Florida Senate - 2026 SB 152
By Senator Harrell
31-00500-26 2026152__
1 A bill to be entitled
2 An act relating to Medicaid provider networks;
3 amending s. 409.908, F.S.; requiring Medicaid managed
4 care plans and providers to negotiate mutually
5 acceptable rates, methods, and terms of payment for
6 purposes of Medicaid reimbursements; requiring plans
7 to pay dentists at certain rates; amending s. 409.967,
8 F.S.; specifying additional requirements for the
9 provider network contracts under the statewide managed
10 care program; amending ss. 409.9071, 427.0135, and
11 1011.70, F.S.; conforming cross-references; reenacting
12 ss. 409.966(3)(c), 409.975(1), and 409.9855(4)(b),
13 F.S., relating to eligible managed care plans, managed
14 care plan accountability, and the pilot program for
15 individuals with developmental disabilities,
16 respectively, to incorporate the amendment made to s.
17 409.967, F.S., in references thereto; providing an
18 effective date.
19
20 Be It Enacted by the Legislature of the State of Florida:
21
22 Section 1. Present subsections (11) through (26) of section
23 409.908, Florida Statutes, are redesignated as subsections (12)
24 through (27), respectively, and a new subsection (11) is added
25 to that section, to read:
26 409.908 Reimbursement of Medicaid providers.—Subject to
27 specific appropriations, the agency shall reimburse Medicaid
28 providers, in accordance with state and federal law, according
29 to methodologies set forth in the rules of the agency and in
30 policy manuals and handbooks incorporated by reference therein.
31 These methodologies may include fee schedules, reimbursement
32 methods based on cost reporting, negotiated fees, competitive
33 bidding pursuant to s. 287.057, and other mechanisms the agency
34 considers efficient and effective for purchasing services or
35 goods on behalf of recipients. If a provider is reimbursed based
36 on cost reporting and submits a cost report late and that cost
37 report would have been used to set a lower reimbursement rate
38 for a rate semester, then the provider’s rate for that semester
39 shall be retroactively calculated using the new cost report, and
40 full payment at the recalculated rate shall be effected
41 retroactively. Medicare-granted extensions for filing cost
42 reports, if applicable, shall also apply to Medicaid cost
43 reports. Payment for Medicaid compensable services made on
44 behalf of Medicaid-eligible persons is subject to the
45 availability of moneys and any limitations or directions
46 provided for in the General Appropriations Act or chapter 216.
47 Further, nothing in this section shall be construed to prevent
48 or limit the agency from adjusting fees, reimbursement rates,
49 lengths of stay, number of visits, or number of services, or
50 making any other adjustments necessary to comply with the
51 availability of moneys and any limitations or directions
52 provided for in the General Appropriations Act, provided the
53 adjustment is consistent with legislative intent.
54 (11) Managed care plans and providers shall negotiate
55 mutually acceptable rates, methods, and terms of payment. Plans
56 shall pay dentists an amount equal to or higher than the dental
57 payment rates set by the agency.
58 Section 2. Paragraph (c) of subsection (2) of section
59 409.967, Florida Statutes, is amended to read:
60 409.967 Managed care plan accountability.—
61 (2) The agency shall establish such contract requirements
62 as are necessary for the operation of the statewide managed care
63 program. In addition to any other provisions the agency may deem
64 necessary, the contract must require:
65 (c) Access.—
66 1. The agency shall establish specific standards for the
67 number, type, and regional distribution of providers in managed
68 care plan networks to ensure access to care for both adults and
69 children. Each plan must maintain a regionwide network of
70 providers in sufficient numbers to meet the access standards for
71 specific medical services for all recipients enrolled in the
72 plan. The exclusive use of mail-order pharmacies may not be
73 sufficient to meet network access standards. Consistent with the
74 standards established by the agency, provider networks may
75 include providers located outside the region. Each plan shall
76 establish and maintain an accurate and complete electronic
77 database of contracted providers, including information about
78 licensure or registration, locations and hours of operation,
79 specialty credentials and other certifications, specific
80 performance indicators, and such other information as the agency
81 deems necessary. The database must be available online to both
82 the agency and the public and have the capability to compare the
83 availability of providers to network adequacy standards and to
84 accept and display feedback from each provider’s patients. Each
85 plan shall submit quarterly reports to the agency identifying
86 the number of enrollees assigned to each primary care provider.
