Florida Senate - 2025 SB 306
By Senator Sharief
35-00489-25 2025306__
1 A bill to be entitled
2 An act relating to managed care plan network access;
3 amending s. 409.967, F.S.; requiring that the Agency
4 for Health Care Administration include specified
5 requirements in its contracts with Medicaid managed
6 care plans; amending s. 409.975, F.S.; authorizing
7 enrollees of Medicaid managed care plans to receive
8 care from Medicaid providers not under contract with
9 the plan under certain circumstances; requiring the
10 plans to reimburse such providers at the applicable
11 rates paid for such services under the plan; providing
12 an effective date.
13
14 Be It Enacted by the Legislature of the State of Florida:
15
16 Section 1. Paragraph (c) of subsection (2) of section
17 409.967, Florida Statutes, is amended to read:
18 409.967 Managed care plan accountability.—
19 (2) The agency shall establish such contract requirements
20 as are necessary for the operation of the statewide managed care
21 program. In addition to any other provisions the agency may deem
22 necessary, the contract must require:
23 (c) Access.—
24 1. The agency shall establish specific standards for the
25 number, type, and regional distribution of providers in managed
26 care plan networks to ensure access to care for both adults and
27 children. Each plan must maintain a regionwide network of
28 providers in sufficient numbers to meet the access standards for
29 specific medical services for all recipients enrolled in the
30 plan. Plans must allow enrollees to receive care from Medicaid
31 providers not under contract with the plan if an enrollee is
32 unable to receive care from a participating provider under the
33 plan in a timely manner consistent with a reasonable access
34 standard, as determined by agency rule, or there is another
35 appropriate Medicaid provider in a location more geographically
36 accessible to the enrollee’s residence than those under the
37 plan. The plan must reimburse the nonparticipating Medicaid
38 providers for such services at the applicable Medicaid rate for
39 such services under the plan. The exclusive use of mail-order
40 pharmacies may not be sufficient to meet network access
41 standards. Consistent with the standards established by the
42 agency, provider networks may include providers located outside
43 the region. Each plan must shall establish and maintain an
44 accurate and complete electronic database of contracted
45 providers, including information about licensure or
46 registration, locations and hours of operation, specialty
47 credentials and other certifications, specific performance
48 indicators, and such other information as the agency deems
49 necessary. The database must be available online to both the
50 agency and the public and have the capability to compare the
51 availability of providers to network adequacy standards and to
52 accept and display feedback from each provider’s patients. Each
53 plan must shall submit quarterly reports to the agency
54 identifying the number of enrollees assigned to each primary
55 care provider. The agency shall conduct, or contract for,
56 systematic and continuous testing of the provider network
57 databases maintained by each plan to confirm accuracy, confirm
58 that behavioral health providers are accepting enrollees, and
59 confirm that enrollees have access to behavioral health
60 services.
61 2. Each managed care plan must publish any prescribed drug
62 formulary or preferred drug list on the plan’s website in a
63 manner that is accessible to and searchable by enrollees and
64 providers. The plan must update the list within 24 hours after
65 making a change. Each plan must ensure that the prior
66 authorization process for prescribed drugs is readily accessible
67 to health care providers, including posting appropriate contact
68 information on its website and providing timely responses to
69 providers. For Medicaid recipients diagnosed with hemophilia who
70 have been prescribed anti-hemophilic-factor replacement
71 products, the agency shall provide for those products and
72 hemophilia overlay services through the agency’s hemophilia
73 disease management program.
74 3. Managed care plans, and their fiscal agents or
75 intermediaries, must accept prior authorization requests for any
76 service electronically.
77 4. Managed care plans serving children in the care and
78 custody of the Department of Children and Families must maintain
79 complete medical, dental, and behavioral health encounter
80 information and participate in making such information available
81 to the department or the applicable contracted community-based
82 care lead agency for use in providing comprehensive and
83 coordinated case management. The agency and the department shall
84 establish an interagency agreement to provide guidance for the
85 format, confidentiality, recipient, scope, and method of
86 information to be made available and the deadlines for
87 submission of the data. The scope of information available to
88 the department is shall be the data that managed care plans are
89 required to submit to the agency. The agency shall determine the
90 plan’s compliance with standards for access to medical, dental,
91 and behavioral health services; the use of medications; and
92 follow-up followup on all medically necessary services
93 recommended as a result of early and periodic screening,
94 diagnosis, and treatment.
95 Section 2. Paragraph (f) is added to subsection (1) of
96 section 409.975, Florida Statutes, to read:
97 409.975 Managed care plan accountability.—In addition to
98 the requirements of s. 409.967, plans and providers
99 participating in the managed medical assistance program shall
100 comply with the requirements of this section.
101 (1) PROVIDER NETWORKS.—Managed care plans must develop and
102 maintain provider networks that meet the medical needs of their
103 enrollees in accordance with standards established pursuant to
104 s. 409.967(2)(c). Except as provided in this section, managed
105 care plans may limit the providers in their networks based on
106 credentials, quality indicators, and price.
107 (f) If an enrollee is unable to receive care from a
108 participating provider under the managed care plan in a timely
109 manner consistent with a reasonable access standard, as
110 determined by agency rule, or there is another appropriate
111 Medicaid provider in a location more geographically accessible
112 to the enrollee’s residence than those under the plan, an
113 enrollee may receive such care from a Medicaid provider not
114 under contract with the plan. Plans must reimburse a
115 nonparticipating Medicaid provider for services rendered under
116 this paragraph at the applicable Medicaid rate for such services
117 under the plan.
118 Section 3. This act shall take effect July 1, 2025.