Bill Text: FL S0670 | 2017 | Regular Session | Comm Sub
Bill Title: Managed Care Plans' Provider Networks
Spectrum: Moderate Partisan Bill (Republican 4-1)
Status: (Failed) 2017-05-05 - Died in Appropriations [S0670 Detail]
Download: Florida-2017-S0670-Comm_Sub.html
Florida Senate - 2017 CS for SB 670 By the Committee on Banking and Insurance; and Senators Bean, Lee, and Mayfield 597-02144-17 2017670c1 1 A bill to be entitled 2 An act relating to managed care plans’ provider 3 networks; amending s. 409.975, F.S.; prohibiting a 4 managed care plan from excluding a pharmacy that meets 5 the credentialing requirements and standards 6 established by the Agency for Health Care 7 Administration and that accepts the terms of the plan; 8 requiring a managed care plan to offer the same rate 9 of reimbursement to all pharmacies in the plan’s 10 network; authorizing rulemaking; providing an 11 effective date. 12 13 Be It Enacted by the Legislature of the State of Florida: 14 15 Section 1. Subsection (1) of section 409.975, Florida 16 Statutes, is amended to read: 17 409.975 Managed care plan accountability.—In addition to 18 the requirements of s. 409.967, plans and providers 19 participating in the managed medical assistance program shall 20 comply with the requirements of this section. 21 (1) PROVIDER NETWORKS.—Managed care plans must develop and 22 maintain provider networks that meet the medical needs of their 23 enrollees in accordance with standards established pursuant to 24 s. 409.967(2)(c). Except as provided in this section, managed 25 care plans may limit the providers in their networks based on 26 credentials, quality indicators, and price. 27 (a) A managed care plan may not exclude any pharmacy that 28 meets the credentialing requirements, complies with agency 29 standards, and accepts the terms of the plan. The managed care 30 plan must offer the same rate of reimbursement to all pharmacies 31 in the plan’s network. 32 (b) Plans must include all providers in the region which 33thatare classified by the agency as essential Medicaid 34 providers, unless the agency approves, in writing, an 35 alternative arrangement for securing the types of services 36 offered by the essential providers. Providers are essential for 37 serving Medicaid enrollees if they offer services that are not 38 available from any other provider within a reasonable access 39 standard, or if they provided a substantial share of the total 40 units of a particular service used by Medicaid patients within 41 the region during the last 3 years and the combined capacity of 42 other service providers in the region is insufficient to meet 43 the total needs of the Medicaid patients. The agency may not 44 classify physicians and other practitioners as essential 45 providers. The agency, at a minimum, shall determine which 46 providers in the following categories are essential Medicaid 47 providers: 48 1. Federally qualified health centers. 49 2. Statutory teaching hospitals as defined in s. 50 408.07(45). 51 3. Hospitals that are trauma centers as defined in s. 52 395.4001(14). 53 4. Hospitals located at least 25 miles from any other 54 hospital with similar services. 55 56 Managed care plans that have not contracted with all essential 57 providers in the region as of the first date of recipient 58 enrollment, or with whom an essential provider has terminated 59 its contract, must negotiate in good faith with such essential 60 providers for 1 year or until an agreement is reached, whichever 61 is first. Payments for services rendered by a nonparticipating 62 essential provider shall be made at the applicable Medicaid rate 63 as of the first day of the contract between the agency and the 64 plan. A rate schedule for all essential providers shall be 65 attached to the contract between the agency and the plan. After 66 1 year, managed care plans that are unable to contract with 67 essential providers shall notify the agency and propose an 68 alternative arrangement for securing the essential services for 69 Medicaid enrollees. The arrangement must rely on contracts with 70 other participating providers, regardless of whether those 71 providers are located within the same region as the 72 nonparticipating essential service provider. If the alternative 73 arrangement is approved by the agency, payments to 74 nonparticipating essential providers after the date of the 75 agency’s approval shall equal 90 percent of the applicable 76 Medicaid rate. Except for payment for emergency services, if the 77 alternative arrangement is not approved by the agency, payment 78 to nonparticipating essential providers shall equal 110 percent 79 of the applicable Medicaid rate. 80 (c)(b)Certain providers are statewide resources and 81 essential providers for all managed care plans in all regions. 82 All managed care plans must include these essential providers in 83 their networks. Statewide essential providers include: 84 1. Faculty plans of Florida medical schools. 85 2. Regional perinatal intensive care centers as defined in 86 s. 383.16(2). 87 3. Hospitals licensed as specialty children’s hospitals as 88 defined in s. 395.002(28). 89 4. Accredited and integrated systems serving medically 90 complex children which comprise separately licensed, but 91 commonly owned, health care providers delivering at least the 92 following services: medical group home, in-home and outpatient 93 nursing care and therapies, pharmacy services, durable medical 94 equipment, and Prescribed Pediatric Extended Care. 95 96 Managed care plans that have not contracted with all statewide 97 essential providers in all regions as of the first date of 98 recipient enrollment must continue to negotiate in good faith. 99 Payments to physicians on the faculty of nonparticipating 100 Florida medical schools shall be made at the applicable Medicaid 101 rate. Payments for services rendered by regional perinatal 102 intensive care centers shall be made at the applicable Medicaid 103 rate as of the first day of the contract between the agency and 104 the plan. Except for payments for emergency services, payments 105 to nonparticipating specialty children’s hospitals shall equal 106 the highest rate established by contract between that provider 107 and any other Medicaid managed care plan. 108 (d)(c)After 12 months of active participation in a plan’s 109 network, the plan may exclude any essential provider from the 110 network for failure to meet quality or performance criteria. If 111 the plan excludes an essential provider from the plan, the plan 112 must provide written notice to all recipients who have chosen 113 that provider for care. The notice shall be provided at least 30 114 days before the effective date of the exclusion. For purposes of 115 this paragraph, the term “essential provider” includes providers 116 determined by the agency to be essential Medicaid providers 117 under paragraph (b)(a)and the statewide essential providers 118 specified in paragraph (c)(b). 119 (e)(d)The applicable Medicaid rates for emergency services 120 paid by a plan under this section to a provider with which the 121 plan does not have an active contract shall be determined 122 according to s. 409.967(2)(b). 123 (f)(e)Each managed care plan must offer a network contract 124 to each home medical equipment and supplies provider in the 125 region which meets quality and fraud prevention and detection 126 standards established by the plan and which agrees to accept the 127 lowest price previously negotiated between the plan and another 128 such provider. 129 (g)The agency may adopt rules necessary to administer this 130 section, including rules establishing credentialing requirements 131 and quality standards for pharmacies. 132 Section 2. This act shall take effect October 1, 2017. 133