87 The agency shall conduct, or contract for, systematic and
88 continuous testing of the provider network databases maintained
89 by each plan to confirm accuracy, confirm that behavioral health
90 providers are accepting enrollees, and confirm that enrollees
91 have access to behavioral health services.
92 a. A dentist may appear on the provider network database as
93 an active Medicaid provider only if he or she devotes a minimum
94 average of 20 hours per week of direct patient care at the
95 location where he or she is listed as an active Medicaid
96 provider.
97 b. A secondary provider network may be published on the
98 database for those providers who offer less than the minimum
99 average of 20 hours per week of direct patient care at the
100 location where they are listed as a provider.
101 c. A provider may not be listed on the network provider
102 database if he or she offers less than 4 hours per week of
103 direct patient care to beneficiaries of the Medicaid program at
104 the indicated location.
105 d. Specialty care providers must be listed separately from
106 general dentists on the network provider database and must be
107 listed under the specialty they provide.
108 e. If a group practice or university employs or uses
109 multiple dental providers, each working less than the parameters
110 established in sub-subparagraphs a.-c., that group practice or
111 university must be listed on the network provider database as a
112 single entity provider and may not have each dental provider
113 listed individually.
114 f. Each provider in the network provider database must
115 indicate what services he or she provides and whether the
116 practice is accepting new patients for each of those services.
117 This information must also specify the location at which the
118 services are provided. Endodontists, oral surgeons, and
119 periodontists must specify the age range for each of the
120 services they provide.
121 g. To ensure true adequacy and access of care, dental plans
122 must categorize and report provider availability more
123 specifically, listing which of the following services is
124 provided by each provider, including specialists:
125 (I) Preventive care.
126 (II) Restorative care.
127 (III) Conscious sedation, specifying whether nitrous oxide
128 or oral sedation, or both, are offered.
129 (IV) In-office anesthesia, specifying whether intravenous
130 sedation or general anesthesia, or both, are offered.
131 (V) Access to emergent care, specifying whether the
132 provider has access to an ambulatory surgical center, a general
133 hospital, or a children’s hospital.
134
135 If a provider provides any of the services specified in this
136 sub-subparagraph, the dental plan must disclose whether the
137 provider is experienced in and willing to provide such care to
138 patients with intellectual or developmental disabilities and
139 whether there are any age or other limitations on such services.
140 2. Each managed care plan must publish any prescribed drug
141 formulary or preferred drug list on the plan’s website in a
142 manner that is accessible to and searchable by enrollees and
143 providers. The plan must update the list within 24 hours after
144 making a change. Each plan must ensure that the prior
145 authorization process for prescribed drugs is readily accessible
146 to health care providers, including posting appropriate contact
147 information on its website and providing timely responses to
148 providers. For Medicaid recipients diagnosed with hemophilia who
149 have been prescribed anti-hemophilic-factor replacement
150 products, the agency shall provide for those products and
151 hemophilia overlay services through the agency’s hemophilia
152 disease management program.
153 3. Managed care plans, and their fiscal agents or
154 intermediaries, must accept prior authorization requests for any
155 service electronically.
156 4. Managed care plans serving children in the care and
157 custody of the Department of Children and Families must maintain
158 complete medical, dental, and behavioral health encounter
159 information and participate in making such information available
160 to the department or the applicable contracted community-based
161 care lead agency for use in providing comprehensive and
162 coordinated case management. The agency and the department shall
163 establish an interagency agreement to provide guidance for the
164 format, confidentiality, recipient, scope, and method of
165 information to be made available and the deadlines for
166 submission of the data. The scope of information available to
167 the department shall be the data that managed care plans are
168 required to submit to the agency. The agency shall determine the
169 plan’s compliance with standards for access to medical, dental,
170 and behavioral health services; the use of medications; and
171 follow-up care followup on all medically necessary services
172 recommended as a result of early and periodic screening,
173 diagnosis, and treatment.
174 Section 3. Subsection (1) of section 409.9071, Florida
175 Statutes, is amended to read:
176 409.9071 Medicaid provider agreements for school districts
177 certifying state match.—
178 (1) The agency shall reimburse school-based services as
179 provided in ss. 409.908(22) and 1011.70 ss. 409.908(21) and
180 1011.70 pursuant to the rehabilitative services option provided
181 under 42 U.S.C. s. 1396d(a)(13). For purposes of this section,
182 billing agent consulting services are considered billing agent
183 services, as that term is used in s. 409.913(10), and, as such,
184 payments to such persons may not be based on amounts for which
185 they bill nor based on the amount a provider receives from the
186 Medicaid program. This provision may not restrict privatization
187 of Medicaid school-based services. Subject to any limitations
188 provided for in the General Appropriations Act, the agency, in
189 compliance with appropriate federal authorization, shall develop
190 policies and procedures and shall allow for certification of
191 state and local education funds that have been provided for
192 school-based services as specified in s. 1011.70 and authorized
193 by a physician’s order where required by federal Medicaid law.
