Florida Senate - 2025 CS for SB 1490
By the Committee on Health Policy; and Senator Harrell
588-03165-25 20251490c1
1 A bill to be entitled
2 An act relating to the Children’s Medical Services
3 program; transferring operation of the Children’s
4 Medical Services Managed Care Plan from the Department
5 of Health to the Agency for Health Care
6 Administration, effective on a specified date;
7 providing construction as to judicial and
8 administrative actions pending as of a specified date
9 and time; requiring the department’s Children’s
10 Medical Services (CMS) program to collaborate with the
11 agency in the care of children and youth with special
12 health care needs; requiring the CMS program to
13 conduct certain clinical eligibility screenings and
14 provide ongoing consultation to the agency for a
15 specified purpose; amending s. 409.974, F.S.;
16 requiring the CMS program to transfer operation of
17 certain managed care contracts from the department to
18 the agency effective on a specified date; requiring
19 the CMS program to conduct clinical eligibility
20 screening for certain children and youth with special
21 health care needs; requiring the program to provide
22 ongoing consultation to the agency for a specified
23 purpose; requiring the agency to establish specific
24 measures for evaluation of services provided to
25 children and youth with special health care needs;
26 requiring the agency to contract with an independent
27 evaluator to conduct the evaluation of services
28 provided; specifying requirements for the evaluation;
29 requiring the agency to submit the results of the
30 evaluation to the Governor and the Legislature by a
31 specified date; amending s. 391.016, F.S.; revising
32 the purposes and functions of the CMS program;
33 amending s. 391.021, F.S.; revising definitions;
34 amending s. 391.025, F.S.; revising the scope of the
35 CMS program; amending s. 391.026, F.S.; revising the
36 powers and duties of the department to conform to
37 changes made by the act; providing for the future
38 repeal of s. 391.026(8) through (11), F.S., relating
39 to the department’s oversight and administration of
40 the CMS program; repealing s. 391.028, F.S., relating
41 to administration of the program; amending s. 391.029,
42 F.S.; revising program eligibility requirements;
43 conforming provisions to changes made by the act;
44 amending s. 391.0315, F.S.; conforming provisions to
45 changes made by the act; providing for future repeal
46 of specified provisions; repealing ss. 391.035,
47 391.037, 391.045, 391.047, 391.055, and 391.071, F.S.,
48 relating to provider qualifications, physicians and
49 private sector services, provider reimbursements,
50 third-party payments, service delivery systems under
51 the program, and quality of care requirements,
52 respectively; amending s. 391.097, F.S.; conforming a
53 provision to changes made by the act; repealing part
54 II of ch. 391, F.S., consisting of ss. 391.221 and
55 391.223, F.S., relating to Children’s Medical Services
56 councils and panels; amending ss. 409.166, 409.811,
57 409.813, 409.8134, 409.814, 409.815, 409.8177,
58 409.818, 409.912, 409.9126, 409.9131, 409.920, and
59 409.962, F.S.; conforming provisions to changes made
60 by the act; requiring the agency to develop a
61 comprehensive plan to redesign the Florida Medicaid
62 Model Waiver for home and community-based services to
63 include children who receive private duty nursing
64 services; providing requirements for the redesign of
65 the waiver plan; requiring the agency to submit a
66 report to the Governor and the Legislature by a
67 specified date; providing requirements for the report;
68 providing effective dates.
69
70 Be It Enacted by the Legislature of the State of Florida:
71
72 Section 1. Transfer of operation of the Children’s Medical
73 Services Managed Care Plan.—
74 (1) Effective July 1, 2025, all statutory powers, duties,
75 functions, records, personnel, pending issues, existing
76 contracts, administrative authority, administrative rules, and
77 unexpended balances of appropriations, allocations, and other
78 funds for the operation of the Department of Health’s Children’s
79 Medical Services Managed Care Plan are transferred to the Agency
80 for Health Care Administration.
