Florida Senate - 2022 SB 742



By Senator Rodriguez





39-00799A-22 2022742__
1 A bill to be entitled
2 An act relating to pharmacies and pharmacy benefit
3 managers; amending s. 409.967, F.S.; requiring that
4 certain pharmacies be included in managed care plan
5 pharmacy networks; requiring managed care plans to
6 publish the Agency for Health Care Administration’s
7 preferred drug list, rather than any prescribed drug
8 formulary; requiring plans to update the list within a
9 certain timeframe after the agency makes a change;
10 amending s. 409.973, F.S.; providing requirements for
11 managed care plans using pharmacy benefit managers;
12 requiring the agency to seek a plan amendment or
13 federal waiver by a specified date; amending s.
14 409.975, F.S.; conforming a provision to changes made
15 by the act; amending s. 624.3161, F.S.; requiring the
16 Office of Insurance Regulation to examine pharmacy
17 benefit managers under certain circumstances;
18 specifying that certain examination costs are payable
19 by persons examined; amending 624.490, F.S.;
20 authorizing the Office of Insurance Regulation to
21 suspend or revoke a pharmacy benefit manager’s
22 registration or impose a fine for specified
23 violations; defining the terms “spread pricing” and
24 “affiliate”; transferring, renumbering, and amending
25 s. 465.1885, F.S.; revising the entities conducting
26 pharmacy audits to which certain requirements and
27 restrictions apply; authorizing audited pharmacies to
28 appeal certain findings; providing that health
29 insurers and health maintenance organizations that
30 transfer a certain payment obligation to pharmacy
31 benefit managers remain responsible for specified
32 violations; amending s. 627.6131, F.S.; revising the
33 definition of the term “claim” and defining the term
34 “pharmacy claim”; providing an exception to
35 applicability; making technical changes; prohibiting
36 pharmacy benefit managers from charging pharmacists
37 and pharmacies certain fees and from retroactively
38 denying, holding back, or reducing payments for
39 covered claims; requiring that the Department of
40 Financial Services have access to certain records,
41 data, and information; providing applicability;
42 amending ss. 627.64741, 627.6572, and 641.314, F.S.;
43 revising the definition of the term “maximum allowable
44 cost”; requiring that the department have access to
45 certain records, data, and information; providing that
46 pharmacy benefit managers that violate certain
47 provisions are subject to administrative penalties;
48 authorizing the Financial Services Commission to adopt
49 rules; revising applicability; amending s. 627.6699,
50 F.S.; requiring certain health benefit plans covering
51 small employers to comply with specified provisions;
52 amending s. 641.3155, F.S.; revising the definition of
53 the term “claim” and providing a definition for the
54 term “pharmacy claim”; making technical changes;
55 prohibiting pharmacy benefit managers from charging
56 pharmacists and pharmacies certain fees and from
57 retroactively denying, holding back, or reducing
58 payments for covered claims; requiring that the
59 department have access to certain records, data, and
60 information; providing applicability; providing an
61 effective date.
62
63 Be It Enacted by the Legislature of the State of Florida:
64
65 Section 1. Paragraph (c) of subsection (2) of section
66 409.967, Florida Statutes, is amended to read:
67 409.967 Managed care plan accountability.—
68 (2) The agency shall establish such contract requirements
69 as are necessary for the operation of the statewide managed care
70 program. In addition to any other provisions the agency may deem
71 necessary, the contract must require:
72 (c) Access.—
73 1. The agency shall establish specific standards for the
74 number, type, and regional distribution of providers in managed
75 care plan networks to ensure access to care for both adults and
76 children. Each plan must maintain a regionwide network of
77 providers in sufficient numbers to meet the access standards for
78 specific medical services for all recipients enrolled in the
79 plan. Any pharmacy willing to accept reasonable terms and
80 conditions established by the agency shall be included in a
81 managed care plan’s pharmacy network. The exclusive use of mail
82 order pharmacies may not be sufficient to meet network access
83 standards. Consistent with the standards established by the
84 agency, provider networks may include providers located outside
85 the region. A plan may contract with a new hospital facility
86 before the date the hospital becomes operational if the hospital
87 has commenced construction, will be licensed and operational by
88 January 1, 2013, and a final order has issued in any civil or
89 administrative challenge. Each plan shall establish and maintain
90 an accurate and complete electronic database of contracted
91 providers, including information about licensure or
92 registration, locations and hours of operation, specialty
93 credentials and other certifications, specific performance
94 indicators, and such other information as the agency deems
95 necessary. The database must be available online to both the
96 agency and the public and have the capability to compare the
97 availability of providers to network adequacy standards and to
98 accept and display feedback from each provider’s patients. Each
99 plan shall submit quarterly reports to the agency identifying
100 the number of enrollees assigned to each primary care provider.
