New bill revises AHCA Medicaid practices

Gov. Ron DeSantis signed CS/HB 1057 this week, eliminating some of the Agency for Health Care Administration (AHCA) requirements regarding Medicaid. The most notable eliminations include several progress reports. 


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Medicaid, the second largest single program in the state after education, currently serves about 4.5 million low-income Floridians and makes up roughly one third of the FY 2020-2021 state budget. According to the bill analysis, some of the information in some progress reports are already published online, or only apply to a small portion of recipients, and are therefore unnecessary. 

The list of reports eliminated includes:

  • Medicaid Managed Care Transition Report
  • Pharmaceutical Expense Assistance Program Report
  • Medicaid Drug Spending Control Program Report

The quarterly published Medicaid Managed Care Transition Report detailed the AHCA’s progress as it transitioned from traditional Medicaid programming to Medicaid managed care. According to the analysis:

“The bill deletes this reporting requirement, as the transition to Medicaid managed care was completed in 2014. Moreover, the content and frequency of reporting on the Managed Medical Assistance (MMA) waiver are dictated by CMS and have changed periodically, making them out of sync with statutory requirements.”

The Pharmaceutical Expense Assistance Program Report ensured certain individuals with cancer or who received organ transplants received coverage for drugs via Medicare. However, this report only applied to individuals who were also eligible for Medicaid prior to 2006. That number of individuals has declined steadily over the years, with just 14 people still eligible for this type of assistance in 2020. The analysis clarified: 

“The pharmaceutical expense assistance program will continue to serve eligible individuals, but the agency will not be required to provide an annual report to the Legislature.”

The last eliminated report concerns the Medicaid Drug Spending Control Program. The program was created before the transition to the MMA program, and only applies to individuals under the Fee-For-Service (FFS) model. 

The FFS model includes about 20 percent of Medicaid individuals, most of which are dually eligible for Medicaid and Medicare or receive partial benefits due to specific health needs, other insurance, or receiving drugs through nursing homes or other facilities. The analysis concluded:

“This population is very different from the larger MMA population and has very different drug utilization patterns. Thus, it is unclear if drug spending data for the FFS population are reflective of spending trends for the broader Medicaid population.” 

Additional changes to AHCA practices include revising fee-for-service drug reimbursement benchmarks, clarifying response times for authorization requests with prescribed drugs, and giving doctoral-level, certified behavior analysts the ability to make medical necessity determinations. 

The bill will take effect July 1.