Bill Text: FL S1166 | 2025 | Regular Session | Introduced
Bill Title: Services for Medically Needy Children
Spectrum: Partisan Bill (Republican 1-0)
Status: (Introduced) 2025-02-25 - Withdrawn prior to introduction [S1166 Detail]
Download: Florida-2025-S1166-Introduced.html
Florida Senate - 2025 SB 1166
By Senator Harrell
31-00872B-25 20251166__
1 A bill to be entitled
2 An act relating to services for medically needy
3 children; 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. 409.906, F.S.;
16 requiring the agency to pay for individual and family
17 therapy services provided to Medicaid recipients by
18 certain behavioral health providers if certain
19 conditions are met; conforming a cross-reference;
20 requiring the agency to seek federal approval to amend
21 the state’s Medicaid Model Waiver for home and
22 community-based services to include certain services;
23 requiring the agency to implement the approved waiver
24 amendment subject to certain conditions; authorizing
25 the agency to adopt rules; amending s. 409.974, F.S.;
26 requiring the CMS program to transfer operation of
27 certain managed care contracts from the department to
28 the agency effective on a specified date; requiring
29 the CMS program to conduct clinical eligibility
30 screening for certain children and youth with special
31 health care needs; requiring the program to provide
32 ongoing consultation to the agency for a specified
33 purpose; requiring the agency to establish specific
34 measures for evaluation of services provided to
35 children and youth with special health care needs;
36 requiring the agency to contract with an independent
37 evaluator to conduct the evaluation of services
38 provided; specifying requirements for the evaluation;
39 requiring the agency to submit the results of the
40 evaluation to the Governor and the Legislature by a
41 specified date; amending s. 391.016, F.S.; revising
42 the purposes and functions of the CMS program;
43 amending s. 391.021, F.S.; revising definitions;
44 amending s. 391.025, F.S.; revising the scope of the
45 CMS program; amending s. 391.026, F.S.; revising the
46 powers and duties of the department to conform to
47 changes made by the act; providing for the future
48 repeal of s. 391.026(8)-(11), F.S., relating to the
49 department’s oversight and administration of the CMS
50 program; repealing s. 391.028, F.S., relating to
51 administration of the program; amending s. 391.029,
52 F.S.; revising program eligibility requirements;
53 conforming provisions to changes made by the act;
54 amending s. 391.0315, F.S.; conforming provisions to
55 changes made by the act; providing for future repeal
56 of specified provisions; repealing ss. 391.035,
57 391.037, 391.045, 391.047, 391.055, and 391.071, F.S.,
58 relating to provider qualifications, physicians and
59 private sector services, provider reimbursements,
60 third-party payments, service delivery systems under
61 the program, and quality of care requirements,
62 respectively; amending s. 391.097, F.S.; conforming a
63 provision to changes made by the act; repealing part
64 II of ch. 391, F.S., consisting of ss. 391.221 and
65 391.223, F.S., relating to Children’s Medical Services
66 councils and panels; amending ss. 409.166, 409.811,
67 409.813, 409.8134, 409.814, 409.815, 409.8177,
68 409.818, 409.912, 409.9126, 409.9131, 409.920,
69 409.962, 409.968, and 409.972, F.S.; conforming
70 provisions to changes made by the act; amending s.
71 400.4765, F.S.; revising the training requirements for
72 family caregivers participating in the home health
73 aide for medically fragile children program;
74 specifying that services provided by a home health
75 aide for a medically fragile child may not exceed a
76 specified percentage of the total annual hours
77 authorized for private duty nursing services for that
78 child; revising requirements for the Medicaid fee
79 schedule for home health aides for medically fragile
80 children; requiring the Agency for Health Care
81 Administration, within a specified timeframe, to seek
82 federal approval to implement specified practices
83 under the program; amending s. 400.54, F.S.; requiring
84 Medicaid managed care plans to provide certain data to
85 the agency as part of an annual assessment of the home
86 health aide for medically fragile children program;
87 revising requirements for such assessment; providing a
88 directive to the Division of Law Revision; providing
89 effective dates.
90
91 Be It Enacted by the Legislature of the State of Florida:
92
93 Section 1. Transfer of operation of the Children’s Medical
94 Services Managed Care Plan.—
95 (1) Effective July 1, 2025, all statutory powers, duties,
96 functions, records, personnel, pending issues, existing
97 contracts, administrative authority, administrative rules, and
98 unexpended balances of appropriations, allocations, and other
99 funds for the operation of the Department of Health’s Children’s
100 Medical Services Managed Care Plan are transferred to the Agency
101 for Health Care Administration.
