Fla. Stat. § 409.973 — Florida Code / Title XXX / Chapter 409 / Part IV / Section 409.973
409.973 Benefits.
Status: in_force

(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) Donor human milk bank services. (f) Early periodic screening diagnosis and treatment services for recipients under age 21. (g) Emergency services. (h) 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. (i) Healthy start services, except as provided in s. 409.975(4). (j) Hearing services. (k) Home health agency services. (l) Hospice services. (m) Hospital inpatient services. (n) Hospital outpatient services. (o) Laboratory and imaging services. (p) Medical supplies, equipment, prostheses, and orthoses. (q) Mental health services. (r) Nursing care. (s) Optical services and supplies. (t) Optometrist services. (u) Physical, occupational, respiratory, and speech therapy services. (v) Physician services, including physician assistant services. (w) Podiatric services. (x) Prescription drugs. (y) Renal dialysis services. (z) Respiratory equipment and supplies. (aa) Rural health clinic services. (bb) Substance abuse treatment services. (cc) 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 tobacco cessation program, a medically directed weight loss program, and a medically approved alcohol recovery program or substance abuse recovery program that must include, but may not be limited to, opioid abuse recovery. 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 initial appointment with the primary care provider. If possible, such enrollee’s initial appointment should be made within 30 days after enrollment in the plan. If an initial appointment is not made within such 30-day period, the plan must continue assisting the enrollee to schedule an initial appointment and must report the delay and the reason for the delay to the agency. The plan shall seek to ensure that such an enrollee has at least one appointment annually with his or her primary care provider. (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. (f) Coordinate with a hospital that contacts the plan under the requirements of s. 395.1055(1)(j) for the purpose of establishing the appropriate delivery of primary care services for the plan’s members who present at the hospital’s emergency department for nonemergent care or emergency care that could potentially have been avoided through the regular provision of primary care. The plan shall coordinate with such member and the member’s primary care provider for such purpose.

(5) PROVISION OF DENTAL SERVICES. — (a) The Legislature may use the findings of the Office of Program Policy Analysis and Government Accountability’s report no. 16-07, December 2016, 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 paragraph (a), 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. Beginning with the contract procurement process initiated during the 2023 calendar year, the contracts must be for 6 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. The agency shall extend until December 31, 2024, the term of existing plan contracts awarded pursuant to the invitation to negotiate published in October 2017.

(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; s. 45, ch. 2020-156; s. 32, ch. 2021-51; s. 3, ch. 2022-40; s. 7, ch. 2022-42; s. 31, ch. 2024-15.