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.
   13  Be It Enacted by the Legislature of the State of Florida:
   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
   33  that are 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.
   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.
   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.