102 (2) The transfer of operations of the Children’s Medical
103 Services Managed Care Plan does not affect the validity of any
104 judicial or administrative action pending as of 11:59 p.m. on
105 the day before the effective date of the transfer to which the
106 Department of Health’s Children’s Medical Services Managed Care
107 Plan is at that time a party, and the Agency for Health Care
108 Administration shall be substituted as a party in interest in
109 any such action.
110 (3) The Department of Health’s Children’s Medical Services
111 program shall collaborate with the Agency for Health Care
112 Administration in the care of children and youth with special
113 health care needs. The Department of Health’s Children’s Medical
114 Services program shall do all of the following:
115 (a) Conduct clinical eligibility screening for children and
116 youth with special health care needs who are eligible for or
117 enrolled in Medicaid or the Children’s Health Insurance Program.
118 (b) Provide ongoing consultation to the Agency for Health
119 Care Administration to ensure high-quality, family-centered,
120 coordinated health services within an effective system of care
121 for children and youth with special health care needs.
122 Section 2. Paragraph (d) of subsection (13) of section
123 409.906, Florida Statutes, is amended, and paragraph (c) is
124 added to subsection (8) and paragraph (e) is added to subsection
125 (13) of that section, to read:
126 409.906 Optional Medicaid services.—Subject to specific
127 appropriations, the agency may make payments for services which
128 are optional to the state under Title XIX of the Social Security
129 Act and are furnished by Medicaid providers to recipients who
130 are determined to be eligible on the dates on which the services
131 were provided. Any optional service that is provided shall be
132 provided only when medically necessary and in accordance with
133 state and federal law. Optional services rendered by providers
134 in mobile units to Medicaid recipients may be restricted or
135 prohibited by the agency. Nothing in this section shall be
136 construed to prevent or limit the agency from adjusting fees,
137 reimbursement rates, lengths of stay, number of visits, or
138 number of services, or making any other adjustments necessary to
139 comply with the availability of moneys and any limitations or
140 directions provided for in the General Appropriations Act or
141 chapter 216. If necessary to safeguard the state’s systems of
142 providing services to elderly and disabled persons and subject
143 to the notice and review provisions of s. 216.177, the Governor
144 may direct the Agency for Health Care Administration to amend
145 the Medicaid state plan to delete the optional Medicaid service
146 known as “Intermediate Care Facilities for the Developmentally
147 Disabled.” Optional services may include:
148 (8) COMMUNITY MENTAL HEALTH SERVICES.—
149 (c) The agency shall pay for individual and family therapy
150 services provided by a provider employed by or under contract
151 with a community behavioral health provider who holds a
152 bachelor-level certification in mental health or substance abuse
153 treatment from a recognized credentialing entity as defined in
154 s. 397.311 if such services are provided under the supervision
155 of a physician or a physician assistant licensed under chapter
156 458 or chapter 459; a mental health professional licensed under
157 chapter 490 or chapter 491; or an advanced practice registered
158 nurse licensed under part I of chapter 464.
159 (13) HOME AND COMMUNITY-BASED SERVICES.—
160 (d) The agency shall seek federal approval to pay for
161 flexible services for persons with severe mental illness or
162 substance use disorders, including, but not limited to,
163 temporary housing assistance. Payments may be made as enhanced
164 capitation rates or incentive payments to managed care plans
165 that meet the requirements of s. 409.968(3) s. 409.968(4).
166 (e) The agency shall seek federal approval to amend
167 Florida’s Medicaid Model Waiver for home and community-based
168 services to include children who receive private duty nursing
169 services. The amended waiver must provide an array of services
170 through a tiered approach to more broadly serve medically
171 fragile children who receive private duty nursing services and
172 must ensure that institutional care is avoided so children can
173 remain in the home or community setting. Services provided under
174 the waiver must be provided by health plans participating in the
175 Statewide Medicaid Managed Care program. The agency shall
176 implement the approved waiver amendment subject to the
177 availability of funds and any limitations provided in the
178 General Appropriations Act, including a limitation on the number
179 of enrollees in the revised waiver. The agency may adopt rules
180 to implement this paragraph.
