Florida Senate - 2017                        COMMITTEE AMENDMENT
       Bill No. CS for SB 670
                              LEGISLATIVE ACTION                        
                    Senate             .             House              
                   Comm: WD            .                                
                  03/22/2017           .                                

       Appropriations Subcommittee on Health and Human Services (Bean)
       recommended the following:
    1         Senate Amendment (with title amendment)
    3         Delete lines 27 - 131
    4  and insert:
    5         (a) A managed care plan may not enter into a contract with
    6  a pharmacy benefits manager (PBM) to manage the prescription
    7  drug coverage provided under the plan or to control the costs of
    8  the prescription drug coverage under such plan unless:
    9         1. The contract prevents the PBM from requiring that a plan
   10  enrollee use a retail pharmacy or other pharmacy entity
   11  providing pharmacy services in which the PBM has an ownership
   12  interest or which has an ownership interest in the PBM, or the
   13  contract provides an incentive to a plan enrollee to encourage
   14  the enrollee to use a retail pharmacy, mail order pharmacy,
   15  specialty pharmacy, or other pharmacy entity providing pharmacy
   16  services in which the PBM has an ownership interest or which has
   17  an ownership interest in the PBM, if the incentive is applicable
   18  only to such pharmacies; and
   19         2. The contract requires the PBM to update the maximum
   20  allowable cost as defined by s. 465.1862(1)(a) every 7 calendar
   21  days beginning on January 1 of each year, to accurately reflect
   22  the market price of acquiring the drug.
   23         (b) Plans must include all providers in the region which
   24  that are classified by the agency as essential Medicaid
   25  providers, unless the agency approves, in writing, an
   26  alternative arrangement for securing the types of services
   27  offered by the essential providers. Providers are essential for
   28  serving Medicaid enrollees if they offer services that are not
   29  available from any other provider within a reasonable access
   30  standard, or if they provided a substantial share of the total
   31  units of a particular service used by Medicaid patients within
   32  the region during the last 3 years and the combined capacity of
   33  other service providers in the region is insufficient to meet
   34  the total needs of the Medicaid patients. The agency may not
   35  classify physicians and other practitioners as essential
   36  providers. The agency, at a minimum, shall determine which
   37  providers in the following categories are essential Medicaid
   38  providers:
   39         1. Federally qualified health centers.
   40         2. Statutory teaching hospitals as defined in s.
   41  408.07(45).
   42         3. Hospitals that are trauma centers as defined in s.
   43  395.4001(14).
   44         4. Hospitals located at least 25 miles from any other
   45  hospital with similar services.
   47  Managed care plans that have not contracted with all essential
   48  providers in the region as of the first date of recipient
   49  enrollment, or with whom an essential provider has terminated
   50  its contract, must negotiate in good faith with such essential
   51  providers for 1 year or until an agreement is reached, whichever
   52  is first. Payments for services rendered by a nonparticipating
   53  essential provider shall be made at the applicable Medicaid rate
   54  as of the first day of the contract between the agency and the
   55  plan. A rate schedule for all essential providers shall be
   56  attached to the contract between the agency and the plan. After
   57  1 year, managed care plans that are unable to contract with
   58  essential providers shall notify the agency and propose an
   59  alternative arrangement for securing the essential services for
   60  Medicaid enrollees. The arrangement must rely on contracts with
   61  other participating providers, regardless of whether those
   62  providers are located within the same region as the
   63  nonparticipating essential service provider. If the alternative
   64  arrangement is approved by the agency, payments to
   65  nonparticipating essential providers after the date of the
   66  agency’s approval shall equal 90 percent of the applicable
   67  Medicaid rate. Except for payment for emergency services, if the
   68  alternative arrangement is not approved by the agency, payment
   69  to nonparticipating essential providers shall equal 110 percent
   70  of the applicable Medicaid rate.
   71         (c)(b) Certain providers are statewide resources and
   72  essential providers for all managed care plans in all regions.
   73  All managed care plans must include these essential providers in
   74  their networks. Statewide essential providers include:
   75         1. Faculty plans of Florida medical schools.
   76         2. Regional perinatal intensive care centers as defined in
   77  s. 383.16(2).
   78         3. Hospitals licensed as specialty children’s hospitals as
   79  defined in s. 395.002(28).
   80         4. Accredited and integrated systems serving medically
   81  complex children which comprise separately licensed, but
   82  commonly owned, health care providers delivering at least the
   83  following services: medical group home, in-home and outpatient
   84  nursing care and therapies, pharmacy services, durable medical
   85  equipment, and Prescribed Pediatric Extended Care.
   87  Managed care plans that have not contracted with all statewide
   88  essential providers in all regions as of the first date of
   89  recipient enrollment must continue to negotiate in good faith.
   90  Payments to physicians on the faculty of nonparticipating
   91  Florida medical schools shall be made at the applicable Medicaid
   92  rate. Payments for services rendered by regional perinatal
   93  intensive care centers shall be made at the applicable Medicaid
   94  rate as of the first day of the contract between the agency and
   95  the plan. Except for payments for emergency services, payments
   96  to nonparticipating specialty children’s hospitals shall equal
   97  the highest rate established by contract between that provider
   98  and any other Medicaid managed care plan.
   99         (d)(c) After 12 months of active participation in a plan’s
  100  network, the plan may exclude any essential provider from the
  101  network for failure to meet quality or performance criteria. If
  102  the plan excludes an essential provider from the plan, the plan
  103  must provide written notice to all recipients who have chosen
  104  that provider for care. The notice shall be provided at least 30
  105  days before the effective date of the exclusion. For purposes of
  106  this paragraph, the term “essential provider” includes providers
  107  determined by the agency to be essential Medicaid providers
  108  under paragraph (b) (a) and the statewide essential providers
  109  specified in paragraph (c) (b).
  110         (e)(d) The applicable Medicaid rates for emergency services
  111  paid by a plan under this section to a provider with which the
  112  plan does not have an active contract shall be determined
  113  according to s. 409.967(2)(b).
  114         (f)(e) Each managed care plan must offer a network contract
  115  to each home medical equipment and supplies provider in the
  116  region which meets quality and fraud prevention and detection
  117  standards established by the plan and which agrees to accept the
  118  lowest price previously negotiated between the plan and another
  119  such provider.
  121  ================= T I T L E  A M E N D M E N T ================
  122  And the title is amended as follows:
  123         Delete lines 3 - 10
  124  and insert:
  125         networks; amending s. 409.975, F.S.; prohibiting a
  126         managed care plan from contracting with a pharmacy
  127         benefits manager to manage the prescription drug
  128         coverage provided under the plan unless certain
  129         requirements are met; providing an