194 Section 4. Subsection (3) of section 427.0135, Florida
195 Statutes, is amended to read:
196 427.0135 Purchasing agencies; duties and responsibilities.
197 Each purchasing agency, in carrying out the policies and
198 procedures of the commission, shall:
199 (3) Not procure transportation disadvantaged services
200 without initially negotiating with the commission, as provided
201 in s. 287.057(3)(e)12., or unless otherwise authorized by
202 statute. If the purchasing agency, after consultation with the
203 commission, determines that it cannot reach mutually acceptable
204 contract terms with the commission, the purchasing agency may
205 contract for the same transportation services provided in a more
206 cost-effective manner and of comparable or higher quality and
207 standards. The Medicaid agency shall implement this subsection
208 in a manner consistent with s. 409.908(19) s. 409.908(18) and as
209 otherwise limited or directed by the General Appropriations Act.
210 Section 5. Subsections (1) and (5) of section 1011.70,
211 Florida Statutes, are amended to read:
212 1011.70 Medicaid certified school funding maximization.—
213 (1) Each school district, subject to the provisions of ss.
214 409.9071 and 409.908(22) ss. 409.9071 and 409.908(21) and this
215 section, is authorized to certify funds provided for a category
216 of required Medicaid services termed “school-based services,”
217 which are reimbursable under the federal Medicaid program. Such
218 services shall include, but not be limited to, physical,
219 occupational, and speech therapy services, behavioral health
220 services, mental health services, transportation services, Early
221 Periodic Screening, Diagnosis, and Treatment (EPSDT)
222 administrative outreach for the purpose of determining
223 eligibility for exceptional student education, and any other
224 such services, for the purpose of receiving federal Medicaid
225 financial participation. Certified school funding shall not be
226 available for the following services:
227 (a) Family planning.
228 (b) Immunizations.
229 (c) Prenatal care.
230 (5) Lab schools, as authorized under s. 1002.32, shall be
231 authorized to participate in the Medicaid certified school match
232 program on the same basis as school districts subject to the
233 provisions of subsections (1)-(4) and ss. 409.9071 and
234 409.908(22) ss. 409.9071 and 409.908(21).
235 Section 6. For the purpose of incorporating the amendment
236 made by this act to section 409.967, Florida Statutes, in a
237 reference thereto, paragraph (c) of subsection (3) of section
238 409.966, Florida Statutes, is reenacted to read:
239 409.966 Eligible plans; selection.—
240 (3) QUALITY SELECTION CRITERIA.—
241 (c) After negotiations are conducted, the agency shall
242 select the eligible plans that are determined to be responsive
243 and provide the best value to the state. Preference shall be
244 given to plans that:
245 1. Have signed contracts with primary and specialty
246 physicians in sufficient numbers to meet the specific standards
247 established pursuant to s. 409.967(2)(c).
248 2. Have well-defined programs for recognizing patient
249 centered medical homes and providing for increased compensation
250 for recognized medical homes, as defined by the plan.
251 3. Are organizations that are based in and perform
252 operational functions in this state, in-house or through
253 contractual arrangements, by staff located in this state. Using
254 a tiered approach, the highest number of points shall be awarded
255 to a plan that has all or substantially all of its operational
256 functions performed in the state. The second highest number of
257 points shall be awarded to a plan that has a majority of its
258 operational functions performed in the state. The agency may
259 establish a third tier; however, preference points may not be
260 awarded to plans that perform only community outreach, medical
261 director functions, and state administrative functions in the
262 state. For purposes of this subparagraph, operational functions
263 include corporate headquarters, claims processing, member
264 services, provider relations, utilization and prior
265 authorization, case management, disease and quality functions,
266 and finance and administration. For purposes of this
267 subparagraph, the term “corporate headquarters” means the
268 principal office of the organization, which may not be a
269 subsidiary, directly or indirectly through one or more
270 subsidiaries of, or a joint venture with, any other entity whose
271 principal office is not located in the state.
272 4. Have contracts or other arrangements for cancer disease
273 management programs that have a proven record of clinical
274 efficiencies and cost savings.