181 Section 3. Subsection (4) of section 409.974, Florida
182 Statutes, is amended to read:
183 409.974 Eligible plans.—
184 (4) CHILDREN’S MEDICAL SERVICES NETWORK.—
185 (a) The Department of Health’s Children’s Medical Services
186 program shall do all of the following:
187 1. Effective July 1, 2025, transfer to the agency the
188 operation of managed care contracts procured by the department
189 for Medicaid and Children’s Health Insurance Program services
190 provided to children and youth with special health care needs
191 who are enrolled in the Children’s Medical Services Managed Care
192 Plan.
193 2. Conduct clinical eligibility screening for children and
194 youth with special health care needs who are eligible for or are
195 enrolled in Medicaid or the Children’s Health Insurance Program.
196 3. Provide ongoing consultation to the agency to ensure
197 high-quality, family-centered, coordinated health services are
198 provided within an effective system of care for children and
199 youth with special health care needs.
200 (b) The agency shall establish specific measures of access,
201 quality, and costs of providing health care services to children
202 and youth with special health care needs. The agency shall
203 contract with an independent evaluator to conduct an evaluation
204 of services provided. The evaluation must include, but need not
205 be limited to, all of the following:
206 1. A performance comparison of plans contracted to provide
207 services to children and youth with special health care needs as
208 well as plans contracted to serve a broader population of
209 Managed Medical Assistance enrollees. The performance comparison
210 must be based on the measures established by the agency and
211 differentiated based on the age and medical condition or
212 diagnosis of patients receiving services under each plan.
213 2. For each plan, an assessment of cost savings, patient
214 choice, access to services, coordination of care, person
215 centered planning, health and quality-of-life outcomes, patient
216 and provider satisfaction, and provider networks and quality of
217 care.
218
219 The agency shall submit the results of the evaluation to the
220 Governor, the President of the Senate, and the Speaker of the
221 House of Representatives by January 15, 2028 Participation by
222 the Children’s Medical Services Network shall be pursuant to a
223 single, statewide contract with the agency that is not subject
224 to the procurement requirements or regional plan number limits
225 of this section. The Children’s Medical Services Network must
226 meet all other plan requirements for the managed medical
227 assistance program.
228 Section 4. Subsection (1) of section 391.016, Florida
229 Statutes, is amended to read:
230 391.016 Purposes and functions.—The Children’s Medical
231 Services program is established for the following purposes and
232 authorized to perform the following functions:
233 (1) Provide to children and youth with special health care
234 needs a family-centered, comprehensive, and coordinated
235 statewide managed system of care that links community-based
236 health care with multidisciplinary, regional, and tertiary
237 pediatric specialty care. The program shall coordinate and
238 maintain a consistent medical home for participating children.
239 Section 5. Subsections (1), (2), and (4) of section
240 391.021, Florida Statutes, are reordered and amended to read:
241 391.021 Definitions.—When used in this act, the term:
242 (2)(1) “Children’s Medical Services Managed Care Plan
243 network” or “plan network” means a statewide managed care
244 service system that includes health care providers, as defined
245 in this section.
246 (1)(2) “Children and youth with special health care needs”
247 means those children and youth younger than 21 years of age who
248 have chronic and serious physical, developmental, behavioral, or
249 emotional conditions and who require health care and related
250 services of a type or amount beyond that which is generally
251 required by children and youth.
252 (4) “Eligible individual” means a child or youth with a
253 special health care need or a female with a high-risk pregnancy,
254 who meets the financial and medical eligibility standards
255 established in s. 391.029.
256 Section 6. Subsection (1) of section 391.025, Florida
257 Statutes, is amended to read:
258 391.025 Applicability and scope.—
259 (1) The Children’s Medical Services program consists of the
260 following components:
261 (a) The newborn screening program established in s. 383.14
262 and the newborn, infant, and toddler hearing screening program
263 established in s. 383.145.
264 (b) The regional perinatal intensive care centers program
265 established in ss. 383.15-383.19.
266 (c) The developmental evaluation and intervention program,
267 including the Early Steps Program established in ss. 391.301
268 391.308.
269 (d) The Children’s Medical Services Managed Care Plan
270 through the end of June 30, 2025 network.
271 (e) The Children’s Multidisciplinary Assessment Team.
272 (f) The Medical Foster Care Program.
273 (g) The Title V Children and Youth with Special Health Care
274 Needs program.
275 (h) The Safety Net Program.
276 (i) The Networks for Access and Quality.
