SB 1760 — Health Care Coverage

409.967 Managed care plan accountability.— (1) CONTRACT PROCUREMENT PROCESS.—Beginning with the contract procurement process initiated during the 2023 calendar year, the agency shall establish a 6-year contract with each managed care plan selected through the procurement process Page 9 of 3034 CODING:

Florida Senate - 2026 CS for CS for SB 1760 576-03338-26588-02792-26 20261760c220261760c1 year, the agency shall establish a 6-year contract with each managed care plan selected through the procurement process described in s.

The usual and customary provider charges for similar servicesPage in10 theof community34 whereCODING: the services were provided;

3.

The charge mutually agreed to by the entity and the Page 10 of 30 CODING:

Florida Senate - 2026 CS for CS for SB 1760 576-03338-26588-02792-26 20261760c220261760c1 providerservices withinin 60the dayscommunity afterwhere submittalthe ofservices thewere claim;provided;

3.

The charge mutually agreed to by the entity and the provider within 60 days after submittal of the claim;

Each plan shall establish and maintain an accurate and complete electronic database of contracted providers, including information about licensure or registration, locations and hours of operation, specialty credentials and other certifications, specific Page 11 of 3034 CODING:

Florida Senate - 2026 CS for CS for SB 1760 576-03338-26588-02792-26 20261760c220261760c1 licensure or registration, locations and hours of operation, specialty credentials and other certifications, specific performance indicators, and such other information as the agency deems necessary.

Managed care plans, and their fiscal agents or intermediaries, must accept prior authorization requests for any servicePage electronically.12 of 34 CODING:

4.

Managed care plans serving children in the care and Page 12 of 30 CODING:

Florida Senate - 2026 CS for CS for SB 1760 576-03338-26588-02792-26 20261760c220261760c1 custodyservice ofelectronically. the Department of Children and Families must maintain complete medical, dental, and behavioral health encounter information and participate in making such information available to the department or the applicable contracted community-based care lead agency for use in providing comprehensive and coordinated case management.

4.

Managed care plans serving children in the care and custody of the Department of Children and Families must maintain complete medical, dental, and behavioral health encounter information and participate in making such information available to the department or the applicable contracted community-based care lead agency for use in providing comprehensive and coordinated case management.

(e) Encounter data.—The agency shall maintain and operate a Medicaid Encounter Data System to collect, process, store, and report on covered services provided to all Medicaid recipients Page 13 of 3034 CODING:

Florida Senate - 2026 CS for CS for SB 1760 576-03338-26588-02792-26 20261760c220261760c1 Medicaid Encounter Data System to collect, process, store, and report on covered services provided to all Medicaid recipients enrolled in prepaid plans.

The analysis shall be used in managed care plan capitation rate-setting processes provided under this part.Page 14 of 34 CODING:

3.

The agency shall make encounter data available to those Page 14 of 30 CODING:

Florida Senate - 2026 CS for CS for SB 1760 576-03338-26588-02792-26 20261760c220261760c1 planspart. accepting enrollees who are assigned to them from other plans leaving a region.

3.

The agency shall make encounter data available to those plans accepting enrollees who are assigned to them from other plans leaving a region.

Each managed care plan shall establish an internal healthPage care15 qualityof improvement34 system,CODING: including enrollee satisfaction and disenrollment surveys.

The quality improvement Page 15 of 30 CODING:

Florida Senate - 2026 CS for CS for SB 1760 576-03338-26588-02792-26 20261760c220261760c1 systemhealth mustcare includequality incentivesimprovement andsystem, disincentivesincluding forenrollee networksatisfaction providers.and disenrollment surveys.

The quality improvement system must include incentives and disincentives for network providers.

(g) Program integrity.—Each managed care plan shall establish program integrity functions and activities to reduce thePage incidence16 of fraud34 andCODING: abuse, including, at a minimum:

1.

A provider credentialing system and ongoing provider Page 16 of 30 CODING:

Florida Senate - 2026 CS for CS for SB 1760 576-03338-26588-02792-26 20261760c220261760c1 monitoring,the includingincidence maintenance of writtenfraud provider credentialing policies and proceduresabuse, whichincluding, complyat witha federalminimum: and agency guidelines;

1.

A provider credentialing system and ongoing provider monitoring, including maintenance of written provider credentialing policies and procedures which comply with federal and agency guidelines;

In addition to the payment of costs, departing provider services networks must pay a per-enrollee penalty of up to 3 months’ payment and continue to provide services to the enrollee for 90 days or until the enrollee is enrolled in another plan, Page 17 of 3034 CODING:

Florida Senate - 2026 CS for CSSB 1760 588-02792-26 20261760c1 payment and continue to provide services to the enrollee for SB90 1760days 576-03338-26or 20261760c2until the enrollee is enrolled in another plan, whichever occurs first.

