HOUSE OF REPRESENTATIVES STAFF ANALYSIS
BILL #: CS/HB 783 Medicaid Managed Care Plan Performance Metrics
SPONSOR(S): Select Committee on Health Innovation, Berfield and others
TIED BILLS: IDEN./SIM. BILLS: SB 794
REFERENCE ACTION ANALYST STAFF DIRECTOR or
BUDGET/POLICY CHIEF
1) Select Committee on Health Innovation 11 Y, 0 N, As CS Lloyd Calamas
2) Health Care Appropriations Subcommittee 15 Y, 0 N Smith Clark
3) Health & Human Services Committee
SUMMARY ANALYSIS
The Medicaid program is a medical assistance program for low-income people and disabled individuals,
funded jointly by the state and federal governments. The Agency for Health Care Administration (AHCA)
administers the Medicaid program, primarily through a managed care model under contracts with managed
care plans. The Statewide Medicaid Managed Care Program (SMMC) operates under a federal waiver to
deliver primary and acute care services as the Managed Medical Assistance (MMA) program, and under a
second federal waiver to deliver comprehensive long-term care services.
Current law requires AHCA to monitor plan performance, including requiring the managed care plans to report
various data related to provider interactions and provider network administration. AHCA imposes detailed
reporting requirements for the plans through their contracts, including data not currently published or analyzed
by AHCA in a systematic manner.
CS/HB 783 establishes detailed requirements for analysis and publication of data on managed care plan
administrative performance related to providers, including data on provider credentialing, prior authorization
processing, claims payment and complaints from providers and recipients. AHCA must contract with a third-
party vendor to analyze the data submitted by the plans and develop an online dashboard on the agency’s
website to publish the data.
AHCA must publish the data on the dashboard quarterly beginning October 1, 2024. AHCA must also produce
an annual report on the data beginning January 1, 2026, and submit the report to the Medical Care Advisory
Committee, the Governor and the Legislature.
The implementation costs of the bill can be absorbed within existing agency resources. See Fiscal Analysis.
The bill has an effective date of July 1, 2024.
This docum ent does not reflect the intent or official position of the bill sponsor or House of Representatives .
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DATE: 2/13/2024
 FULL ANALYSIS
I. SUBSTANTIVE ANALYSIS
A. EFFECT OF PROPOSED CHANGES:
Background
Medicaid
The Medicaid program is a medical assistance program funded jointly between the state and federal
governments. The program provides health care coverage for over 4.8 million low-income families and
individuals, the elderly, and individuals with disabilities in Florida, including 3.4 million recipients who
receive their services through a managed care plan.1 In Florida, two in every five Florida children
receive Medicaid, and 45 percent of all births in the state are covered by the program. 2
The Agency for Health Care Administration (AHCA) administers the Florida Medicaid program
authorized under Title XIX of the federal Social Security Act and Ch. 409, F.S. The AHCA administers
the program through the managed care model,3 under contracts with managed care plans. The
program operates under two separate federal Medicaid waivers: Section 1115 waiver for primary and
acute care services called the Managed Medical Assistance (MMA) program, and Long Term Care
(LTC) services waiver under Sections 1915(b) and (c) of the Social Security Act. 4 Currently, the AHCA
is conducting its third procurement process under these waivers with the selection of new contracts
anticipated at the end of February, 2024.5 The existing SMMC contracts have been effective for almost
seven years and will expire December 31, 2024.
Managed Care Plan Accreditation
Accreditation is a “seal of approval” given to an organization by an independent evaluator, which has
reviewed the practices and performances of the managed care plan. An accreditation rating indicates
that a plan meets or exceeds certain quality criteria based on the level or rating that a plan has earned.
Accreditation status is one of the statutorily-designated quality selection criteria that the AHCA must
consider in the selection of eligible plans during the procurement process. Plans must be accredited by
the National Committee for Quality Assurance6, the Joint Commission7 or another nationally recognized
accrediting body, or have initiated the accreditation process, within one year after the contract is
executed.
Each accrediting organization has its own standards and assesses those standards against the health
plan’s performance and organizational structure to determine if its established standards and
performance standards meet the accrediting body’s requirements. The plan may be reviewed for its
provider credentialing processes, prior authorization procedures, and prompt payments of provider
claims. Accreditation can be awarded for different lengths of time and then must be renewed.