277 (j) Child Protection Teams and sexual abuse treatment
278 programs established under s. 39.303.
279 (k) The State Child Abuse Death Review Committee and local
280 child abuse death review committees established in s. 383.402.
281 Section 7. Section 391.026, Florida Statutes, is amended to
282 read:
283 391.026 Powers and duties of the department.—The department
284 shall have the following powers, duties, and responsibilities:
285 (1) To provide or contract for the provision of health
286 services to eligible individuals.
287 (2) To provide services to abused and neglected children
288 through Child Protection Teams pursuant to s. 39.303.
289 (3) To determine the medical and financial eligibility of
290 individuals seeking health services from the program.
291 (4) To coordinate a comprehensive delivery system for
292 eligible individuals to take maximum advantage of all available
293 funds.
294 (5) To coordinate with programs relating to children’s
295 medical services in cooperation with other public and private
296 agencies.
297 (6) To initiate and coordinate applications to federal
298 agencies and private organizations for funds, services, or
299 commodities relating to children’s medical programs.
300 (7) To sponsor or promote grants for projects, programs,
301 education, or research in the field of children and youth with
302 special health care needs, with an emphasis on early diagnosis
303 and treatment.
304 (8) To oversee and operate the Children’s Medical Services
305 Managed Care Plan through the end of June 30, 2025 network.
306 (9) To establish reimbursement mechanisms for the
307 Children’s Medical Services network.
308 (10) To establish Children’s Medical Services network
309 standards and credentialing requirements for health care
310 providers and health care services.
311 (11) To serve as a provider and principal case manager for
312 children with special health care needs under Titles XIX and XXI
313 of the Social Security Act.
314 (12) To monitor the provision of health services in the
315 program, including the utilization and quality of health
316 services.
317 (10)(13) To administer the Children and Youth with Special
318 Health Care Needs program in accordance with Title V of the
319 Social Security Act.
320 (14) To establish and operate a grievance resolution
321 process for participants and health care providers.
322 (15) To maintain program integrity in the Children’s
323 Medical Services program.
324 (11)(16) To receive and manage health care premiums,
325 capitation payments, and funds from federal, state, local, and
326 private entities for the program. The department may contract
327 with a third-party administrator for processing claims,
328 monitoring medical expenses, and other related services
329 necessary to the efficient and cost-effective operation of the
330 Children’s Medical Services Managed Care Plan through the end of
331 June 30, 2025 network. The department is authorized to maintain
332 a minimum reserve for the Children’s Medical Services network in
333 an amount that is the greater of:
334 (a) Ten percent of total projected expenditures for Title
335 XIX-funded and Title XXI-funded children; or
336 (b) Two percent of total annualized payments from the
337 Agency for Health Care Administration for Title XIX and Title
338 XXI of the Social Security Act.
339 (12)(17) To provide or contract for peer review and other
340 quality-improvement activities.
341 (13)(18) To adopt rules pursuant to ss. 120.536(1) and
342 120.54 to administer the Children’s Medical Services Act.
343 (14)(19) To serve as the lead agency in administering the
344 Early Steps Program pursuant to part C of the federal
345 Individuals with Disabilities Education Act and part III of this
346 chapter.
347 (15) To administer the Medical Foster Care Program,
348 including all of the following:
349 (a) Recruitment, training, assessment, and monitoring for
350 the Medical Foster Care Program.
351 (b) Monitoring access and facilitating admissions of
352 eligible children and youth to the program and designated
353 medical foster care homes.
354 (c) Coordination with the Department of Children and
355 Families and the Agency for Health Care Administration or their
356 designees.
357 Section 8. Effective January 1, 2026, subsections (8)
358 through (11) of section 391.026, Florida Statutes, as amended by
359 this act, are repealed.
360 Section 9. Effective July 1, 2025, section 391.028, Florida
361 Statutes, is repealed.
362 Section 10. Subsections (2) and (3) of section 391.029,
363 Florida Statutes, are amended to read:
364 391.029 Program eligibility.—
365 (2) The following individuals are eligible to receive
366 services through the program:
367 (a) Related to the regional perinatal intensive care
368 centers, a high-risk pregnant female who is enrolled in
369 Medicaid.
370 (b) Children and youth with serious special health care
371 needs from birth to 21 years of age who are enrolled in
372 Medicaid.
373 (c) Children and youth with serious special health care
374 needs from birth to 19 years of age who are enrolled in a
375 program under Title XXI of the Social Security Act.
