The Florida Senate

CS/SB 7016—Health Care

by Fiscal Policy Committee and Health Policy Committee

This summary is provided for information only and does not represent the opinion of any Senator, Senate Officer, or Senate Office.

Prepared by: Health Policy Committee (HP)

The bill is the flagship of the 2024 “Live Healthy” initiative. The bill revises preexisting health care programs, creates new programs, revises licensure and regulatory requirements for health care practitioners and facilities, creates new provisions within programs relating to health care practitioner education, amends the state Medicaid program, and appropriates both general revenue and trust fund dollars for the purpose of growing Florida’s health care workforce and increasing access to health care services.

The bill contains numerous provisions, which are summarized below under various generalized subject headings.

The Creation of New Health Care Programs and Revisions to Existing Programs

The DSLR and FRAME Programs

The bill expands the Dental Student Loan Repayment (DSLR) and the Florida Reimbursement Assistance for Medical Education (FRAME) programs, which offer student loan repayment dollars to practitioners who agree to provide services in underserved areas where there are shortages of such personnel, to include dental hygienists (at $7,500 per year for up to five years) and mental health practitioners (at $75,000 total over a four-year period), respectively, and to require all participants in each program to provide 25 volunteer hours annually through specified volunteer or pro bono programs in order to qualify for loan repayment.

Specific to the FRAME program, the bill also increases the four-year award amounts for all practitioners participating in the program as follows:

• $150,000 for allopathic and osteopathic physicians;
• $90,000 for advanced practice registered nurses (APRNs) engaged in autonomous practice;
• $75,000 for non-autonomous APRNs and mental health professionals; and
• $45,000 for licensed practical nurses (LPNs) and registered nurses (RNs).

The bill also specifies that certain practice settings qualify for the FRAME program and that the awards for both the DSLR and FRAME programs are not required to be awarded in consecutive years. The bill requires the Agency for Health Care Administration to seek federal authority to use Title XIX matching funds for the DSLR and FRAME programs and the bill establishes a sunset date for both programs of July 1, 2034.

For both the DSLR and the FRAME programs, the bill establishes new reporting requirements with details that the Department of Health (DOH) must provide to the Governor and the Legislature beginning July 1, 2024. The bill requires the DOH to contract with an independent third party to evaluate the impact of each program and to develop a report which must be presented to the Governor and the Legislature by January 1, 2030. These provisions also sunset on July 1, 2034. 

The Telehealth Minority Maternity Care Pilot Program

The bill revises the Telehealth Minority Maternity Care Pilot Program, which was created in 2021 to increase positive maternal health outcomes in racial and ethnic minority populations in several Florida counties through the use of telehealth, to remove the “pilot” status and expand the program statewide. The bill also clarifies that the program is not required to be run through county health departments, that program providers can provide both telehealth and in-home services, and that the Healthy Start program may refer prospective clients to the program as well as receive referrals from the program. 

Mobile Response Teams

The bill revises definitions and standards for mobile response teams (MRTs), which are behavioral health crisis response mechanisms that can be beneficial to individuals, their families, and any involved first responder when an individual is experiencing a behavioral health crisis.

The bill clarifies that the terms “mobile crisis response service” and “mobile response teams” have the same meaning. The bill also requires that the minimum standards for mobile crisis response services include the standards of MRTs established under ch. 394, part III, F.S., for children, adolescents, and young adults and creates a structure for general MRTs with a focus on crisis diversion and the reduction of involuntary commitment that requires, but is not limited to:

• Triage and rapid crisis intervention within 60 minutes;
• Provision of and referral to evidence-based services that are responsive to the needs of the individual and family;
• Screening, assessment, early identification, care-coordination; and
• Confirmation that the individual who received mobile crisis response was connected to a service provider and prescribed medications, if needed.

The bill also requires the Agency for Health Care Administration (AHCA) to seek federal Medicaid coverage and reimbursement authority for crisis response services. Under the bill, the Department of Children and Families (DCF) must coordinate with the AHCA to educate contracted providers of child, adolescent, and young adult MRT services on the enrollment process as a Medicaid provider, encourage and incentivize enrollment as a Medicaid provider, and reduce barriers to maximize federal reimbursement for community-based mobile crisis response services.

