions between the 1372
managed care plan and any affiliated person during the 12-month 1373
period in the annual financial reporting required under s. 1374
409.967(3). 1375
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(3) Each managed care plan shall report any change in 1376
information required by subsection (1) to the agency and the 1377
Office of Insurance Regulation in writing within 60 days after 1378
such change occurs. 1379
(4) By December 31, 2026, and annually thereafter, the 1380
agency shall calculate, analyze, and publicly report on the 1381
agency's website an assessment of affiliated entity payment 1382
transactions in the Medicaid program for medical benefit and 1383
administrative costs as reported for purposes of the achieved 1384
savings rebate. The baseline assessment, at a minimum, must 1385
include achieved savings rebate transactions for the years 2021, 1386
2022, and 2023; the amount and associated percentage of 1387
affiliated entity payments within the medical loss ratio; and 1388
the payment deviation percentages and associated amounts at the 1389
Healthcare Common Procedure Coding System level for affiliated 1390
entities as compared to nonaffiliated entities. The assessment 1391
must also compare payment amounts for value-based or alternative 1392
payment arrangements. 1393
Section 12. Paragraph (c) is added to subsection (5) of 1394
section 409.973, Florida Statutes, to read: 1395
409.973 Benefits.— 1396
(5) PROVISION OF DENTAL SERVICES.— 1397
(c) By July 1, 2027, the agency shall implement an 1398
Integrated Managed Care Pilot Program in which Medicaid 1399
recipients in designated regions of this state shall receive 1400
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both medical and dental covered benefits through the same 1401
managed medical assistance plan. 1402
1. The agency shall submit a request for federal approval 1403
for the pilot program by August 1, 2026, and to implement the 1404
pilot program in Statewide Medicaid Managed Care Regions A and B 1405
by July 1, 2027, contingent upon federal approval. 1406
2. The agency is directed to amend contracts awarded to 1407
managed care plans for the provision of managed medical 1408
assistance services in Statewide Medicaid Managed Care Regions A 1409
and B to include coverage of state plan dental services 1410
effective upon implementation of the pilot program. Managed care 1411
plans providing managed medical assistance services in Regions A 1412
and B must begin providing dental services by July 1, 2027, for 1413
all Medicaid recipients in their region previously eligible for 1414
services under the statewide prepaid dental program and must 1415
comply with contractual continuity of care requirements. Managed 1416
care plans must also agree to provide the same level of service 1417
as the prepaid dental plans in their region, including expanded 1418
benefits offered by those plans at no cost to the state. Managed 1419
care plans that provide dental services in Regions A and B must 1420
maintain a minimum dental medical loss ratio of 85 percent, 1421
calculated in accordance with 42 C.F.R. 438.8. The agency shall 1422
separately identify the amounts included in the capitation rates 1423
for dental services. The managed care plans shall recognize 1424
existing provider credentialing performed by the prepaid dental 1425
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plans for providers who remain in good standing with the state 1426
Medicaid program for a period not to exceed 12 months after the 1427
effective date of implementation of the pilot program. If a 1428
managed care plan fails to execute contracts or contract 1429
amendments needed to implement the pilot program, the agency 1430
must terminate all contracts with that plan. Contracts in 1431
Statewide Medicaid Managed Care Regions A and B which provide 1432
services under the statewide prepaid Medicaid dental health 1433
program authorized by paragraph (b) terminate upon 1434
implementation of the pilot program in these regions. 1435
3. The agency shall establish specific measures of access, 1436
quality, and costs for evaluations of the pilot program. The 1437
agency shall contract with an independent evaluator to conduct 1438
the program evaluations. The evaluations must compare the 1439
experience in the regions participating in the pilot program 1440
with the experience in the regions not participating in the 1441
pilot program. The evaluations must include consideration of all 1442
of the following, at a minimum: 1443
a. Utilization of routine preventive dental care, 1444
including routine preventive dental care provided as expanded 1445
benefits, and avoidable emergency or surgical dental services. 1446
b. Dental health outcomes and other associated health 1447
outcomes impacted by dental health. 1448
c. Recipient satisfaction and continuity of care. 1449
d. Impact on the provider network, including any increase 1450
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in the number of dental practitioners willing to accept 1451
Medicaid. 1452
e. Costs of Medicaid services for the pilot program 1453
population with specific focus on utilization, outcomes, and 1454
costs associated with children and disabled populations. 1455
4. The agency shall submit a report on the performance of 1456
the pilot program to the Governor, the President of the Senate, 1457
and the Speaker of the House of Representatives beginning on 1458
December 1, 2028, and annually thereafter. 1459
Section 13. Subsection (1) of section 409.91196, Florida 1460
Statutes, is amended to read: 1461
409.91196 Supplemental rebate agreements; public records 1462
and public meetings exemption.— 1463
(1) The rebate amount, percent of rebate, manufacturer's 1464
pricing, and supplemental rebate, and other trade secrets as 1465
defined in s. 688.002 that the agency has identified for use in 1466
negotiations, held by the Agency for Health Care Administration 1467
under s. 409.912(5)(a)11. s. 409.912(5)(a)7. are confidential 1468
and exempt from s. 119.07(1) and s. 24(a), Art. I of the State 1469
Constitution. 1470
Section 14. Subsection (1) of section 627.42392, Florida 1471
Statutes, is amended to read: 1472
627.42392 Prior authorization.— 1473
(1) As used in this section, the term "health insurer" 1474
means an authorized insurer offering health insurance as defined 1475
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in s. 624.603, a managed care plan as defined in s. 409.962(12) 1476
s. 409.962(10), or a health maintenance organization as defined 1477
in s. 641.19(12). 1478
Section 15. This act shall take effect July 1, 2026. 1479