275 5. Have contracts or other arrangements for diabetes
276 disease management programs that have a proven record of
277 clinical efficiencies and cost savings.
278 6. Have a claims payment process that ensures that claims
279 that are not contested or denied will be promptly paid pursuant
280 to s. 641.3155.
281 Section 7. For the purpose of incorporating the amendment
282 made by this act to section 409.967, Florida Statutes, in a
283 reference thereto, subsection (1) of section 409.975, Florida
284 Statutes, is reenacted to read:
285 409.975 Managed care plan accountability.—In addition to
286 the requirements of s. 409.967, plans and providers
287 participating in the managed medical assistance program shall
288 comply with the requirements of this section.
289 (1) PROVIDER NETWORKS.—Managed care plans must develop and
290 maintain provider networks that meet the medical needs of their
291 enrollees in accordance with standards established pursuant to
292 s. 409.967(2)(c). Except as provided in this section, managed
293 care plans may limit the providers in their networks based on
294 credentials, quality indicators, and price.
295 (a) Plans must include all providers in the region that are
296 classified by the agency as essential Medicaid providers, unless
297 the agency approves, in writing, an alternative arrangement for
298 securing the types of services offered by the essential
299 providers. Providers are essential for serving Medicaid
300 enrollees if they offer services that are not available from any
301 other provider within a reasonable access standard, or if they
302 provided a substantial share of the total units of a particular
303 service used by Medicaid patients within the region during the
304 last 3 years and the combined capacity of other service
305 providers in the region is insufficient to meet the total needs
306 of the Medicaid patients. The agency may not classify physicians
307 and other practitioners as essential providers. The agency, at a
308 minimum, shall determine which providers in the following
309 categories are essential Medicaid providers:
310 1. Federally qualified health centers.
311 2. Statutory teaching hospitals as defined in s.
312 408.07(46).
313 3. Hospitals that are trauma centers as defined in s.
314 395.4001(15).
315 4. Hospitals located at least 25 miles from any other
316 hospital with similar services.
317
318 Managed care plans that have not contracted with all essential
319 providers in the region as of the first date of recipient
320 enrollment, or with whom an essential provider has terminated
321 its contract, must negotiate in good faith with such essential
322 providers for 1 year or until an agreement is reached, whichever
323 is first. Payments for services rendered by a nonparticipating
324 essential provider shall be made at the applicable Medicaid rate
325 as of the first day of the contract between the agency and the
326 plan. A rate schedule for all essential providers shall be
327 attached to the contract between the agency and the plan. After
328 1 year, managed care plans that are unable to contract with
329 essential providers shall notify the agency and propose an
330 alternative arrangement for securing the essential services for
331 Medicaid enrollees. The arrangement must rely on contracts with
332 other participating providers, regardless of whether those
333 providers are located within the same region as the
334 nonparticipating essential service provider. If the alternative
335 arrangement is approved by the agency, payments to
336 nonparticipating essential providers after the date of the
337 agency’s approval shall equal 90 percent of the applicable
338 Medicaid rate. Except for payment for emergency services, if the
339 alternative arrangement is not approved by the agency, payment
340 to nonparticipating essential providers shall equal 110 percent
341 of the applicable Medicaid rate.
342 (b) Certain providers are statewide resources and essential
343 providers for all managed care plans in all regions. All managed
344 care plans must include these essential providers in their
345 networks. Statewide essential providers include:
346 1. Faculty plans of Florida medical schools.
347 2. Regional perinatal intensive care centers as defined in
348 s. 383.16(2).
349 3. Hospitals licensed as specialty children’s hospitals as
350 defined in s. 395.002(28).
351 4. Accredited and integrated systems serving medically
352 complex children which comprise separately licensed, but
353 commonly owned, health care providers delivering at least the
354 following services: medical group home, in-home and outpatient
355 nursing care and therapies, pharmacy services, durable medical
356 equipment, and Prescribed Pediatric Extended Care.
357 5. Florida cancer hospitals that meet the criteria in 42
358 U.S.C. s. 1395ww(d)(1)(B)(v).
359
360 Managed care plans that have not contracted with all statewide
361 essential providers in all regions as of the first date of
362 recipient enrollment must continue to negotiate in good faith.
363 Payments to physicians on the faculty of nonparticipating
364 Florida medical schools shall be made at the applicable Medicaid
365 rate. Payments for services rendered by regional perinatal
366 intensive care centers shall be made at the applicable Medicaid
367 rate as of the first day of the contract between the agency and
368 the plan. Except for payments for emergency services, payments
369 to nonparticipating specialty children’s hospitals, and payments
370 to nonparticipating Florida cancer hospitals that meet the
371 criteria in 42 U.S.C. s. 1395ww(d)(1)(B)(v), shall equal the
372 highest rate established by contract between that provider and
373 any other Medicaid managed care plan.
374 (c) After 12 months of active participation in a plan’s
375 network, the plan may exclude any essential provider from the
376 network for failure to meet quality or performance criteria. If
377 the plan excludes an essential provider from the plan, the plan
378 must provide written notice to all recipients who have chosen
379 that provider for care. The notice shall be provided at least 30
380 days before the effective date of the exclusion. For purposes of
381 this paragraph, the term “essential provider” includes providers
382 determined by the agency to be essential Medicaid providers
383 under paragraph (a) and the statewide essential providers
384 specified in paragraph (b).
385 (d) The applicable Medicaid rates for emergency services
386 paid by a plan under this section to a provider with which the
387 plan does not have an active contract shall be determined
388 according to s. 409.967(2)(b).
389 (e) Each managed care plan may offer a network contract to
390 each home medical equipment and supplies provider in the region
391 which meets quality and fraud prevention and detection standards
392 established by the plan and which agrees to accept the lowest
393 price previously negotiated between the plan and another such
394 provider.
395 Section 8. For the purpose of incorporating the amendment
396 made by this act to section 409.967, Florida Statutes, in a
397 reference thereto, paragraph (b) of subsection (4) of section
398 409.9855, Florida Statutes, is reenacted to read:
399 409.9855 Pilot program for individuals with developmental
400 disabilities.—
401 (4) ELIGIBLE PLANS; PLAN SELECTION.—
402 (b) The agency shall select, as provided in s. 287.057(1),
403 one plan to participate in the pilot program for each of the two
404 regions. The director of the Agency for Persons with
405 Disabilities or his or her designee must be a member of the
406 negotiating team.
407 1. The invitation to negotiate must specify the criteria
408 and the relative weight assigned to each criterion that will be
409 used for determining the acceptability of submitted responses
410 and guiding the selection of the plans with which the agency and
411 the Agency for Persons with Disabilities negotiate. In addition
412 to any other criteria established by the agency, in consultation
413 with the Agency for Persons with Disabilities, the agency shall
414 consider the following factors in the selection of eligible
415 plans:
416 a. Experience serving similar populations, including the
417 plan’s record in achieving specific quality standards with
418 similar populations.
419 b. Establishment of community partnerships with providers
420 which create opportunities for reinvestment in community-based
421 services.
422 c. Provision of additional benefits, particularly
423 behavioral health services, the coordination of dental care, and
424 other initiatives that improve overall well-being.
425 d. Provision of and capacity to provide mental health
426 therapies and analysis designed to meet the needs of individuals
427 with developmental disabilities.
428 e. Evidence that an eligible plan has written agreements or
429 signed contracts or has made substantial progress in
430 establishing relationships with providers before submitting its
431 response.
432 f. Experience in the provision of person-centered planning
433 as described in 42 C.F.R. s. 441.301(c)(1).
434 g. Experience in robust provider development programs that
435 result in increased availability of Medicaid providers to serve
436 the developmental disabilities community.
437 2. After negotiations are conducted, the agency shall
438 select the eligible plans that are determined to be responsive
439 and provide the best value to the state. Preference must be
440 given to plans that:
441 a. Have signed contracts in sufficient numbers to meet the
442 specific standards established under s. 409.967(2)(c), including
443 contracts for personal supports, skilled nursing, residential
444 habilitation, adult day training, mental health services,
445 respite care, companion services, and supported employment, as
446 those services are defined in the Florida Medicaid Developmental
447 Disabilities Individual Budgeting Waiver Services Coverage and
448 Limitations Handbook as adopted by reference in rule 59G-13.070,
449 Florida Administrative Code.
450 b. Have well-defined programs for recognizing patient
451 centered medical homes and providing increased compensation to
452 recognized medical homes, as defined by the plan.
453 c. Have well-defined programs related to person-centered
454 planning as described in 42 C.F.R. s. 441.301(c)(1).
455 d. Have robust and innovative programs for provider
456 development and collaboration with the Agency for Persons with
457 Disabilities.
458 Section 9. This act shall take effect July 1, 2026.