376 (3) Subject to the availability of funds, the following
377 individuals may receive services through the program:
378 (a) Children and youth with serious special health care
379 needs from birth to 21 years of age who do not qualify for
380 Medicaid or Title XXI of the Social Security Act but who are
381 unable to access, due to lack of providers or lack of financial
382 resources, specialized services that are medically necessary or
383 essential family support services. Families shall participate
384 financially in the cost of care based on a sliding fee scale
385 established by the department.
386 (b) Children and youth with special health care needs from
387 birth to 21 years of age, as provided in Title V of the Social
388 Security Act.
389 (c) An infant who receives an award of compensation under
390 s. 766.31(1). The Florida Birth-Related Neurological Injury
391 Compensation Association shall reimburse the Children’s Medical
392 Services Network the state’s share of funding, which must
393 thereafter be used to obtain matching federal funds under Title
394 XXI of the Social Security Act.
395 Section 11. Section 391.0315, Florida Statutes, is amended
396 to read:
397 391.0315 Benefits.—Benefits provided under the Children’s
398 Medical Services Managed Care Plan program for children with
399 special health care needs shall be equivalent to benefits
400 provided to children as specified in ss. 409.905 and 409.906.
401 The department may offer additional benefits through Children’s
402 Medical Services programs for early intervention services,
403 respite services, genetic testing, genetic and nutritional
404 counseling, and parent support services, if such services are
405 determined to be medically necessary. This section expires June
406 30, 2025, and this section is repealed on January 1, 2026.
407 Section 12. Section 391.035, Florida Statutes, is repealed.
408 Section 13. Effective January 1, 2026, section 391.037,
409 Florida Statutes, is repealed.
410 Section 14. Section 391.045, Florida Statutes, is repealed.
411 Section 15. Effective January 1, 2026, section 391.047,
412 Florida Statutes, is repealed.
413 Section 16. Effective January 1, 2026, section 391.055,
414 Florida Statutes, is repealed.
415 Section 17. Effective January 1, 2026, section 391.071,
416 Florida Statutes, is repealed.
417 Section 18. Section 391.097, Florida Statutes, is amended
418 to read:
419 391.097 Research and evaluation.—
420 (1) The department may initiate, fund, and conduct research
421 and evaluation projects to improve the delivery of children’s
422 medical services. The department may cooperate with public and
423 private agencies engaged in work of a similar nature.
424 (2) The Children’s Medical Services network shall be
425 included in any evaluation conducted in accordance with the
426 provisions of Title XXI of the Social Security Act as enacted by
427 the Legislature.
428 Section 19. Part II of chapter 391, Florida Statutes,
429 consisting of ss. 391.221 and 391.223, Florida Statutes, is
430 repealed, and part III of that chapter is redesignated as part
431 II.
432 Section 20. Effective July 1, 2025, paragraph (b) of
433 subsection (5) of section 409.166, Florida Statutes, is amended
434 to read:
435 409.166 Children within the child welfare system; adoption
436 assistance program.—
437 (5) ELIGIBILITY FOR SERVICES.—
438 (b) A child who is handicapped at the time of adoption is
439 shall be eligible for services through a plan under contract
440 with the agency to serve children and youth with special heath
441 care needs the Children’s Medical Services network established
442 under part I of chapter 391 if the child was eligible for such
443 services before prior to the adoption.
444 Section 21. Effective July 1, 2025, subsection (7) of
445 section 409.811, Florida Statutes, is amended to read:
446 409.811 Definitions relating to Florida Kidcare Act.—As
447 used in ss. 409.810-409.821, the term:
448 (7) “Children’s Medical Services Network” or “network”
449 means a statewide managed care service system as defined in s.
450 391.021(1).
451 Section 22. Effective July 1, 2025, subsection (1) of
452 section 409.813, Florida Statutes, is amended to read:
453 409.813 Health benefits coverage; program components;
454 entitlement and nonentitlement.—
455 (1) The Florida Kidcare program includes health benefits
456 coverage provided to children through the following program
457 components, which shall be marketed as the Florida Kidcare
458 program:
459 (a) Medicaid;
460 (b) Medikids as created in s. 409.8132;
461 (c) The Florida Healthy Kids Corporation as created in s.