81 (2) The transfer of operations of the Children’s Medical
82 Services Managed Care Plan does not affect the validity of any
83 judicial or administrative action pending as of 11:59 p.m. on
84 the day before the effective date of the transfer to which the
85 Department of Health’s Children’s Medical Services Managed Care
86 Plan is at that time a party, and the Agency for Health Care
87 Administration shall be substituted as a party in interest in
88 any such action.
89 (3) The Department of Health’s Children’s Medical Services
90 program shall collaborate with the Agency for Health Care
91 Administration in the care of children and youth with special
92 health care needs. The Department of Health’s Children’s Medical
93 Services program shall do all of the following:
94 (a) Conduct clinical eligibility screening for children and
95 youth with special health care needs who are eligible for or
96 enrolled in Medicaid or the Children’s Health Insurance Program.
97 (b) Provide ongoing consultation to the Agency for Health
98 Care Administration to ensure high-quality, family-centered,
99 coordinated health services within an effective system of care
100 for children and youth with special health care needs.
101 Section 2. Subsection (4) of section 409.974, Florida
102 Statutes, is amended to read:
103 409.974 Eligible plans.—
104 (4) CHILDREN’S MEDICAL SERVICES NETWORK.—
105 (a) The Department of Health’s Children’s Medical Services
106 program shall do all of the following:
107 1. Effective July 1, 2025, transfer to the agency the
108 operation of managed care contracts procured by the department
109 for Medicaid and Children’s Health Insurance Program services
110 provided to children and youth with special health care needs
111 who are enrolled in the Children’s Medical Services Managed Care
112 Plan.
113 2. Conduct clinical eligibility screening for children and
114 youth with special health care needs who are eligible for or are
115 enrolled in Medicaid or the Children’s Health Insurance Program.
116 3. Provide ongoing consultation to the agency to ensure
117 high-quality, family-centered, coordinated health services are
118 provided within an effective system of care for children and
119 youth with special health care needs.
120 (b) The agency shall establish specific measures of access,
121 quality, and costs of providing health care services to children
122 and youth with special health care needs. The agency shall
123 contract with an independent evaluator to conduct an evaluation
124 of services provided. The evaluation must include, but need not
125 be limited to, all of the following:
126 1. A performance comparison of plans contracted to provide
127 services to children and youth with special health care needs as
128 well as plans contracted to serve a broader population of
129 Managed Medical Assistance enrollees. The performance comparison
130 must be based on the measures established by the agency and
131 differentiated based on the age and medical condition or
132 diagnosis of patients receiving services under each plan.
133 2. For each plan, an assessment of cost savings, patient
134 choice, access to services, coordination of care, person
135 centered planning, health and quality-of-life outcomes, patient
136 and provider satisfaction, and provider networks and quality of
137 care.
138
139 The agency shall submit the results of the evaluation to the
140 Governor, the President of the Senate, and the Speaker of the
141 House of Representatives by January 15, 2028 Participation by
142 the Children’s Medical Services Network shall be pursuant to a
143 single, statewide contract with the agency that is not subject
144 to the procurement requirements or regional plan number limits
145 of this section. The Children’s Medical Services Network must
146 meet all other plan requirements for the managed medical
147 assistance program.
148 Section 3. Subsection (1) of section 391.016, Florida
149 Statutes, is amended to read:
150 391.016 Purposes and functions.—The Children’s Medical
151 Services program is established for the following purposes and
152 authorized to perform the following functions:
153 (1) Provide to children and youth with special health care
154 needs a family-centered, comprehensive, and coordinated
155 statewide managed system of care that links community-based
156 health care with multidisciplinary, regional, and tertiary
157 pediatric specialty care. The program shall coordinate and
158 maintain a consistent medical home for participating children.
159 Section 4. Subsections (1), (2), and (4) of section
160 391.021, Florida Statutes, are reordered and amended to read:
161 391.021 Definitions.—When used in this act, the term:
162 (2)(1) “Children’s Medical Services Managed Care Plan
163 network” or “plan network” means a statewide managed care
164 service system that includes health care providers, as defined
165 in this section.
166 (1)(2) “Children and youth with special health care needs”
167 means those children and youth younger than 21 years of age who
168 have chronic and serious physical, developmental, behavioral, or
169 emotional conditions and who require health care and related
170 services of a type or amount beyond that which is generally
171 required by children and youth.