Florida Center for Nursing

The bill removes the sunset date from the Florida Center for Nursing’s duty to submit a report each year to the Governor, the President of the Senate, and the Speaker of the House of Representatives containing its analysis of LPN, RN, and APRN education programs and to assess Florida’s nurse supply, including the numbers of nurses, demographics, education, employment status, and specialization. Under preexisting law, the requirement to submit the annual report would expire after the January 1, 2025 report.

Charitable Care at Free Clinics

The bill amends the “Access to Health Care Act” to increase the maximum income a patient can have in order to be considered low-income, from 200 percent to 300 percent of the federal poverty level. In order for a charitable free clinic to qualify as a health care provider and be eligible for sovereign immunity, the free clinic must serve exclusively low-income patients. This change will increase the number of people a free clinic can serve while still maintaining its eligibility for sovereign immunity under Florida law. 

The Dr. and Mrs. Alfonse and Kathleen Cinotti Health Care Screening and Services Grant Program

The bill requires the Department of Health (DOH) to implement the Dr. and Mrs. Alfonse and Kathleen Cinotti Health Care Screening and Services Grant Program (Cinotti Program). The purpose of the Cinotti Program is to fund the provision of no-cost health care screenings or services for the general public by nonprofit entities. The bill requires the DOH to:

• Publicize the availability of funds and enlist the aid of county health departments for outreach to potential applicants at the local level.
• Establish an application process for submitting a grant proposal and criteria an applicant must meet to be eligible.
• Develop guidelines a grant recipient must follow for expenditure of grant funds and uniform data reporting requirements for the purpose of evaluating the performance of grant recipients. The guidelines must require grant funds to be spent on screenings, including referrals for treatment, if appropriate, or related services for one or more of a specified list of health care conditions.

A nonprofit entity may apply under the bill for Cinotti Program grant funding to implement new health care screening or services programs or to provide the same or similar screenings that it is currently providing in new locations or through a mobile health clinic or mobile unit in order to expand the program’s delivery capabilities. Entities that receive funding under the Cinotti Program are required to:

• Follow DOH guidelines for reporting on expenditure of grant funds and measures to evaluate the effectiveness of the entity’s health care screening or services program; and
• Publicize to the general public and encourage the use of the health care screening and services portal that is also created under the bill. 

Statewide Health Care Screenings and Services Portal

The bill requires the DOH to create and maintain an Internet-based portal to direct the general public to events, organizations, and venues from which health screenings or services may be obtained at no cost or at a reduced cost and for the purpose of directing licensed health care practitioners to opportunities for volunteering their services to conduct, administer, or facilitate such health screenings or services. The DOH may contract with a third-party vendor for the creation or maintenance of the portal.

Health Care Practitioner Licensure and Regulation

Physician Licensure

The bill amends physician licensure statutes relating to the licensure of foreign-trained allopathic physicians or applicants for licensure who have not met all of the requirements normally needed for licensure by examination.

The bill amends s. 458.311(8), F.S., to authorize the Board of Medicine (BOM) to:

• Certify for licensure a person desiring to be licensed as an allopathic physician who has held an active medical faculty certificate under s. 458.3145, F.S., for at least three years and has held a full-time faculty appointment for at least three consecutive years to teach in a program of medicine at a medical school located in Florida; and
• Certify an application for licensure submitted by a graduate of a foreign medical school that has not been excluded from the BOM’s consideration as a medical school that offers education and training comparable to U.S. medical schools, if the graduate has not completed an approved residency, which is normally required for unrestricted licensure, but meets the following criteria:
  • Has an active, unencumbered license to practice medicine in a foreign country;
  • Has actively practiced medicine during the entire four-year period preceding the date of the licensure application submission;
  • Has completed a residency or substantially similar postgraduate medical training in a country recognized by his or her licensing jurisdiction which is substantially similar to a residency program accredited by the Accreditation Council for Graduate Medical Education, as determined by the BOM;
  • Has had his or her medical credentials evaluated by the Educational Commission for Foreign Medical Graduates, holds an active, valid certificate issued by that commission, and has passed the examination used by that commission; and
  • Has an offer for full-time employment as a physician from a health care provider that operates in this state.