462 624.91;
463 (d) Employer-sponsored group health insurance plans
464 approved under ss. 409.810-409.821; and
465 (e) Plans under contract with the agency to serve children
466 and youth with special health care needs The Children’s Medical
467 Services network established in chapter 391.
468 Section 23. Effective July 1, 2025, subsection (3) of
469 section 409.8134, Florida Statutes, is amended to read:
470 409.8134 Program expenditure ceiling; enrollment.—
471 (3) Upon determination by the Social Services Estimating
472 Conference that there are insufficient funds to finance the
473 current enrollment in the Florida Kidcare program within current
474 appropriations, the program shall initiate disenrollment
475 procedures to remove enrollees, except those children enrolled
476 in a plan under contract with the agency to serve children with
477 special health care needs the Children’s Medical Services
478 Network, on a last-in, first-out basis until the expenditure and
479 appropriation levels are balanced.
480 Section 24. Subsection (3) and paragraph (c) of subsection
481 (10) of section 409.814, Florida Statutes, are amended to read:
482 409.814 Eligibility.—A child who has not reached 19 years
483 of age whose family income is equal to or below 300 percent of
484 the federal poverty level is eligible for the Florida Kidcare
485 program as provided in this section. If an enrolled individual
486 is determined to be ineligible for coverage, he or she must be
487 immediately disenrolled from the respective Florida Kidcare
488 program component.
489 (3) A Title XXI-funded child who is eligible for the
490 Florida Kidcare program who is a child with special health care
491 needs, as determined through a medical or behavioral screening
492 instrument, is eligible for health benefits coverage from and
493 shall be assigned to and may opt out of a plan under contract
494 with the agency to serve children with special health care needs
495 the Children’s Medical Services Network.
496 (10) In determining the eligibility of a child, an assets
497 test is not required. If eligibility for the Florida Kidcare
498 program cannot be verified using reliable data sources in
499 accordance with federal requirements, each applicant shall
500 provide documentation during the application process and the
501 redetermination process, including, but not limited to, the
502 following:
503 (c) To enroll in a plan under contract with the agency to
504 service children with special health care needs the Children’s
505 Medical Services Network, a completed application, including a
506 Children’s Medical Services clinical screening.
507 Section 25. Effective July 1, 2025, paragraph (t) of
508 subsection (2) of section 409.815, Florida Statutes, is amended
509 to read:
510 409.815 Health benefits coverage; limitations.—
511 (2) BENCHMARK BENEFITS.—In order for health benefits
512 coverage to qualify for premium assistance payments for an
513 eligible child under ss. 409.810-409.821, the health benefits
514 coverage, except for coverage under Medicaid and Medikids, must
515 include the following minimum benefits, as medically necessary.
516 (t) Enhancements to minimum requirements.—
517 1. This section sets the minimum benefits that must be
518 included in any health benefits coverage, other than Medicaid or
519 Medikids coverage, offered under ss. 409.810-409.821. Health
520 benefits coverage may include additional benefits not included
521 under this subsection, but may not include benefits excluded
522 under paragraph (r).
523 2. Health benefits coverage may extend any limitations
524 beyond the minimum benefits described in this section.
525
526 Except for a plan under contract with the agency to serve
527 children with special health care needs the Children’s Medical
528 Services Network, the agency may not increase the premium
529 assistance payment for either additional benefits provided
530 beyond the minimum benefits described in this section or the
531 imposition of less restrictive service limitations.
532 Section 26. Effective July 1, 2025, paragraph (i) of
533 subsection (1) of section 409.8177, Florida Statutes, is amended
534 to read:
535 409.8177 Program evaluation.—
536 (1) The agency, in consultation with the Department of
537 Health, the Department of Children and Families, and the Florida
538 Healthy Kids Corporation, shall contract for an evaluation of
539 the Florida Kidcare program and shall by January 1 of each year
540 submit to the Governor, the President of the Senate, and the
541 Speaker of the House of Representatives a report of the program.
542 In addition to the items specified under s. 2108 of Title XXI of
543 the Social Security Act, the report shall include an assessment
544 of crowd-out and access to health care, as well as the
545 following:
546 (i) An assessment of the effectiveness of the Florida
547 Kidcare program, including Medicaid, the Florida Healthy Kids
548 program, Medikids, and the plans under contract with the agency
549 to serve children with special health care needs Children’s
550 Medical Services network, and other public and private programs
551 in the state in increasing the availability of affordable
552 quality health insurance and health care for children.