101 The agency shall conduct, or contract for, systematic and
102 continuous testing of the provider network databases maintained
103 by each plan to confirm accuracy, confirm that behavioral health
104 providers are accepting enrollees, and confirm that enrollees
105 have access to behavioral health services.
106 2. Each managed care plan must publish the agency’s any
107 prescribed drug formulary or preferred drug list on the plan’s
108 website in a manner that is accessible to and searchable by
109 enrollees and providers. The plan must update the list within 24
110 hours after the agency makes making a change. Each plan must
111 ensure that the prior authorization process for prescribed drugs
112 is readily accessible to health care providers, including
113 posting appropriate contact information on its website and
114 providing timely responses to providers. For Medicaid recipients
115 diagnosed with hemophilia who have been prescribed anti
116 hemophilic-factor replacement products, the agency shall provide
117 for those products and hemophilia overlay services through the
118 agency’s hemophilia disease management program.
119 3. Managed care plans, and their fiscal agents or
120 intermediaries, must accept prior authorization requests for any
121 service electronically.
122 4. Managed care plans serving children in the care and
123 custody of the Department of Children and Families must maintain
124 complete medical, dental, and behavioral health encounter
125 information and participate in making such information available
126 to the department or the applicable contracted community-based
127 care lead agency for use in providing comprehensive and
128 coordinated case management. The agency and the department shall
129 establish an interagency agreement to provide guidance for the
130 format, confidentiality, recipient, scope, and method of
131 information to be made available and the deadlines for
132 submission of the data. The scope of information available to
133 the department shall be the data that managed care plans are
134 required to submit to the agency. The agency shall determine the
135 plan’s compliance with standards for access to medical, dental,
136 and behavioral health services; the use of medications; and
137 followup on all medically necessary services recommended as a
138 result of early and periodic screening, diagnosis, and
139 treatment.
140 Section 2. Subsection (7) is added to section 409.973,
141 Florida Statutes, to read:
142 409.973 Benefits.—
143 (7) PRESCRIPTION DRUG BENEFITS.—
144 (a) Each plan operating in the managed medical assistance
145 program using a pharmacy benefit manager shall:
146 1. Ensure the pharmacy benefit manager complies with the
147 requirements of s. 624.490.
148 2. Require the pharmacy benefit manager to reimburse
149 Medicaid pharmacy providers and providers enrolled as dispensing
150 practitioners for drugs dispensed in an amount equal to the
151 National Average Drug Acquisition Cost (NADAC) plus a
152 professional dispensing fee of $10.60. If the NADAC is
153 unavailable, the pharmacy benefit manager must reimburse the
154 providers in an amount equal to the wholesale acquisition cost
155 plus a professional dispensing fee of $10.60.
156 3. Require the pharmacy benefit manager to use preferred
157 drug lists established by the agency.
158 (b) The agency shall seek any state plan amendment or
159 federal waiver necessary to implement this subsection no later
160 than December 31, 2022.
161 Section 3. Subsection (1) of section 409.975, Florida
162 Statutes, is amended to read:
163 409.975 Managed care plan accountability.—In addition to
164 the requirements of s. 409.967, plans and providers
165 participating in the managed medical assistance program shall
166 comply with the requirements of this section.
167 (1) PROVIDER NETWORKS.—Managed care plans must develop and
168 maintain provider networks that meet the medical needs of their
169 enrollees in accordance with standards established pursuant to
170 s. 409.967(2)(c). Except as provided in this section and in s.
171 409.967(2)(c), managed care plans may limit the providers in
172 their networks based on credentials, quality indicators, and
173 price.
174 (a) Plans must include all providers in the region that are
175 classified by the agency as essential Medicaid providers, unless
176 the agency approves, in writing, an alternative arrangement for
177 securing the types of services offered by the essential
178 providers. Providers are essential for serving Medicaid
179 enrollees if they offer services that are not available from any
180 other provider within a reasonable access standard, or if they
181 provided a substantial share of the total units of a particular
182 service used by Medicaid patients within the region during the
183 last 3 years and the combined capacity of other service
184 providers in the region is insufficient to meet the total needs
185 of the Medicaid patients. The agency may not classify physicians
186 and other practitioners as essential providers. The agency, at a
187 minimum, shall determine which providers in the following
188 categories are essential Medicaid providers:
189 1. Federally qualified health centers.