1
Agency for Health Care Administration, Comprehensive Medicaid Managed Care Enrollment Reports (December 31, 2023) available at
https://ahca.myflorida.com/medicaid/medicaid-finance-and-analytics/medicaid-data-analytics/medicaid-monthly-enrollment-report (last visited February
8, 2024).
2
Kaiser Family Foundation, Medicaid in Florida (June 2023), available at https://files.kff.org/attachment/fact-sheet-medicaid-state-FL (last visited
February 8, 2024).
3
The vast majority of Medicaid enrollees receive services through the managed care model; those w ith limited benefits (such as the family planning
program) are not, and some populations (such as enrollees in the home and community-based w aiver for persons with developmental disabilities) may
choose managed care or the fee-for-services model. S. 409.965, F.S.
4
S. 409.964, F.S.
5
See AHCA ITN 23/24 010 for Statew ide Medicaid Managed Care (MMA and LTC) available at MyFloridaMarket Place Vendor Information Portal (last
visited February 8, 2024) and the AHCA ITN for Statew ide Medicaid Prepaid Dental Services available at MyFloridaMarket Place Vendor Information
Portal (last visited February 8, 2024).
6
National Committee on Quality Assurance (NCQA), About NCQA, Health Care Accreditation, Health Plan Accreditation Organization - NCQA - NCQA
(last visited February 8, 2024).
7
The Joint Commission, Who We Are, A Trusted Partner in Patient Care | The Joint Commission (last visited February 8, 2024).
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 Provider Network Credentialing
Medicaid Provider Identification Number
To deliver health care services to a Medicaid recipient and be paid for that service, an individual
provider must be an enrolled provider through AHCA’s provider enrollment system. The credentialing
process ensures that health care workers and organizations have the proper education, training,
qualifications, and licenses to care for patients. The provider enrollment system also reduces improper
payments in Medicaid by minimizing the risk of allowing unscrupulous providers to bill the Medicaid
program, according to AHCA. 8
For providers who only need to enroll for a Medicaid Provider Identification Number for billing under a
Medicaid managed care contract and will only be paid through the plan and not through FFS, AHCA
established a streamlined credentialing process that includes basic credentialing, licensure verification,
review of background screening history, and a check with the federal exclusion database checks. 9 If a
provider contracts with more than one SMMC plan, the basic credentialing by AHCA reduces the time it
takes for a provider to complete each plan’s unique or supplemental credentialing requirements.
The limited provider enrollment option is only for those providers participating with the managed care
plans and is not a sufficient process for a provider who is reimbursed as an individual provider in the
FFS delivery system.10 Providers credentialed through the limited process do not have access to the
necessary web portal tools, including the ability to submit claims, upload or download files, or view
reports.11 A Limited Enrollment Provider can always submit a new application to become an Enrolled
Provider later to have his or her access upgraded to direct billing and other options. 12
Managed Care Plan Network Credentialing
A plan may conduct its own credentialing process or contract with an accreditation credential
verification organization(s) to conduct the process on its behalf. While the managed care plan’s
credentialing process may be conducted concurrently with the Medicaid provider enrollment process,
which could shorten the length of the credentialing period, most of the current plans require a
prospective provider to obtain its Medicaid provider ID prior to submitting its credentialing application to
the managed care plan for credentialing.13
The Medicaid Provider Enrollment Application Guide presents example timeframes for provider
application processing based on stages and if there are no deficiencies with the application. The
following stages and timeframes would likely apply for a new application:14
 In Process: Application is being reviewed for accuracy and compliance with all provider eligibility
requirements (approximately 14 business days).
 Background Screening: Application processing has been completed. Results of the background
screening have not yet been received from the Background Screening Clearinghouse
(approximately 5 business days)
 Clearinghouse Screening: The application has no deficiencies and is awaiting the results of the
background screening (less than 15 calendar days). If screening results are not received within
14 days, the provider receives a deficiency letter.
 State Review: Applications pending verification by AHCA will show a status of “State Review.”
State Review means validating the information on the application, such as certification and
expiration dates, search for any prior history with the applicant and Medicaid or any other state
agencies, and a review of the applicant’s financial history.
8
Supra, note 5.