The bill requires that a physician licensed under this latter pathway must maintain his or her employment with his or her original employer, or with another health care provider that also operates at a location within the state, for at least two consecutive years. In this context, the term “health care provider” means a health care professional, health care facility, or entity licensed or certified to provide health services in this state as recognized by the BOM. Such licensed physicians must notify the BOM within five business days after any change of employer.

Limited Licenses for Graduate Assistant Physicians

The bill creates limited licenses for both allopathic and osteopathic graduate assistant physicians (GAPs). The BOM and the Board of Osteopathic Medicine (BOOM), respectively, must issue a limited license for a duration of two years to an applicant seeking GAP licensure who meets certain requirements, among which are that the applicant:

• Is a graduate of an allopathic or osteopathic medical school or college, as applicable, approved by an accrediting agency recognized by the U.S. Department of Education;
• Has successfully passed all parts of the USMLE for allopathic physicians or the examination conducted by the National Board of Osteopathic Medical Examiners or other examination approved by the BOOM;
• Has not received a residency match from the National Resident Match Program (NRMP) within the first year following graduation from medical school;
• Has submitted documentation that the applicant has agreed to enter into a written protocol, with specific provisions required by applicable boards rules, drafted by a Florida physician with a full, active, and unencumbered license;
• Has submitted a copy of the protocol to the appropriate board; and
• Has submitted to the DOH a set of fingerprints as specified by the DOH.

The bill authorizes a GAP to apply for a one-time renewal for one additional year of his or her limited license. The bill specifies that a practitioner is only eligible for one GAP licensure period of up to two years, plus the optional one-year renewal.

The bill authorizes a GAP to only provide health care services under the direct supervision of a board-approved Florida physician who has a full, active, and unencumbered license. The supervising physician:

• May supervise no more than two GAPS;
• Must be physically present at the location where the GAP’s services are rendered; and
• Must draft the protocol to specify the duties and GAP’s responsibilities as specified by board rule, and must ensure that:
  • The delegation of any medical task or procedure is within the supervising physician’s scope of practice and appropriate for the GAP’s level of competency;
  • The limited licensed GAP’s prescriptive authority is governed by the physician-drafted protocol and may not exceed that of his or her supervising physician; and
  • Any prescriptions and orders issued by the GAP must identify both the GAP and the supervising physician.

The bill requires the supervising physician to be liable for any acts or omissions of the GAP acting under the physician’s supervision and control; and authorizes third-party payers to reimburse employers of GAPs for covered services rendered by GAPs.

The bill authorizes the BOM and the BOOM to adopt rules to implement the bill’s GAP provisions.

Certification of Foreign Medical Education Institutions

The bill amends s. 458.314(8), F.S., to authorize the BOM, at its own discretion, to exclude any foreign medical school that fails to apply for certification under that section, from being considered as an institution that provides medical education that is reasonably comparable to similar accredited institutions in the U.S.

Medical Faculty Certificates for Allopathic Physicians

The bill amends s. 458.3145, F.S., to revise the criteria for issuing medical faculty certificates for medical doctors to delete the cap on the maximum number of certificates that may be issued at specified Florida medical schools.

APRN and Physician Assistant Licensure

The bill authorizes the BOM and the BOOM to issue temporary certificates to allopathic and osteopathic physician assistants (PAs), who have a current valid license in any U.S. jurisdiction, to practice in areas of critical need, under physician supervision, under the same general criteria as physicians are statutorily authorized to practice in those areas.

The bill also authorizes the Board of Nursing (BON) to issue temporary certificates to APRNs, who have a current valid license in any U.S. jurisdiction and who meet the educational and training requirements established by the BON, to practice in areas of critical need.

The bill provides that an APRN’s temporary certificate to practice in areas of critical need is valid only so long as the State Surgeon General maintains the determination that the critical need that supported the issuance of the temporary certificate remains a critical need.

The bill requires the BON to review each temporary certificate-holder at least annually to ascertain that the certificate-holder is complying with the minimum requirements of the Nurse Practice Act and its adopted rules. If the BON determines that the certificate-holder is not meeting the minimum requirements, the BON must revoke the temporary certificate or impose restrictions or conditions, or both, as a condition of continued practice.