(k) Electronic claims.—Managed care plans, and their fiscal agents or intermediaries, shall accept electronic claims in Page 18 of 3034 CODING:

Florida Senate - 2026 CS for CS for SB 1760 576-03338-26588-02792-26 20261760c220261760c1 (k) Electronic claims.—Managed care plans, and their fiscal agents or intermediaries, shall accept electronic claims in compliance with federal standards.

2.Page 19 of 34 CODING:

Any financial incentive payments made to the plan outside of the capitation rate.

Page 19 of 30 CODING:

Florida Senate - 2026 CS for CS for SB 1760 576-03338-26588-02792-26 20261760c220261760c1 3.2.

Any financial incentive payments made to the plan outside of the capitation rate.

3.

If a plan participates in the managed medical assistance program, the long-term care managed care program, or the pilot program for individuals with developmental disabilities, the agency must calculate medical loss ratios for the plan’s participation in each program separately and, if the plan participates in more Page 20 of 3034 CODING:

Florida Senate - 2026 CS for CSSB 1760 588-02792-26 20261760c1 calculate medical loss ratios for SBthe 1760plan’s 576-03338-26participation 20261760c2in each program separately and, if the plan participates in more than one of these programs, for the plan’s overall participation in statewide Medicaid managed care.

(5) AFFILIATED ENTITIES AND RELATED PARTIES.— (a) The agency shall ensure oversight of affiliated entities and related parties paid by managed care plans under this part, including, but not limited to, examining financial Page 21 of 3034 CODING:

Florida Senate - 2026 CS for CS for SB 1760 576-03338-26588-02792-26 20261760c220261760c1 entities and related parties paid by managed care plans under this part, including, but not limited to, examining financial records and self-referral data of any managed care plan providing services within the statewide managed care program which uses affiliated entities and related parties.

3.Page 22 of 34 CODING:

One hundred percent of income above 10 percent of revenue shall be refunded to the state and adjusted for the Page 22 of 30 CODING:

Florida Senate - 2026 CS for CS for SB 1760 576-03338-26588-02792-26 20261760c220261760c1 Federal3. Medical Assistance Percentages.

One hundred percent of income above 10 percent of revenue shall be refunded to the state and adjusted for the Federal Medical Assistance Percentages.

(b) Any affiliation of any kind or nature with any person who has, either directly or indirectly through one or more Page 23 of 3034 CODING:

Florida Senate - 2026 CS for CS for SB 1760 576-03338-26588-02792-26 20261760c220261760c1 (b) Any affiliation of any kind or nature with any person which has, either directly or indirectly through one or more intermediaries, an investment or ownership interest representing 10 percent or more, shares common ownership with, or has an investor or a holder of an ownership interest representing 10 percent or more with any person providing pharmacy services, diagnostics, care coordination, care delivery, health care services, medical equipment, administrative services, or financial services for, to, or on behalf of the managed care plan.

(4) By December 31, 2026, and annually thereafter, the agency shall calculate, analyze, and publicly report on the agency’s website an assessment of affiliated entity payment Page 24 of 3034 CODING:

Florida Senate - 2026 CS for CS for SB 1760 576-03338-26588-02792-26 20261760c220261760c1 agency shall calculate, analyze, and publicly report on the agency’s website an assessment of affiliated entity payment transactions in the Medicaid program for medical benefit and administrative costs as reported for purposes of the achieved savings rebate.

Present paragraphs (b)(b), (c), and (d), and (e) through (x) of subsection (1) of section 626.8825, Florida Statutes, are redesignated as paragraphs (c)(c), (d), and (e), and (g) through (z), respectively, a new paragraphparagraphs (b) isand (f) are added to that subsection, and present paragraph (u) of subsection (1)(1), paragraphs (e) and (g) of subsection (2), and paragraphs (c) and (h) of subsection (3) of that section are amended, to read:

Has an investment or ownership interest in a pharmacy benefitPage manager25 holding a certificate of authority34 issuedCODING: under this part;

2.

Shares common ownership with a pharmacy benefit manager holding a certificate of authority issued under this part;

or Page 25 of 30 CODING:

Florida Senate - 2026 CS for CS for SB 1760 576-03338-26588-02792-26 20261760c220261760c1 3.benefit manager holding a certificate of authority issued under this part;

2.

Shares common ownership with a pharmacy benefit manager holding a certificate of authority issued under this part;

or 3.

