Bill > H1453

Introduced Session

An act relating to the state Medicaid program; amending s. 409.904, F.S.; authorizing the Agency for Health Care Administration to conduct retrospective reviews and audits of certain claims under the state Medicaid program for a specified purpose; creating s. 409.9041, F.S.; providing legislative findings; requiring the agency, in coordination with the Department of Children and Families, to implement mandatory work and community engagement requirements for able-bodied adults as a condition of obtaining and maintaining Medicaid coverage; requiring the agency to seek federal approval to implement such requirements for certain populations; specifying populations that are subject to such work and community engagement requirements; providing exceptions; defining the term "family caregiver"; specifying the types of activities which may satisfy the work and community engagement requirements; providing that a certain population is required to engage in work or community engagement activities only during standard school hours; requiring persons eligible for Medicaid to demonstrate compliance with the work and community engagement requirements at specified times as a condition of maintaining Medicaid coverage; requiring the agency to develop a process for ensuring compliance with the work and community engagement requirements; requiring that such process align, to the extent possible, with certain existing processes; requiring the department to verify compliance with the work and community engagement requirements at specified intervals; requiring the agency, in coordination with the department, to conduct outreach regarding implementation of the work and community engagement requirements; specifying requirements for such outreach; specifying procedures in the event of noncompliance; requiring the agency, in coordination with the department, to notify a Medicaid recipient of a finding of noncompliance and the impact to eligibility for continued receipt of services; specifying requirements for such notice; amending s. 409.905, F.S.; requiring the agency to maintain cost- effective purchasing practices in its coverage of hospital inpatient services rendered to Medicaid recipients; amending 409.906, F.S.; requiring the agency to seek federal approval to implement a program for expanded coverage of home- and community-based behavioral health services for a specified population; specifying the goal of the program; requiring the agency to work in coordination with the department to develop and implement the program upon federal approval; amending s. 409.91195, F.S.; revising the purpose of the Medicaid Pharmaceutical and Therapeutics Committee to include creation of a Medicaid preferred physician-administered drug list, a Medicaid preferred product list, and a high-cost drug list; requiring the agency to adopt such lists upon recommendation of the committee; specifying the frequency with which the committee must review such lists for any recommended additions or deletions; specifying parameters for such recommended additions and deletions; providing that reimbursement for drugs not included on such lists is subject to prior authorization, with an exception; requiring the agency to publish and disseminate such lists to all Medicaid providers in the state by posting on the agency's website or in other media; providing requirements for public testimony related to proposed inclusions on or exclusions from certain lists; requiring the committee to consider certain factors when developing such recommended additions and deletions; amending s. 409.912, F.S.; revising the components of the Medicaid prescribed-drug spending-control program to include the preferred physician-administered drug list, the preferred product list, and the high-cost drug list; providing requirements for such lists; providing that the agency does not need to follow rulemaking procedures of ch. 120, F.S., when posting updates to such lists; establishing an alternative reimbursement methodology for long-acting injectables administered in a hospital facility setting for severe mental illness; requiring the agency to contract with a vendor to perform a fiscal impact study of the federal 340B Drug Pricing Program; providing requirements for the study; requiring specified entities to submit certain data to the agency for purposes of the study; providing that noncompliance with such requirement may result in sanctions from the agency or the Board of Pharmacy, as applicable; requiring the agency to submit the results of the study to the Governor and the Legislature by a specified date; providing construction; amending s. 409.9122, F.S.; revising requirements for managed care plan encounter data submission and analysis under the Medicaid Encounter Data System; amending s. 409.913, F.S.; revising the definition of the term "overpayment"; providing that determinations of an overpayment under the Medicaid program may be based upon retrospective reviews, investigations, analyses, or audits conducted by the agency to determine possible fraud, abuse, overpayment, or recipient neglect; providing that certain notices may be provided using other common carriers, as well as through the United States Postal Service; amending s. 409.962, F.S.; defining the term "affiliate"; amending s. 409.967, F.S.; requiring that managed care plan contracts require any third-party administrative entity contracted with the plan to adhere to specified requirements; specifying additional types of payments which may not be included in calculating income for purposes of the achieved savings rebate; requiring the agency to ensure oversight of affiliated entities and related parties within the Statewide Medicaid Managed Care program; requiring the agency to examine specified records and data related to such entities and parties; requiring the agency to consider certain data and findings when determining its final medical loss ratio and during the rate setting process under the program; creating s. 409.9675, F.S.; defining the term "control"; requiring managed care plans to report to the agency and the Office of Insurance Regulation the existence of and details relating to certain affiliations by a specified date and annually thereafter; requiring managed care plans to report any change in such information to the agency and the office in writing within a specified timeframe; requiring the agency to calculate, analyze, and publicly report on the agency's website an assessment of affiliated entity payment transactions in the Medicaid program and certain administrative costs by a specified date and annually thereafter; providing requirements for the assessment; amending s. 409.973, F.S.; requiring the agency to implement an Integrated Managed Care Pilot Program in designated regions by a specified date; requiring the agency to submit a request for federal approval for the program by a specified date; requiring the agency to implement the program in specified regions by a specified date, contingent on federal approval; providing requirements for implementing the program, including requirements for plan contracts, service delivery, and provider credentialing; providing for the termination of plan contracts under certain circumstances; requiring the agency to establish measures for evaluating the program; requiring the agency to contract with an independent evaluator to conduct the evaluations; specifying requirements for the evaluations; requiring the agency to submit a report on the performance of the pilot program to the Governor and the Legislature beginning on a specified date and annually thereafter; amending ss. 409.91196 and 627.42392, F.S.; conforming cross-references; providing an effective date.

AI Summary

Committee Categories

John Snyder (R)*, 

Now in Health Care Facilities & Systems Subcommittee (on 01/15/2026)

Official Document