The bill waives all licensure fees for APRNs obtaining a temporary certificate to practice in areas of critical need for the purpose of providing volunteer, uncompensated care for low-income residents. The applicant must submit an affidavit from the employing agency or institution stating that the APRN will not receive any compensation for any health care services that he or she provides. 

Out-of-Hospital Intrapartum Care Provided by Autonomous APRN Midwives

The bill amends s. 464.0123, F.S., to require an autonomous APRN certified nurse midwife, as a condition precedent to providing out-of-hospital intrapartum care, to have a written transfer policy for patients needing a higher acuity of care or emergency services, including an emergency plan-of-care form signed by the patient before admission which contains the following:

• The name and address of the closest hospital that provides maternity and newborn services;
• Reasons for which transfer of care would be necessary, including the transfer-of-care conditions prescribed by BON rule; and
• Ambulances or other emergency medical services that would be used to transport the patient in the event of an emergency.

The bill requires autonomous APRN certified nurse midwives to document the following information on the patients emergency plan-of-care form if a transfer of care is determined to be necessary:

• The name, date of birth, and condition of the patient;
• The gravidity and parity of the patient and the gestational age and condition of the fetus or newborn infant;
• The reasons that necessitated the transfer of care;
• A description of the situation, relevant clinical background, assessment, and recommendations;
• The planned mode of transporting the patient to the receiving facility; and
• The expected time of arrival at the receiving facility.

The bill requires autonomous APRN certified nurse midwives to provide the receiving provider with the patient’s emergency plan-of-care form, and the patient’s prenatal records including patient history, prenatal laboratory results, sonograms, prenatal care flow sheets, maternal fetal medical reports, and labor flow charting and current notations. The bill requires autonomous APRN certified nurse midwives to provide the receiving provider with a verbal summary of the information on the patient’s emergency plan-of-care form, and make himself or herself immediately available for consultation.

The bill eliminates the requirement that an autonomous APRN certified nurse midwife must have a written patient transfer agreement with a hospital and a written referral agreement with a physician to engage in autonomous nurse midwifery. 

Clinical Psychologists

The bill revises the definition of “clinical psychologist” to remove the three years of experience required under preexisting law and authorizes a licensed clinical psychologist of any experience:

• To perform an involuntary examination under the Baker Act;
• If a psychiatrist or clinical psychologist with three years’ experience is unavailable, to provide a second opinion to support a recommendation that a patient receive involuntary inpatient or outpatient services; and
• To determine if the treatment plan for a patient is clinically appropriate.

Psychiatric Nurses

The bill revises the definition of “psychiatric nurse” to reduce the experience requirement from two years to one year and authorizes a psychiatric nurse with one year of experience:

• To prohibit a patient from accessing clinical records if the psychiatric nurse determines such access would be harmful to the patient;
• Determine if the treatment plan for a patient is clinically appropriate;
• Authorize a person who is 14 years of age or older to be admitted to a bed in a room or ward in a mental health unit with an adult if the psychiatric nurse documents that such placement is medically indicated or for safety reasons; and
• Authorize the substitution of medications upon discharge of certain indigent patients if the psychiatric nurse determines such substitution is clinically indicated.

Multistate Practitioner Licensure Compacts

The bill provides that Florida will enter into the Interstate Medical Licensure Compact (for medical doctors and osteopathic physicians), the Audiology and Speech-Language Pathology Interstate Compact, and the Physical Therapy Licensure Compact. 

Health Care Facility Licensure and Regulation

Advanced Birth Centers

The bill creates a new designation for an advanced birth center (ABC) and defines an ABC as a licensed birth center which may perform trial of labor after cesarean deliveries for screened patients who qualify; planned low-risk cesarean deliveries; and anticipated vaginal deliveries for laboring patients from the beginning of the 37th week of gestation through the end of the 41st week of gestation. The bill establishes minimum requirements for ABC designation, including, but not limited to:

• Employing two medical directors to oversee the activities of the center, one of whom must be a board-certified obstetrician and one of whom must be a board-certified anesthesiologist.
• Entering into a written agreement with a blood bank for emergency blood bank services and have written protocols for the management of obstetrical hemorrhage which include provisions for emergency blood transfusions.
• Requiring AHCA rules for ABCs be, at a minimum, equivalent to the rules for ambulatory surgical centers.