553 Section 27. Effective July 1, 2025, subsection (4) of
554 section 409.818, Florida Statutes, is amended to read:
555 409.818 Administration.—In order to implement ss. 409.810
556 409.821, the following agencies shall have the following duties:
557 (4) The Office of Insurance Regulation shall certify that
558 health benefits coverage plans that seek to provide services
559 under the Florida Kidcare program, except those offered through
560 the Florida Healthy Kids Corporation or the Children’s Medical
561 Services Network, meet, exceed, or are actuarially equivalent to
562 the benchmark benefit plan and that health insurance plans will
563 be offered at an approved rate. In determining actuarial
564 equivalence of benefits coverage, the Office of Insurance
565 Regulation and health insurance plans must comply with the
566 requirements of s. 2103 of Title XXI of the Social Security Act.
567 The department shall adopt rules necessary for certifying health
568 benefits coverage plans.
569 Section 28. Effective July 1, 2025, subsection (11) of
570 section 409.912, Florida Statutes, is amended to read:
571 409.912 Cost-effective purchasing of health care.—The
572 agency shall purchase goods and services for Medicaid recipients
573 in the most cost-effective manner consistent with the delivery
574 of quality medical care. To ensure that medical services are
575 effectively utilized, the agency may, in any case, require a
576 confirmation or second physician’s opinion of the correct
577 diagnosis for purposes of authorizing future services under the
578 Medicaid program. This section does not restrict access to
579 emergency services or poststabilization care services as defined
580 in 42 C.F.R. s. 438.114. Such confirmation or second opinion
581 shall be rendered in a manner approved by the agency. The agency
582 shall maximize the use of prepaid per capita and prepaid
583 aggregate fixed-sum basis services when appropriate and other
584 alternative service delivery and reimbursement methodologies,
585 including competitive bidding pursuant to s. 287.057, designed
586 to facilitate the cost-effective purchase of a case-managed
587 continuum of care. The agency shall also require providers to
588 minimize the exposure of recipients to the need for acute
589 inpatient, custodial, and other institutional care and the
590 inappropriate or unnecessary use of high-cost services. The
591 agency shall contract with a vendor to monitor and evaluate the
592 clinical practice patterns of providers in order to identify
593 trends that are outside the normal practice patterns of a
594 provider’s professional peers or the national guidelines of a
595 provider’s professional association. The vendor must be able to
596 provide information and counseling to a provider whose practice
597 patterns are outside the norms, in consultation with the agency,
598 to improve patient care and reduce inappropriate utilization.
599 The agency may mandate prior authorization, drug therapy
600 management, or disease management participation for certain
601 populations of Medicaid beneficiaries, certain drug classes, or
602 particular drugs to prevent fraud, abuse, overuse, and possible
603 dangerous drug interactions. The Pharmaceutical and Therapeutics
604 Committee shall make recommendations to the agency on drugs for
605 which prior authorization is required. The agency shall inform
606 the Pharmaceutical and Therapeutics Committee of its decisions
607 regarding drugs subject to prior authorization. The agency is
608 authorized to limit the entities it contracts with or enrolls as
609 Medicaid providers by developing a provider network through
610 provider credentialing. The agency may competitively bid single
611 source-provider contracts if procurement of goods or services
612 results in demonstrated cost savings to the state without
613 limiting access to care. The agency may limit its network based
614 on the assessment of beneficiary access to care, provider
615 availability, provider quality standards, time and distance
616 standards for access to care, the cultural competence of the
617 provider network, demographic characteristics of Medicaid
618 beneficiaries, practice and provider-to-beneficiary standards,
619 appointment wait times, beneficiary use of services, provider
620 turnover, provider profiling, provider licensure history,
621 previous program integrity investigations and findings, peer
622 review, provider Medicaid policy and billing compliance records,
623 clinical and medical record audits, and other factors. Providers
624 are not entitled to enrollment in the Medicaid provider network.
625 The agency shall determine instances in which allowing Medicaid
626 beneficiaries to purchase durable medical equipment and other
627 goods is less expensive to the Medicaid program than long-term
628 rental of the equipment or goods. The agency may establish rules
629 to facilitate purchases in lieu of long-term rentals in order to
630 protect against fraud and abuse in the Medicaid program as
631 defined in s. 409.913. The agency may seek federal waivers
632 necessary to administer these policies.