(v)(u)(f) “Pharmacy“Covered benefitsprescription plandrug” or program” means aany plandrug or programbiologic thatincluded paysin for,a reimburses,pharmacy coversbenefit themanager’s costformulary of,which oris providespaid accessfor toas discountsa onpharmacy pharmacistbenefit servicesunder providedthe byplan oneat orany moreof pharmaciesthe toplan’s coverednetwork personspharmacies. who reside in, are employed by, or receive pharmacist services from this state.

(w)(u) “Pharmacy benefits plan or program” means a plan or program that pays for, reimburses, covers the cost of, or provides access to discounts on pharmacist services provided by one or more pharmacies to covered persons who reside in, are employed by, or receive pharmacist services from this state.

(2) CONTRACTS BETWEEN A PHARMACY BENEFIT MANAGER AND A PHARMACY BENEFITS PLAN OR PROGRAM.—In addition to any other requirements in the Florida Insurance Code, all contractual arrangements executed, amended, adjusted, or renewed on or after Page 26 of 34 CODING:

Words stricken are deletions;

words underlined are additions.

Florida Senate - 2026 CS for SB 1760 588-02792-26 20261760c1 July 1, 2023, which are applicable to pharmacy benefits covered on or after January 1, 2024, between a pharmacy benefit manager and a pharmacy benefits plan or program must include, in substantial form, terms that ensure compliance with all of the following requirements and that, except to the extent not allowed by law, shall supersede any contractual terms to the contrary:

(e) Include network adequacy requirements that meet or exceed Medicare Part D program standards for convenient access to the network pharmacies set forth in 42 C.F.R.

s.

423.120(a)(1) and that:

1.

Do not limit a network to solely include affiliated pharmacies;

2.

Require a pharmacy benefit manager to offer a provider contract to licensed pharmacies physically located on the physical site of providers that are:

a.

Within the pharmacy benefits plan’s or program’s geographic service area and that have been specifically designated as essential providers by the Agency for Health Care Administration pursuant to s.

409.975(1)(a);

b.

Designated as cancer centers of excellence under s.

381.925, regardless of the pharmacy benefits plan’s or program’s geographic service area;

c.

Organ transplant hospitals, regardless of the pharmacy benefits plan’s or program’s geographic service area;

d.

Hospitals licensed as specialty children’s hospitals as defined in s.

395.002;

or e.

Regional perinatal intensive care centers as defined in s.

383.16(2), regardless of the pharmacy benefits plan’s or Page 27 of 34 CODING:

Words stricken are deletions;

words underlined are additions.

Florida Senate - 2026 CS for SB 1760 588-02792-26 20261760c1 program’s geographic service area.

Such provider contracts must be solely for the administration and or dispensing of covered prescription drugs, including biological products, which are administered through infusions, intravenously injected, or inhaled during a surgical procedure or are covered parenteral drugs, as part of onsite outpatient care;

3.

Do not require a covered person to receive a prescription drug by United States mail, common carrier, local courier, third-party company or delivery service, or pharmacy direct delivery unless the prescription drug cannot be acquired at any retail pharmacy in the pharmacy benefit manager’s network for the covered person’s pharmacy benefits plan or program.

This subparagraph does not prohibit a pharmacy benefit manager from operating mail order or delivery programs on an opt-in basis at the sole discretion of a covered person, provided that the covered person is not penalized through the imposition of any additional retail cost-sharing obligations or a lower allowed- quantity limit for choosing not to select the mail order or delivery programs;

4.

For the in-person administration of covered prescription drugs, prohibit requiring a covered person to receive pharmacist services from an affiliated pharmacy or an affiliated health care provider;

and 5.

Prohibit offering or implementing pharmacy networks that require or provide a promotional item or an incentive, defined as anything other than a reduced cost-sharing amount or enhanced quantity limit allowed under the benefit design for a covered Page 28 of 34 CODING:

Words stricken are deletions;

words underlined are additions.

Florida Senate - 2026 CS for SB 1760 588-02792-26 20261760c1 drug, to a covered person to use an affiliated pharmacy or an affiliated health care provider for the in-person administration of covered prescription drugs;

or advertising, marketing, or promoting an affiliated pharmacy to covered persons.

Subject to the foregoing, a pharmacy benefit manager may include an affiliated pharmacy in communications to covered persons regarding network pharmacies and prices, provided that the pharmacy benefit manager includes information, such as links to all nonaffiliated network pharmacies, in such communications and that the information provided is accurate and of equal prominence.

This subparagraph may not be construed to prohibit a pharmacy benefit manager from entering into an agreement with an affiliated pharmacy to provide pharmacist services to covered persons.