9
Agency for Health Care Administration. An Overview of Streamlined Credentialing (Limited Enrollment), February 2, 2022, available at
https://portal.flmmis.com/FLPublic/Portals/0/StaticContent/Public/Managed%20Care/Streamlined%20Credentialing%20(Limited%20Enrollment).pdf (last
visited February 8, 2024).
10
Id.
11
Id.
12
Id.
13
Id.
14
Agency for Health Care Administration, Florida Medicaid Provider Enrollment Application Guide (October 2022) available at Florida Medicaid Provider
Enrollment App Guide.pdf (flmmis.com) (last visited February 8, 2024).
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  Enrolled: Enrollment approved. A Welcome letter is mailed within 2 business days after the
activation of the new provider (activated within 5 business days).
The timeframes for activation of a new provider identification number depend on the sufficiency of the
application submitted, and if additional documentation becomes necessary as part of the review
process. Ensuring that an applicant’s name and identification number are clearly marked on items
helps with the matching of supplemental materials and the return of documents after the review.
Prior Authorization
Prior authorization is one method of managing health care utilization and quality. Insurers and
managed care plans may require providers to obtain coverage and reimbursement authorization prior
to providing certain services or prescribing certain drugs. Prior authorization is often used to help
identify under- and over- utilization of services, identify clinical risks such as drug-drug interactions, and
prevent fraud and abuse. In Medicaid managed care, both federal regulations and AHCA plan contracts
establish maximum timelines for plans to resolve both urgent and non-urgent prior authorization
requests.
Prior Authorization Timeline Comparison
Federal Regulations
AHCA Contract
42 CFR 438.210(d)
Standard Request
14 calendar days 7 days
(Non-Urgent)
Standard Request
14 calendar days 4 days
Allow able Extension
Standard Request
28 calendar days 11 days
Maximum Allow ed
Urgent Request 72 hours 2 days
Urgent Request -
14 calendar days 1 day
Allow able Extension
Urgent Request -
17 calendar days 3 days
Maximum Extension
The AHCA reports that when the current SMMC contracts were renewed, a reduced response time for
non-urgent and urgent requests was agreed upon by the parties. The non-urgent prior request
maximum time was modified from the federal limit of 28 calendar days to the contractual standard of 11
days.15 For urgent requests, the current contractual standard is two days with an extension period of
one additional day, which reduces the length of the maximum possible review time from 17 review days
to three days.16
The plans currently report monthly on all service authorization requests completed during the previous
reporting month. Service authorization requests are categorized as standard, extended standard,
expedited, or extended expedited authorizations.17 Plans are specifically prohibited from requiring prior
authorization for emergency services; however, prior authorization for specific Medicaid services or
benefits may be applicable for services with higher utilization or higher costs. In some instances, there
are procedural limitations in state statute if a prior authorization process is applied, including a
requirement that access to the prior authorization system be accessible 24 hours a day, 7 days a week
for approval of hospital inpatient services 18, or that responses to authorization requests be initially
made within 24 hours.19 Other prior authorization directives focus on the entity requesting authorization
and the items necessary for a determination such as clinical and medical records, prior use of a
treatment or prescription, a recipient’s plan of care, and documentation that supports the recipient’s
diagnosis.20
15
Supra, note 5.
16
Supra, note 5.
17
Id.
18
S. 409.905(5), F.S.
19
S. 409.912(5)(1)(a), F.S.
20
See ss. 409.905(4) and(5), 409.906(8), (13), (23), and 24 409.912(5)(a), 409.91195(5) and (9), F.S.
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 Prompt Payment
Federal Medicaid regulations establish standards for the prompt payment of provider claims for
Medicaid beneficiaries.21 The regulation defines a “claim” to mean a bill for services, a line item of
service, or all services for one beneficiary within a bill.” A “clean claim” is considered to be a claim that
can be processed without obtaining additional information from the provider of the service or from a
third party.22
State law also requires the plan to have a claims payment system which ensures the timely payment of
clean claims within state standards under s. 641.3155, F.S. 23 With the receipt of a clean electronic
claim, the plan may either dispute or deny the claim or pay the claim within 20 days after the claim has
been received. If requested, a provider must submit additional information and documentation within 35
days of receipt of the request for additional information. The claim must be paid or denied with 90 days
of receipt. 24
For nonelectronic or paper claims, a plan must pay the provi