172 (4) “Eligible individual” means a child or youth with a
173 special health care need or a female with a high-risk pregnancy,
174 who meets the financial and medical eligibility standards
175 established in s. 391.029.
176 Section 5. Subsection (1) of section 391.025, Florida
177 Statutes, is amended to read:
178 391.025 Applicability and scope.—
179 (1) The Children’s Medical Services program consists of the
180 following components:
181 (a) The newborn screening program established in s. 383.14
182 and the newborn, infant, and toddler hearing screening program
183 established in s. 383.145.
184 (b) The regional perinatal intensive care centers program
185 established in ss. 383.15-383.19.
186 (c) The developmental evaluation and intervention program,
187 including the Early Steps Program established in ss. 391.301
188 391.308.
189 (d) The Children’s Medical Services Managed Care Plan
190 through the end of June 30, 2025 network.
191 (e) The Children’s Multidisciplinary Assessment Team.
192 (f) The Medical Foster Care Program.
193 (g) The Title V Children and Youth with Special Health Care
194 Needs program.
195 (h) The Safety Net Program.
196 (i) Child Protection Teams and sexual abuse treatment
197 programs established under s. 39.303.
198 (j) The State Child Abuse Death Review Committee and local
199 child abuse death review committees established in s. 383.402.
200 Section 6. Section 391.026, Florida Statutes, is amended to
201 read:
202 391.026 Powers and duties of the department.—The department
203 shall have the following powers, duties, and responsibilities:
204 (1) To provide or contract for the provision of health
205 services to eligible individuals.
206 (2) To provide services to abused and neglected children
207 through Child Protection Teams pursuant to s. 39.303.
208 (3) To determine the medical and financial eligibility of
209 individuals seeking health services from the program.
210 (4) To coordinate a comprehensive delivery system for
211 eligible individuals to take maximum advantage of all available
212 funds.
213 (5) To coordinate with programs relating to children’s
214 medical services in cooperation with other public and private
215 agencies.
216 (6) To initiate and coordinate applications to federal
217 agencies and private organizations for funds, services, or
218 commodities relating to children’s medical programs.
219 (7) To sponsor or promote grants for projects, programs,
220 education, or research in the field of children and youth with
221 special health care needs, with an emphasis on early diagnosis
222 and treatment.
223 (8) To oversee and operate the Children’s Medical Services
224 Managed Care Plan through the end of June 30, 2025 network.
225 (9) To establish reimbursement mechanisms for the
226 Children’s Medical Services network.
227 (10) To establish Children’s Medical Services network
228 standards and credentialing requirements for health care
229 providers and health care services.
230 (11) To serve as a provider and principal case manager for
231 children with special health care needs under Titles XIX and XXI
232 of the Social Security Act.
233 (12) To monitor the provision of health services in the
234 program, including the utilization and quality of health
235 services.
236 (10)(13) To administer the Children and Youth with Special
237 Health Care Needs program in accordance with Title V of the
238 Social Security Act.
239 (14) To establish and operate a grievance resolution
240 process for participants and health care providers.
241 (15) To maintain program integrity in the Children’s
242 Medical Services program.
243 (11)(16) To receive and manage health care premiums,
244 capitation payments, and funds from federal, state, local, and
245 private entities for the program. The department may contract
246 with a third-party administrator for processing claims,
247 monitoring medical expenses, and other related services
248 necessary to the efficient and cost-effective operation of the
249 Children’s Medical Services Managed Care Plan through the end of
250 June 30, 2025 network. The department is authorized to maintain
251 a minimum reserve for the Children’s Medical Services network in
252 an amount that is the greater of:
253 (a) Ten percent of total projected expenditures for Title
254 XIX-funded and Title XXI-funded children; or
255 (b) Two percent of total annualized payments from the
256 Agency for Health Care Administration for Title XIX and Title
257 XXI of the Social Security Act.
258 (12)(17) To provide or contract for peer review and other
259 quality-improvement activities.
260 (13)(18) To adopt rules pursuant to ss. 120.536(1) and
261 120.54 to administer the Children’s Medical Services Act.
262 (14)(19) To serve as the lead agency in administering the
263 Early Steps Program pursuant to part C of the federal
264 Individuals with Disabilities Education Act and part III of this
265 chapter.
266 (15) To administer the Medical Foster Care Program,
267 including all of the following:
268 (a) Recruitment, training, assessment, and monitoring for
269 the Medical Foster Care Program.
270 (b) Monitoring access and facilitating admissions of
271 eligible children and youth to the program and designated
272 medical foster care homes.
273 (c) Coordination with the Department of Children and
274 Families and the Agency for Health Care Administration or their
275 designees.
276 Section 7. Effective July 1, 2025, subsections (8) through
277 (11) of section 391.026, Florida Statutes, as amended by this
278 act, are repealed.
279 Section 8. Effective July 1, 2025, section 391.028, Florida
280 Statutes, is repealed.
281 Section 9. Subsections (2) and (3) of section 391.029,
282 Florida Statutes, are amended to read:
283 391.029 Program eligibility.—
284 (2) The following individuals are eligible to receive
285 services through the program:
286 (a) Related to the regional perinatal intensive care
287 centers, a high-risk pregnant female who is enrolled in
288 Medicaid.
289 (b) Children and youth with serious special health care
290 needs from birth to 21 years of age who are enrolled in
291 Medicaid.
292 (c) Children and youth with serious special health care
293 needs from birth to 19 years of age who are enrolled in a
294 program under Title XXI of the Social Security Act.
295 (3) Subject to the availability of funds, the following
296 individuals may receive services through the Children’s Medical
297 Services Safety Net program:
298 (a) Children and youth with serious special health care
299 needs from birth to 21 years of age who do not qualify for
300 Medicaid or Title XXI of the Social Security Act but who are
301 unable to access, due to lack of providers or lack of financial
302 resources, specialized services that are medically necessary or
303 essential family support services. Families shall participate
304 financially in the cost of care based on a sliding fee scale
305 established by the department.
306 (b) Children and youth with special health care needs from
307 birth to 21 years of age, as provided in Title V of the Social
308 Security Act.
309 (c) An infant who receives an award of compensation under
310 s. 766.31(1). The Florida Birth-Related Neurological Injury
311 Compensation Association shall reimburse the Children’s Medical
312 Services Network the state’s share of funding, which must
313 thereafter be used to obtain matching federal funds under Title
314 XXI of the Social Security Act.
315 Section 10. Section 391.0315, Florida Statutes, is amended
316 to read:
317 391.0315 Benefits.—Benefits provided under the Children’s
318 Medical Services Managed Care Plan program for children with
319 special health care needs shall be equivalent to benefits
320 provided to children as specified in ss. 409.905 and 409.906.
321 The department may offer additional benefits through Children’s
322 Medical Services programs for early intervention services,
323 respite services, genetic testing, genetic and nutritional
324 counseling, and parent support services, if such services are
325 determined to be medically necessary. This section is repealed
326 on January 1, 2026.
327 Section 11. Section 391.035, Florida Statutes, is repealed.
328 Section 12. Effective January 1, 2026, section 391.037,
329 Florida Statutes, is repealed.
330 Section 13. Section 391.045, Florida Statutes, is repealed.
331 Section 14. Effective January 1, 2026, section 391.047,
332 Florida Statutes, is repealed.
333 Section 15. Effective January 1, 2026, section 391.055,
334 Florida Statutes, is repealed.
335 Section 16. Effective January 1, 2026, section 391.071,
336 Florida Statutes, is repealed.
337 Section 17. Section 391.097, Florida Statutes, is amended
338 to read:
339 391.097 Research and evaluation.—
340 (1) The department may initiate, fund, and conduct research
341 and evaluation projects to improve the delivery of children’s
342 medical services. The department may cooperate with public and
343 private agencies engaged in work of a similar nature.
344 (2) The Children’s Medical Services network shall be
345 included in any evaluation conducted in accordance with the
346 provisions of Title XXI of the Social Security Act as enacted by
347 the Legislature.
348 Section 18. Part II of chapter 391, Florida Statutes,
349 consisting of ss. 391.221 and 391.223, Florida Statutes, is
350 repealed, and part III of that chapter is redesignated as part
351 II.
352 Section 19. Effective July 1, 2025, paragraph (b) of
353 subsection (5) of section 409.166, Florida Statutes, is amended
354 to read:
355 409.166 Children within the child welfare system; adoption
356 assistance program.—
357 (5) ELIGIBILITY FOR SERVICES.—
358 (b) A child who is handicapped at the time of adoption is
359 shall be eligible for services through a plan under contract
360 with the agency to serve children and youth with special heath
361 care needs the Children’s Medical Services network established
362 under part I of chapter 391 if the child was eligible for such
363 services before prior to the adoption.
364 Section 20. Effective July 1, 2025, subsection (7) of
365 section 409.811, Florida Statutes, is amended to read:
366 409.811 Definitions relating to Florida Kidcare Act.—As
367 used in ss. 409.810-409.821, the term:
368 (7) “Children’s Medical Services Network” or “network”
369 means a statewide managed care service system as defined in s.
370 391.021(1).
371 Section 21. Effective July 1, 2025, subsection (1) of
372 section 409.813, Florida Statutes, is amended to read:
373 409.813 Health benefits coverage; program components;
374 entitlement and nonentitlement.—
375 (1) The Florida Kidcare program includes health benefits
376 coverage provided to children through the following program
377 components, which shall be marketed as the Florida Kidcare
378 program:
379 (a) Medicaid;
380 (b) Medikids as created in s. 409.8132;
381 (c) The Florida Healthy Kids Corporation as created in s.
382 624.91;
383 (d) Employer-sponsored group health insurance plans
384 approved under ss. 409.810-409.821; and
385 (e) Plans under contract with the agency to serve children
386 and youth with special health care needs The Children’s Medical
387 Services network established in chapter 391.
388 Section 22. Effective July 1, 2025, subsection (3) of
389 section 409.8134, Florida Statutes, is amended to read:
390 409.8134 Program expenditure ceiling; enrollment.—
391 (3) Upon determination by the Social Services Estimating
392 Conference that there are insufficient funds to finance the
393 current enrollment in the Florida Kidcare program within current
394 appropriations, the program shall initiate disenrollment
395 procedures to remove enrollees, except those children enrolled
396 in a plan under contract with the agency to serve children with
397 special health care needs the Children’s Medical Services
398 Network, on a last-in, first-out basis until the expenditure and
399 appropriation levels are balanced.
400 Section 23. Subsection (3) and paragraph (c) of subsection
401 (10) of section 409.814, Florida Statutes, are amended to read:
402 409.814 Eligibility.—A child who has not reached 19 years
403 of age whose family income is equal to or below 300 percent of
404 the federal poverty level is eligible for the Florida Kidcare
405 program as provided in this section. If an enrolled individual
406 is determined to be ineligible for coverage, he or she must be
407 immediately disenrolled from the respective Florida Kidcare
408 program component.
409 (3) A Title XXI-funded child who is eligible for the
410 Florida Kidcare program who is a child with special health care
411 needs, as determined through a medical or behavioral screening
412 instrument, is eligible for health benefits coverage from and
413 shall be assigned to and may opt out of a plan under contract
414 with the agency to serve children with special health care needs
415 the Children’s Medical Services Network.
416 (10) In determining the eligibility of a child, an assets
417 test is not required. If eligibility for the Florida Kidcare
418 program cannot be verified using reliable data sources in
419 accordance with federal requirements, each applicant shall
420 provide documentation during the application process and the
421 redetermination process, including, but not limited to, the
422 following:
423 (c) To enroll in a plan under contract with the agency to
424 service children with special health care needs the Children’s
425 Medical Services Network, a completed application, including a
426 Children’s Medical Services clinical screening.
427 Section 24. Effective July 1, 2025, paragraph (t) of
428 subsection (2) of section 409.815, Florida Statutes, is amended
429 to read:
430 409.815 Health benefits coverage; limitations.—
431 (2) BENCHMARK BENEFITS.—In order for health benefits
432 coverage to qualify for premium assistance payments for an
433 eligible child under ss. 409.810-409.821, the health benefits
434 coverage, except for coverage under Medicaid and Medikids, must
435 include the following minimum benefits, as medically necessary.
436 (t) Enhancements to minimum requirements.—
437 1. This section sets the minimum benefits that must be
438 included in any health benefits coverage, other than Medicaid or
439 Medikids coverage, offered under ss. 409.810-409.821. Health
440 benefits coverage may include additional benefits not included
441 under this subsection, but may not include benefits excluded
442 under paragraph (r).
443 2. Health benefits coverage may extend any limitations
444 beyond the minimum benefits described in this section.
445
446 Except for a plan under contract with the agency to serve
447 children with special health care needs the Children’s Medical
448 Services Network, the agency may not increase the premium
449 assistance payment for either additional benefits provided
450 beyond the minimum benefits described in this section or the
451 imposition of less restrictive service limitations.
452 Section 25. Effective July 1, 2025, paragraph (i) of
453 subsection (1) of section 409.8177, Florida Statutes, is amended
454 to read:
455 409.8177 Program evaluation.—
456 (1) The agency, in consultation with the Department of
457 Health, the Department of Children and Families, and the Florida
458 Healthy Kids Corporation, shall contract for an evaluation of
459 the Florida Kidcare program and shall by January 1 of each year
460 submit to the Governor, the President of the Senate, and the
461 Speaker of the House of Representatives a report of the program.
462 In addition to the items specified under s. 2108 of Title XXI of
463 the Social Security Act, the report shall include an assessment
464 of crowd-out and access to health care, as well as the
465 following:
466 (i) An assessment of the effectiveness of the Florida
467 Kidcare program, including Medicaid, the Florida Healthy Kids
468 program, Medikids, and the plans under contract with the agency
469 to serve children with special health care needs Children’s
470 Medical Services network, and other public and private programs
471 in the state in increasing the availability of affordable
472 quality health insurance and health care for children.
473 Section 26. Effective July 1, 2025, subsection (4) of
474 section 409.818, Florida Statutes, is amended to read:
475 409.818 Administration.—In order to implement ss. 409.810
476 409.821, the following agencies shall have the following duties:
477 (4) The Office of Insurance Regulation shall certify that
478 health benefits coverage plans that seek to provide services
479 under the Florida Kidcare program, except those offered through
480 the Florida Healthy Kids Corporation or the Children’s Medical
481 Services Network, meet, exceed, or are actuarially equivalent to
482 the benchmark benefit plan and that health insurance plans will
483 be offered at an approved rate. In determining actuarial
484 equivalence of benefits coverage, the Office of Insurance
485 Regulation and health insurance plans must comply with the
486 requirements of s. 2103 of Title XXI of the Social Security Act.
487 The department shall adopt rules necessary for certifying health
488 benefits coverage plans.
489 Section 27. Effective July 1, 2025, subsection (11) of
490 section 409.912, Florida Statutes, is amended to read:
491 409.912 Cost-effective purchasing of health care.—The
492 agency shall purchase goods and services for Medicaid recipients
493 in the most cost-effective manner consistent with the delivery
494 of quality medical care. To ensure that medical services are
495 effectively utilized, the agency may, in any case, require a
496 confirmation or second physician’s opinion of the correct
497 diagnosis for purposes of authorizing future services under the
498 Medicaid program. This section does not restrict access to
499 emergency services or poststabilization care services as defined
500 in 42 C.F.R. s. 438.114. Such confirmation or second opinion
501 shall be rendered in a manner approved by the agency. The agency
502 shall maximize the use of prepaid per capita and prepaid
503 aggregate fixed-sum basis services when appropriate and other
504 alternative service delivery and reimbursement methodologies,
505 including competitive bidding pursuant to s. 287.057, designed
506 to facilitate the cost-effective purchase of a case-managed
507 continuum of care. The agency shall also require providers to
508 minimize the exposure of recipients to the need for acute
509 inpatient, custodial, and other institutional care and the
510 inappropriate or unnecessary use of high-cost services. The
511 agency shall contract with a vendor to monitor and evaluate the
512 clinical practice patterns of providers in order to identify
513 trends that are outside the normal practice patterns of a
514 provider’s professional peers or the national guidelines of a
515 provider’s professional association. The vendor must be able to
516 provide information and counseling to a provider whose practice
517 patterns are outside the norms, in consultation with the agency,
518 to improve patient care and reduce inappropriate utilization.
519 The agency may mandate prior authorization, drug therapy
520 management, or disease management participation for certain
521 populations of Medicaid beneficiaries, certain drug classes, or
522 particular drugs to prevent fraud, abuse, overuse, and possible
523 dangerous drug interactions. The Pharmaceutical and Therapeutics
524 Committee shall make recommendations to the agency on drugs for
525 which prior authorization is required. The agency shall inform
526 the Pharmaceutical and Therapeutics Committee of its decisions
527 regarding drugs subject to prior authorization. The agency is
528 authorized to limit the entities it contracts with or enrolls as
529 Medicaid providers by developing a provider network through
530 provider credentialing. The agency may competitively bid single
531 source-provider contracts if procurement of goods or services
532 results in demonstrated cost savings to the state without
533 limiting access to care. The agency may limit its network based
534 on the assessment of beneficiary access to care, provider
535 availability, provider quality standards, time and distance
536 standards for access to care, the cultural competence of the
537 provider network, demographic characteristics of Medicaid
538 beneficiaries, practice and provider-to-beneficiary standards,
539 appointment wait times, beneficiary use of services, provider
540 turnover, provider profiling, provider licensure history,
541 previous program integrity investigations and findings, peer
542 review, provider Medicaid policy and billing compliance records,
543 clinical and medical record audits, and other factors. Providers
544 are not entitled to enrollment in the Medicaid provider network.
545 The agency shall determine instances in which allowing Medicaid
546 beneficiaries to purchase durable medical equipment and other
547 goods is less expensive to the Medicaid program than long-term
548 rental of the equipment or goods. The agency may establish rules
549 to facilitate purchases in lieu of long-term rentals in order to
550 protect against fraud and abuse in the Medicaid program as
551 defined in s. 409.913. The agency may seek federal waivers
552 necessary to administer these policies.
553 (11) The agency shall implement a program of all-inclusive
554 care for children. The program of all-inclusive care for
555 children shall be established to provide in-home hospice-like
556 support services to children diagnosed with a life-threatening
557 illness and enrolled in the Children’s Medical Services network
558 to reduce hospitalizations as appropriate. The agency, in
559 consultation with the Department of Health, may implement the
560 program of all-inclusive care for children after obtaining
561 approval from the Centers for Medicare and Medicaid Services.
562 Section 28. Effective July 1, 2025, subsection (1) of
563 section 409.9126, Florida Statutes, is amended to read:
564 409.9126 Children with special health care needs.—
565 (1) Except as provided in subsection (4), children eligible
566 for the Children’s Medical Services program who receive Medicaid
567 benefits, and other Medicaid-eligible children with special
568 health care needs, are shall be exempt from the provisions of s.
569 409.9122 and shall be served through the Children’s Medical
570 Services network established in chapter 391.
571 Section 29. Effective July 1, 2025, paragraph (a) of
572 subsection (5) of section 409.9131, Florida Statutes, is amended
573 to read:
574 409.9131 Special provisions relating to integrity of the
575 Medicaid program.—
576 (5) DETERMINATIONS OF OVERPAYMENT.—In making a
577 determination of overpayment to a physician, the agency must:
578 (a) Use accepted and valid auditing, accounting,
579 analytical, statistical, or peer-review methods, or combinations
580 thereof. Appropriate statistical methods may include, but are
581 not limited to, sampling and extension to the population,
582 parametric and nonparametric statistics, tests of hypotheses,
583 other generally accepted statistical methods, review of medical
584 records, and a consideration of the physician’s client case mix.
585 Before performing a review of the physician’s Medicaid records,
586 however, the agency shall make every effort to consider the
587 physician’s patient case mix, including, but not limited to,
588 patient age and whether individual patients are clients of the
589 Children’s Medical Services Network established in chapter 391.
590 In meeting its burden of proof in any administrative or court
591 proceeding, the agency may introduce the results of such
592 statistical methods and its other audit findings as evidence of
593 overpayment.
594 Section 30. Effective July 1, 2025, paragraph (e) of
595 subsection (1) of section 409.920, Florida Statutes, is amended
596 to read:
597 409.920 Medicaid provider fraud.—
598 (1) For the purposes of this section, the term:
599 (e) “Managed care plans” means a health insurer authorized
600 under chapter 624, an exclusive provider organization authorized
601 under chapter 627, a health maintenance organization authorized
602 under chapter 641, the Children’s Medical Services Network
603 authorized under chapter 391, a prepaid health plan authorized
604 under this chapter, a provider service network authorized under
605 this chapter, a minority physician network authorized under this
606 chapter, and an emergency department diversion program
607 authorized under this chapter or the General Appropriations Act,
608 providing health care services pursuant to a contract with the
609 Medicaid program.
610 Section 31. Effective July 1, 2025, subsection (7) of
611 section 409.962, Florida Statutes, is amended to read:
612 409.962 Definitions.—As used in this part, except as
613 otherwise specifically provided, the term:
614 (7) “Eligible plan” means a health insurer authorized under
615 chapter 624, an exclusive provider organization authorized under
616 chapter 627, a health maintenance organization authorized under
617 chapter 641, or a provider service network authorized under s.
618 409.912(1) or an accountable care organization authorized under
619 federal law. For purposes of the managed medical assistance
620 program, the term also includes the Children’s Medical Services
621 Network authorized under chapter 391 and entities qualified
622 under 42 C.F.R. part 422 as Medicare Advantage Preferred
623 Provider Organizations, Medicare Advantage Provider-sponsored
624 Organizations, Medicare Advantage Health Maintenance
625 Organizations, Medicare Advantage Coordinated Care Plans, and
626 Medicare Advantage Special Needs Plans, and the Program of All
627 inclusive Care for the Elderly.
628 Section 32. The Agency for Health Care Administration shall
629 develop a comprehensive plan to redesign the Florida Medicaid
630 Model Waiver for home- and community-based services to include
631 children who receive private duty nursing services. The plan
632 must propose an array of tiered services with the goal of
633 ensuring that institutional care is avoided so children can
634 remain in the home or other community setting. The agency shall
635 work with stakeholders in developing the plan, including, but
636 not limited to, families of children who are in the model waiver
637 or receiving private duty nursing, advocates for children,
638 providers of services to children receiving private duty
639 nursing, and Statewide Medicaid Managed Care plans. The agency
640 is authorized to contract with necessary experts to assist in
641 developing the plan. The agency shall submit a report to the
642 Governor, the President of the Senate, and the Speaker of the
643 House of Representatives by September 30, 2025, addressing, at a
644 minimum, all of the following:
645 (1) The purpose, rationale, and expected benefits of the
646 redesigned waiver plan.
647 (2) The proposed eligibility criteria for clients and
648 service benefit packages to be offered through the redesigned
649 waiver plan. Managed care plans participating in the Statewide
650 Medicaid Managed Care program must provide services under the
651 redesigned waiver plan.
652 (3) A proposed implementation plan and timeline, including,
653 but not limited to, recommendations for the number of clients
654 served by the redesigned waiver plan at initial implementation,
655 changes over time, and any per-client benefit caps.
656 (4) The fiscal impact for the implementation year and
657 projections for the next 5 years determined on an actuarially
658 sound basis.
659 (5) An analysis of the availability of services and service
660 providers that would be offered under the redesigned waiver plan
661 and recommendations to increase availability of such services,
662 as applicable.
663 (6) A list of all stakeholders, public and private, who
664 were consulted or contacted during the development of the plan.
665 Section 33. Except as otherwise expressly provided in this
666 act, this act shall take effect upon becoming a law.