The bill directs the AHCA to develop any additional ABC standards it deems necessary for patient safety.

Hospital Licensure and Regulations

The bill establishes several new requirements for hospitals, including requiring a hospital to give priority to students from a medical school located in Florida if the hospital accepts payment from any medical school which is directly, or indirectly, related to allowing students from the medical school to obtain clinical hours or instruction at the hospital.

The bill addresses the issue of persons who tend to utilize hospital emergency departments for nonemergent care or emergency care that could have been avoided with the regular provision of primary care. The bill requires all hospitals with emergency departments to develop and present to the AHCA for approval a nonemergent care access plan (NCAP) for assisting a patient gain access to appropriate care settings when the patient presents at a hospital emergency department with nonemergent health care needs or indicates when receiving a medical screening examination, triage, or treatment at the hospital that he or she lacks regular access to primary care.

Effective July 1, 2025, a hospital’s NCAP must be approved by the AHCA before the hospital may receive initial licensure or licensure renewal occurring after that date. A hospital with an approved NCAP must submit data to the AHCA demonstrating the implementation and results of its NCAP as part of the licensure renewal process and must update the plan as necessary, or as directed by the AHCA, before each licensure renewal.

An NCAP must include one or both of the following:

• A collaborative partnership with one or more nearby federally qualified health centers (FQHCs) or other primary care settings. The goals of such partnership must include, but need not be limited to, identifying patients who have presented at the emergency department for nonemergent care, care that would best be provided in a primary care setting, or emergency care that could potentially have been avoided through the regular provision of primary care, and, if such a patient indicates that he or she lacks regular access to primary care, proactively seeking to establish a relationship between the patient and the FQHC or other primary care setting so that the patient develops a medical home at such setting for nonemergent and preventive health care services.
• The establishment, construction, and operation of a hospital-owned urgent care center co-located within or adjacent to the hospital emergency department location. After the hospital conducts a medical screening examination, and if appropriate for the patient’s needs, the hospital may seek to divert to the urgent care center a patient who presents at the emergency department needing nonemergent health care services. An NCAP with procedures for diverting a patient from the emergency department in this manner must include procedures for assisting such patient in identifying appropriate primary care settings, providing a current list, with contact information, of such settings within 20 miles of the hospital location, and subsequently assisting the patient in arranging for a follow-up examination in a primary care setting, as appropriate for the patient.

For such patients who are enrolled in the Medicaid program and are members of a Medicaid managed care plan, the hospital’s NCAP must include outreach to the patient’s Medicaid managed care plan and coordination with the managed care plan for establishing a relationship between the patient and a primary care setting as appropriate for the patient, which may include an FQHC or other primary care setting with which the hospital has a collaborative partnership. For such a Medicaid enrollee, the AHCA is directed to establish a process for the hospital to share with the plan updated contact information for the patient, if such information is in the hospital’s possession.

The bill provides that its provisions relating to a hospital NCAP may not be construed to preclude a hospital from complying with state or federal law relating to treating and/or stabilizing all patients who present at the emergency department for care.

The bill also requires each hospital that maintains a certified electronic health record technology to make available its admit, transfer, and discharge data to the Florida Health Information Exchange program for the purpose of supporting public health data registries and patient care coordination.

The Medicaid Program

Potentially Preventable Health Care Events Report

The bill requires the AHCA to submit a report to the Governor, the President of the Senate, and the Speaker of the House of Representatives by October 1, 2024, and each October 1 thereafter. The report is to be entitled “Analysis of Potentially Preventable Health Care Events of Florida Medicaid Enrollees” and must include, at a minimum, an analysis of potentially preventable hospital emergency department visits, admissions, and readmissions from the previous state fiscal year, reported by age, eligibility group, managed care plan, and region, detailing conditions contributing to each PPE or category of PPEs. The report must demonstrate trends, and the AHCA may contract with a third-party vendor for its production.

Medicaid Primary Care Initiative for Managed Care Plans

The bill amends the Primary Care Initiative within Statewide Medicaid Managed Care (SMMC) to require that managed care plans contracted under the managed medical assistance (MMA) component of SMMC must assist new enrollees with initial primary care provider appointments until scheduled, report delays and the reasons for delays to the AHCA, and seek to ensure that such an enrollee has at least one primary care appointment annually.