(g) Prohibit a pharmacy benefit manager from instituting a network that requires a pharmacy to meet accreditation standards inconsistent with or more stringent than applicable federal and state requirements for licensure and operation as a pharmacy in this state.

However, a pharmacy benefit manager may specify additional specialty networks that require enhanced standards related to the safety and competency necessary to meet the United States Food and Drug Administration’s limited distribution requirements for dispensing any drug that, on a drug-by-drug basis, requires extraordinary special handling, provider coordination, or clinical care or monitoring when such extraordinary requirements cannot be met by a retail pharmacy.

For purposes of this paragraph, drugs requiring extraordinary special handling are limited to drugs that are subject to a risk evaluation and mitigation strategy approved by the United States Page 29 of 34 CODING:

Words stricken are deletions;

words underlined are additions.

Florida Senate - 2026 CS for SB 1760 588-02792-26 20261760c1 Food and Drug Administration and that:

1.

Require special certification of a health care provider to prescribe, receive, dispense, or administer;

or 2.

Require special handling due to the molecular complexity or cytotoxic properties of the biologic or biosimilar product or drug.

For participation in a specialty network, a pharmacy benefit manager may not require a pharmacy to meet requirements for participation beyond those necessary to demonstrate the pharmacy’s ability to dispense the drug in accordance with the United States Food and Drug Administration’s approved manufacturer labeling.

(c) A prohibition of financial clawbacks, reconciliation Pageoffsets, 26or ofoffsets 30to CODING:adjudicated claims.

A pharmacy benefit manager may not charge, withhold, offset, or recoup any direct or indirect remuneration fees, dispensing fees, brand name or generic effective rate adjustments through reconciliation, or Page 30 of 34 CODING:

Florida Senate - 2026 CS for CS for SB 1760 576-03338-26588-02792-26 20261760c220261760c1 offsets,any other monetary charge, withholding, or offsetsrecoupments as related to adjudicateddiscounts, claims.multiple network reconciliation offsets, adjudication transaction fees, and any other instance when an amount a fee may be recouped from a pharmacy if such action would result in a reduction in the amount paid to the pharmacy or pharmacist.

A pharmacy benefit manager may not charge, withhold, offset, or recoup any direct or indirect remuneration fees, dispensing fees, brand name or generic effective rate adjustments through reconciliation, or any other monetary charge, withholding, or recoupments as related to discounts, multiple network reconciliation offsets, adjudication transaction fees, and any other instance when an amount a fee may be recouped from a pharmacy if such action would result in a reduction in the amount paid to the pharmacy or pharmacist.

The administrative appeal procedure must include a Pagetelephone 27number and e-mail address, or a website, for the purpose of 30submitting CODING:the administrative appeal.

The appeal may be submitted by the pharmacy or an agent of the pharmacy directly to the pharmacy benefit manager or through a pharmacy Page 31 of 34 CODING:

Florida Senate - 2026 CS for CS for SB 1760 576-03338-26588-02792-26 20261760c220261760c1 telephoneservice numberadministration andorganization. e-mail address, or a website, for the purpose of submitting the administrative appeal.

The appeal may be submitted by the pharmacy or an agent of the pharmacy directly to the pharmacy benefit manager or through a pharmacy service administration organization.

If the appeal is denied, the pharmacy benefit manager must provide to the pharmacy or pharmacist the national drug code and the name of the national or regional pharmaceutical wholesalers operating in this state which have the drug currently in stock at a price below the maximum allowable cost Page 2832 of 3034 CODING:

Florida Senate - 2026 CS for CS for SB 1760 576-03338-26588-02792-26 20261760c220261760c1 must provide to the pharmacy or pharmacist the national drug code and the name of the national or regional pharmaceutical wholesalers operating in this state which have the drug currently in stock at a price below the maximum allowable cost pricing information.

May 15 for theeach year′s first quarter;

August 15 for theeach year′s second quarter;

and November 15 for theeach year′s third quarter.

(10) Maintain an ownership interest, investment interest, Pageor 29common ownership with an affiliated manufacturer, or share any investor or holder of 30an CODING:ownership interest with an affiliated manufacturer.

Section 9.

Subsection (1) of section 627.42392, Florida Page 33 of 34 CODING:

Florida Senate - 2026 CS for CS for SB 1760 576-03338-26588-02792-26 20261760c220261760c1 orStatutes, commonis ownershipamended withto anread: affiliated manufacturer, or share any investor or holder of an ownership interest with an affiliated manufacturer.

Section 9.

Subsection (1) of section 627.42392, Florida Statutes, is amended to read:

Page 3034 of 3034 CODING: