Florida Senate - 2025 SB 968
By Senator Davis
5-01187-25 2025968__
1 A bill to be entitled
2 An act relating to Medicaid presumptive eligibility
3 for pregnant women; creating s. 409.9026, F.S.;
4 creating a pilot program to provide temporary Medicaid
5 coverage to pregnant women who are presumptively
6 eligible for Medicaid; defining terms; authorizing the
7 Agency for Health Care Administration to approve
8 certain entities to serve as qualified presumptive
9 eligibility locations under the pilot program;
10 providing application requirements; requiring the
11 agency to prioritize the approval of qualified
12 entities located in underserved areas of this state;
13 specifying duties of qualified entities; requiring
14 qualified entities to provide written notice of their
15 determinations to applicants within a specified
16 timeframe; providing requirements for the notice;
17 specifying performance standards qualified entities
18 are required to meet each year to continue
19 participating in the pilot program; specifying the
20 timeframe of the presumptive eligibility period for
21 temporary Medicaid coverage under the pilot program;
22 requiring the agency to implement certain procedures
23 that allow for the seamless transition from temporary
24 Medicaid coverage under the pilot program to
25 enrollment for full Medicaid benefits; requiring the
26 agency, in collaboration with the Department of
27 Health, to implement an outreach program for specified
28 purposes; requiring the agency, by a specified date,
29 to seek federal approval to implement the pilot
30 program; requiring the agency to implement the pilot
31 program within a specified timeframe after receiving
32 such federal approval; providing an effective date.
33
34 Be It Enacted by the Legislature of the State of Florida:
35
36 Section 1. Section 409.9026, Florida Statutes, is created
37 to read:
38 409.9026 Presumptive eligibility for pregnant women.—To
39 increase access to necessary prenatal care for pregnant women in
40 underserved areas of this state, there is established a 10-year
41 pilot program to expand the availability of Medicaid presumptive
42 eligibility locations and coverage for pregnant women.
43 (1) DEFINITIONS.—As used in this section, the term:
44 (a) “Eligible individual” means a pregnant woman who has
45 not yet been deemed eligible for Medicaid but, based on the
46 preliminary personal information disclosed by the woman, is
47 likely to meet the eligibility requirements of the state
48 Medicaid program, including the requirements related to
49 citizenship and residency status and income.
50 (b) “Presumptive eligibility” means temporary Medicaid
51 coverage provided to individuals who are likely to be eligible
52 for the state Medicaid program, to ensure timely access to care
53 while a final eligibility determination is made.
54 (c) “Qualified entity” means a Medicaid provider or other
55 entity that has been approved by the agency to make presumptive
56 eligibility determinations in accordance with the state Medicaid
57 program requirements.
58 (2) QUALIFIED ENTITIES; DUTIES; NOTICE; PERFORMANCE
59 STANDARDS.—In addition to existing qualified hospitals, the
60 agency may approve community health centers, county health
61 departments, birth centers, nonprofit organizations, and other
62 health care facilities that are Medicaid providers to serve as
63 qualified presumptive eligibility locations under the pilot
64 program. To qualify, the entity must apply to the agency in a
65 manner specified by agency rule. The agency shall prioritize the
66 approval of entities located in underserved areas of this state.
67 (a) Qualified entities shall ensure that:
68 1. Employees making the presumptive eligibility
69 determinations have met the training certification requirements
70 set by the agency;
71 2. Presumptive eligibility determinations are made only by
72 employees, not independent contractors or any other third-party
73 vendor, who have received the required training certification;
74 3. Presumptive eligibility determinations are made in
75 accordance with the state Medicaid program requirements; and
76 4. Staff are available to assist eligible individuals with
77 their submission of applications for full Medicaid benefits.
78 (b) Qualified entities shall provide written notice of
79 their presumptive eligibility determinations to applicants
80 within 10 days after making the determination.
81 1. If an applicant is determined to be presumptively
82 eligible, the notice must include all of the following:
83 a. The date the presumptive eligibility period begins.
84 b. An explanation that an application for full Medicaid
85 benefits must be filed before the presumptive eligibility period
86 ends or there may be a gap in coverage for the individual.
87 c. Notification that the presumptive eligibility period
88 ends 180 days after it begins or when an application for full
89 Medicaid benefits is acted upon by the agency, whichever occurs
90 earlier.
91 2. If the applicant is determined not to be presumptively
92 eligible, the notice must include all of the following:
93 a. The reason the individual was not deemed eligible.
94 b. Notification that the individual still has the option to
95 submit an application for full Medicaid benefits.
96 (c) Qualified entities shall assist eligible individuals
97 with completing and submitting an application for full Medicaid
98 benefits, whether by paper application or through online or
99 phone applications. For paper applications, the qualified entity
100 shall provide the eligible individual with the proper mailing
101 address or fax number to submit the application.
102 (d) Qualified entities are required to meet the following
103 performance standards each year in order to continue
104 participating as a qualified entity under the pilot program:
105 1. An average of 90 percent of individuals the qualified
106 entity determines to be presumptively eligible submitted an
107 application for full Medicaid benefits before the end of the
108 presumptive eligibility period.
109 2. On average, individuals submitted applications for full
110 Medicaid benefits within 10 days of being determined to be
111 presumptively eligible.
112 3. An average of 90 percent of individuals who submitted an
113 application for full Medicaid benefits before the end of the
114 presumptive eligibility period were ultimately deemed eligible
115 for full Medicaid benefits.
116 (3) PRESUMPTIVE ELIGIBILITY PERIOD.—The presumptive
117 eligibility period for temporary Medicaid coverage under the
118 pilot program begins on the date a qualified entity determines
119 an eligible individual to be presumptively eligible and ends 180
120 days later or on the date the eligible individual is deemed
121 eligible for full Medicaid benefits, whichever occurs earlier.
122 (4) STREAMLINING BENEFIT ENROLLMENT.—The agency shall
123 implement procedures that allow pregnant women to transition
124 seamlessly from presumptive eligibility coverage under the pilot
125 program to full Medicaid enrollment without any loss of
126 coverage. The agency shall update all existing technology
127 platforms and applications used for Medicaid enrollment to
128 incorporate pregnant women receiving temporary Medicaid coverage
129 under the pilot program and to allow for their transition to
130 full Medicaid benefits automatically once the agency deems them
131 eligible.
132 (5) COMMUNITY OUTREACH.—The agency, in collaboration with
133 the Department of Health, may implement an outreach program to
134 encourage entities to serve as qualified presumptive eligibility
135 locations under the pilot program; facilitate the required
136 training certification for employees of qualified entities; and
137 partner with community organizations to create public awareness
138 about the pilot program.
139 (6) FEDERAL APPROVAL; IMPLEMENTATION.—By October 1, 2025,
140 the agency shall seek federal approval through a Medicaid waiver
141 or state plan amendment to implement the pilot program. The
142 agency shall implement the program 30 days after receiving
143 federal approval.
144 Section 2. This act shall take effect July 1, 2025.