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The Florida Senate

2019 Florida Statutes

F.S. 409.973
409.973 Benefits.
(1) MINIMUM BENEFITS.Managed care plans shall cover, at a minimum, the following services:
(a) Advanced practice registered nurse services.
(b) Ambulatory surgical treatment center services.
(c) Birthing center services.
(d) Chiropractic services.
(e) Early periodic screening diagnosis and treatment services for recipients under age 21.
(f) Emergency services.
(g) Family planning services and supplies. Pursuant to 42 C.F.R. s. 438.102, plans may elect to not provide these services due to an objection on moral or religious grounds, and must notify the agency of that election when submitting a reply to an invitation to negotiate.
(h) Healthy start services, except as provided in s. 409.975(4).
(i) Hearing services.
(j) Home health agency services.
(k) Hospice services.
(l) Hospital inpatient services.
(m) Hospital outpatient services.
(n) Laboratory and imaging services.
(o) Medical supplies, equipment, prostheses, and orthoses.
(p) Mental health services.
(q) Nursing care.
(r) Optical services and supplies.
(s) Optometrist services.
(t) Physical, occupational, respiratory, and speech therapy services.
(u) Physician services, including physician assistant services.
(v) Podiatric services.
(w) Prescription drugs.
(x) Renal dialysis services.
(y) Respiratory equipment and supplies.
(z) Rural health clinic services.
(aa) Substance abuse treatment services.
(bb) Transportation to access covered services.
(2) CUSTOMIZED BENEFITS.Managed care plans may customize benefit packages for nonpregnant adults, vary cost-sharing provisions, and provide coverage for additional services. The agency shall evaluate the proposed benefit packages to ensure services are sufficient to meet the needs of the plan’s enrollees and to verify actuarial equivalence.
(3) HEALTHY BEHAVIORS.Each plan operating in the managed medical assistance program shall establish a program to encourage and reward healthy behaviors. At a minimum, each plan must establish a medically approved smoking cessation program, a medically directed weight loss program, and a medically approved alcohol or substance abuse recovery program. Each plan must identify enrollees who smoke, are morbidly obese, or are diagnosed with alcohol or substance abuse in order to establish written agreements to secure the enrollees’ commitment to participation in these programs.
(4) PRIMARY CARE INITIATIVE.Each plan operating in the managed medical assistance program shall establish a program to encourage enrollees to establish a relationship with their primary care provider. Each plan shall:
(a) Provide information to each enrollee on the importance of and procedure for selecting a primary care provider, and thereafter automatically assign to a primary care provider any enrollee who fails to choose a primary care provider.
(b) If the enrollee was not a Medicaid recipient before enrollment in the plan, assist the enrollee in scheduling an appointment with the primary care provider. If possible the appointment should be made within 30 days after enrollment in the plan. For enrollees who become eligible for Medicaid between January 1, 2014, and December 31, 2015, the appointment should be scheduled within 6 months after enrollment in the plan.
(c) Report to the agency the number of enrollees assigned to each primary care provider within the plan’s network.
(d) Report to the agency the number of enrollees who have not had an appointment with their primary care provider within their first year of enrollment.
(e) Report to the agency the number of emergency room visits by enrollees who have not had at least one appointment with their primary care provider.
(a) The Office of Program Policy Analysis and Government Accountability shall provide a comprehensive report on the provision of dental services under this part to the Governor, the President of the Senate, and the Speaker of the House of Representatives by December 1, 2016. The Office of Program Policy Analysis and Government Accountability is authorized to contract with an independent third party to assist in the preparation of the report required by this paragraph.
1. The report must examine the effectiveness of medical managed care plans in increasing patient access to dental care, improving dental health, achieving satisfactory outcomes for Medicaid recipients and the dental provider community, providing outreach to Medicaid recipients, and delivering value and transparency to the state’s taxpayers regarding the dollars intended for, and spent on, actual dental services. Additionally, the report must examine, by plan and in the aggregate, the historical trends of rates paid to dental providers and to dental plan subcontractors, dental provider participation in plan networks, and provider willingness to treat Medicaid recipients. The report must also compare current and historical efforts and trends and the experiences of other states in delivering dental services, increasing patient access to dental care, and improving dental health.
2. The Legislature may use the findings of this report in setting the scope of minimum benefits set forth in this section for future procurements of eligible plans as described in s. 409.966. Specifically, the decision to include dental services as a minimum benefit under this section, or to provide Medicaid recipients with dental benefits separate from the Medicaid managed medical assistance program described in this part, may take into consideration the data and findings of the report.
(b) In the event the Legislature takes no action before July 1, 2017, with respect to the report findings required under subparagraph (a)2., the agency shall implement a statewide Medicaid prepaid dental health program for children and adults with a choice of at least two licensed dental managed care providers who must have substantial experience in providing dental care to Medicaid enrollees and children eligible for medical assistance under Title XXI of the Social Security Act and who meet all agency standards and requirements. To qualify as a provider under the prepaid dental health program, the entity must be licensed as a prepaid limited health service organization under part I of chapter 636 or as a health maintenance organization under part I of chapter 641. The contracts for program providers shall be awarded through a competitive procurement process. The contracts must be for 5 years and may not be renewed; however, the agency may extend the term of a plan contract to cover delays during a transition to a new plan provider. The agency shall include in the contracts a medical loss ratio provision consistent with s. 409.967(4). The agency is authorized to seek any necessary state plan amendment or federal waiver to commence enrollment in the Medicaid prepaid dental health program no later than March 1, 2019.
(6) INTEGRATED BEHAVIORAL HEALTH INITIATIVE.Each plan operating in the managed medical assistance program shall work with the managing entity in its service area to establish specific organizational supports and protocols that enhance the integration and coordination of primary care and behavioral health services for Medicaid recipients. Progress in this initiative shall be measured using the integration framework and core measures developed by the Agency for Healthcare Research and Quality.
History.s. 14, ch. 2011-134; s. 52, ch. 2012-5; s. 8, ch. 2012-44; ss. 1, 2, ch. 2016-109; s. 45, ch. 2016-241; ss. 40, 41, ch. 2018-106.