The bill also requires a Medicaid managed care plan to coordinate with a hospital that contacts the plan under the requirements of the hospital’s NCAP 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 bill requires a managed care plan to also coordinate with the enrollee and his or her primary care provider for that purpose. 

Acute Hospital Care at Home Program

The bill requires the AHCA to seek federal approval to implement a Florida Medicaid acute hospital care at home program, consistent with the parameters of federal law that allow such programs for Medicare patients.

Health Care Education Programs and Initiatives

Graduate Medical Education

The bill makes multiple changes to the Statewide Medicaid Residency Program, which funds physician residency slots for hospitals and other health care institutions that qualify for such funding. The bill:

• Allows funding for up to 200 residency slots within the “Slots for Doctors” program to be directed to slots that were already in existence (rather than newly-created slots), under certain conditions;
• Adds a number of reporting requirements for hospitals and qualifying institutions that receive state funds from the SMRP, including financial reporting requirements that take effect July 1, 2025;
• Requires each hospital and qualifying institution to request that a resident who is exiting a residency program complete a residency exit survey and specifies minimum questions that must be asked; and
• Creates the Graduate Medical Education Committee within the AHCA to review SMRP data and create a report, beginning July 1, 2025, to the Governor and the Legislature providing specific details about the SMRP.

Training, Education, and Clinicals in Health (TEACH) Funding Program

The bill:

• Creates the TEACH program to reimburse qualified facilities (FQHCs, community mental health centers, rural health clinics, and certified community behavioral health clinics) for the expenses and loss of revenue they incur for providing clinical training to specified health care students and residents;
• Establishes standards for receiving the funds and an hourly rate of reimbursement based on the type of health care student or resident being trained;
• Sets a maximum award for each facility of $75,000, or $100,000 if the facility operates a residency program;
• Provides reporting requirements for facilities receiving funding from the program and requires the AHCA to contract with an independent third party to study and evaluate the impact of the TEACH program and provide a report to the Governor and the Legislature by January 1, 2030; and
• Provides a sunset for the program of July 1, 2034.

Lab Schools

The bill requires each lab school, which is a public developmental research laboratory school affiliated with a college of education at the state university of closet geographic proximity, to develop programs to accelerate the entry of enrolled students into articulated health care programs at its affiliated university or at any public or private postsecondary institution, with the approval of the university president. The bill also requires a lab school to offer technical assistance to any Florida school district seeking to replicate the lab school’s programs and must annually report, starting December 1, 2025, to the Legislature on the development of such programs and their results.

Linking Industry to Nursing Education (LINE)

The bill amends the LINE Fund in s. 1009.8962, F.S., in order to include independent schools, colleges, or universities with an accredited nursing program that is located in Florida and is licensed by the Commission for Independent Education. Additionally, the bill increases the passage rate for the Nursing License Examination, from 70 percent to 75 percent, that is required for LPN, associate of science in nursing, and bachelor of science in nursing programs to participate in the LINE Fund.

Appropriations

For Fiscal Year 2024?2025, the bill appropriates $327.4 million in recurring general revenue, $3 million in nonrecurring general revenue, and $386.7 million from trust funds to provide funding for the various programs and initiatives contained in the bill, including:

• $245.8 million for Medicaid provider rate increases, prioritizing services for individuals with disabilities, maternal care, and dental care;
• $10 million for the Dr. and Mrs. Alfonse and Kathleen Cinotti Health Care Screening and Services Grant Program;
• $11.5 million for mobile response teams;
• $23.4 million for the Telehealth Minority Maternity Care Program;
• $30 million for the FRAME program;
• $8 million for the DSLR program;
• $25 million for the TEACH program;
• $2 million for lab schools;
• $5 million for LINE Fund expansion;
• $50 million for the “Slots for Doctors” within the SMRP, thereby funding 500 new physician residency slots;
• $5.5 million to the AHCA and $4.9 million to the DOH for workload needed to implement their respective portions of the bill.

If approved by the Governor, or allowed to become law without the Governor’s signature, the bill takes effect upon becoming law, except as otherwise provided.

Vote: Senate 39-0; House 117-1