190 2. Statutory teaching hospitals as defined in s.
191 408.07(46).
192 3. Hospitals that are trauma centers as defined in s.
193 395.4001(15).
194 4. Hospitals located at least 25 miles from any other
195 hospital with similar services.
196
197 Managed care plans that have not contracted with all essential
198 providers in the region as of the first date of recipient
199 enrollment, or with whom an essential provider has terminated
200 its contract, must negotiate in good faith with such essential
201 providers for 1 year or until an agreement is reached, whichever
202 is first. Payments for services rendered by a nonparticipating
203 essential provider shall be made at the applicable Medicaid rate
204 as of the first day of the contract between the agency and the
205 plan. A rate schedule for all essential providers shall be
206 attached to the contract between the agency and the plan. After
207 1 year, managed care plans that are unable to contract with
208 essential providers shall notify the agency and propose an
209 alternative arrangement for securing the essential services for
210 Medicaid enrollees. The arrangement must rely on contracts with
211 other participating providers, regardless of whether those
212 providers are located within the same region as the
213 nonparticipating essential service provider. If the alternative
214 arrangement is approved by the agency, payments to
215 nonparticipating essential providers after the date of the
216 agency’s approval shall equal 90 percent of the applicable
217 Medicaid rate. Except for payment for emergency services, if the
218 alternative arrangement is not approved by the agency, payment
219 to nonparticipating essential providers shall equal 110 percent
220 of the applicable Medicaid rate.
221 (b) Certain providers are statewide resources and essential
222 providers for all managed care plans in all regions. All managed
223 care plans must include these essential providers in their
224 networks. Statewide essential providers include:
225 1. Faculty plans of Florida medical schools.
226 2. Regional perinatal intensive care centers as defined in
227 s. 383.16(2).
228 3. Hospitals licensed as specialty children’s hospitals as
229 defined in s. 395.002(28).
230 4. Accredited and integrated systems serving medically
231 complex children which comprise separately licensed, but
232 commonly owned, health care providers delivering at least the
233 following services: medical group home, in-home and outpatient
234 nursing care and therapies, pharmacy services, durable medical
235 equipment, and Prescribed Pediatric Extended Care.
236
237 Managed care plans that have not contracted with all statewide
238 essential providers in all regions as of the first date of
239 recipient enrollment must continue to negotiate in good faith.
240 Payments to physicians on the faculty of nonparticipating
241 Florida medical schools shall be made at the applicable Medicaid
242 rate. Payments for services rendered by regional perinatal
243 intensive care centers shall be made at the applicable Medicaid
244 rate as of the first day of the contract between the agency and
245 the plan. Except for payments for emergency services, payments
246 to nonparticipating specialty children’s hospitals shall equal
247 the highest rate established by contract between that provider
248 and any other Medicaid managed care plan.
249 (c) After 12 months of active participation in a plan’s
250 network, the plan may exclude any essential provider from the
251 network for failure to meet quality or performance criteria. If
252 the plan excludes an essential provider from the plan, the plan
253 must provide written notice to all recipients who have chosen
254 that provider for care. The notice shall be provided at least 30
255 days before the effective date of the exclusion. For purposes of
256 this paragraph, the term “essential provider” includes providers
257 determined by the agency to be essential Medicaid providers
258 under paragraph (a) and the statewide essential providers
259 specified in paragraph (b).
260 (d) The applicable Medicaid rates for emergency services
261 paid by a plan under this section to a provider with which the
262 plan does not have an active contract shall be determined
263 according to s. 409.967(2)(b).
264 (e) Each managed care plan may offer a network contract to
265 each home medical equipment and supplies provider in the region
266 which meets quality and fraud prevention and detection standards
267 established by the plan and which agrees to accept the lowest
268 price previously negotiated between the plan and another such
269 provider.
270 Section 4. Subsections (1) and (3) of section 624.3161,
271 Florida Statutes, are amended to read:
272 624.3161 Market conduct examinations.—
273 (1) As often as it deems necessary, the office shall
274 examine each pharmacy benefit manager as defined in s. 624.490;
275 each licensed rating organization;, each advisory organization;,
276 each group, association, carrier, as defined in s. 440.02, or
277 other organization of insurers which engages in joint
278 underwriting or joint reinsurance;, and each authorized insurer
279 transacting in this state any class of insurance to which the
280 provisions of chapter 627 are applicable. The examination shall
281 be for the purpose of ascertaining compliance by the person
282 examined with the applicabl