633 (11) The agency shall implement a program of all-inclusive
634 care for children. The program of all-inclusive care for
635 children shall be established to provide in-home hospice-like
636 support services to children diagnosed with a life-threatening
637 illness and enrolled in the Children’s Medical Services network
638 to reduce hospitalizations as appropriate. The agency, in
639 consultation with the Department of Health, may implement the
640 program of all-inclusive care for children after obtaining
641 approval from the Centers for Medicare and Medicaid Services.
642 Section 29. Effective July 1, 2025, subsection (1) of
643 section 409.9126, Florida Statutes, is amended to read:
644 409.9126 Children with special health care needs.—
645 (1) Except as provided in subsection (4), children eligible
646 for the Children’s Medical Services program who receive Medicaid
647 benefits, and other Medicaid-eligible children with special
648 health care needs, are shall be exempt from the provisions of s.
649 409.9122 and shall be served through the Children’s Medical
650 Services network established in chapter 391.
651 Section 30. Effective July 1, 2025, paragraph (a) of
652 subsection (5) of section 409.9131, Florida Statutes, is amended
653 to read:
654 409.9131 Special provisions relating to integrity of the
655 Medicaid program.—
656 (5) DETERMINATIONS OF OVERPAYMENT.—In making a
657 determination of overpayment to a physician, the agency must:
658 (a) Use accepted and valid auditing, accounting,
659 analytical, statistical, or peer-review methods, or combinations
660 thereof. Appropriate statistical methods may include, but are
661 not limited to, sampling and extension to the population,
662 parametric and nonparametric statistics, tests of hypotheses,
663 other generally accepted statistical methods, review of medical
664 records, and a consideration of the physician’s client case mix.
665 Before performing a review of the physician’s Medicaid records,
666 however, the agency shall make every effort to consider the
667 physician’s patient case mix, including, but not limited to,
668 patient age and whether individual patients are clients of the
669 Children’s Medical Services Network established in chapter 391.
670 In meeting its burden of proof in any administrative or court
671 proceeding, the agency may introduce the results of such
672 statistical methods and its other audit findings as evidence of
673 overpayment.
674 Section 31. Effective July 1, 2025, paragraph (e) of
675 subsection (1) of section 409.920, Florida Statutes, is amended
676 to read:
677 409.920 Medicaid provider fraud.—
678 (1) For the purposes of this section, the term:
679 (e) “Managed care plans” means a health insurer authorized
680 under chapter 624, an exclusive provider organization authorized
681 under chapter 627, a health maintenance organization authorized
682 under chapter 641, the Children’s Medical Services Network
683 authorized under chapter 391, a prepaid health plan authorized
684 under this chapter, a provider service network authorized under
685 this chapter, a minority physician network authorized under this
686 chapter, and an emergency department diversion program
687 authorized under this chapter or the General Appropriations Act,
688 providing health care services pursuant to a contract with the
689 Medicaid program.
690 Section 32. Effective July 1, 2025, subsection (7) of
691 section 409.962, Florida Statutes, is amended to read:
692 409.962 Definitions.—As used in this part, except as
693 otherwise specifically provided, the term:
694 (7) “Eligible plan” means a health insurer authorized under
695 chapter 624, an exclusive provider organization authorized under
696 chapter 627, a health maintenance organization authorized under
697 chapter 641, or a provider service network authorized under s.
698 409.912(1) or an accountable care organization authorized under
699 federal law. For purposes of the managed medical assistance
700 program, the term also includes the Children’s Medical Services
701 Network authorized under chapter 391 and entities qualified
702 under 42 C.F.R. part 422 as Medicare Advantage Preferred
703 Provider Organizations, Medicare Advantage Provider-sponsored
704 Organizations, Medicare Advantage Health Maintenance
705 Organizations, Medicare Advantage Coordinated Care Plans, and
706 Medicare Advantage Special Needs Plans, and the Program of All
707 inclusive Care for the Elderly.
708 Section 33. Subsection (3) of section 409.968, Florida
709 Statutes, is amended to read:
710 409.968 Managed care plan payments.—
711 (3) Reimbursement for prescribed pediatric extended care
712 services provided to children enrolled in a managed care plan
713 under s. 409.972(1)(g) shall be paid to the prescribed pediatric
714 extended care services provider by the agency on a fee-for
715 service basis.
716 Section 34. Paragraph (g) of subsection (1) of section
717 409.972, Florida Statutes, is amended to read:
718 409.972 Mandatory and voluntary enrollment.—
719 (1) The following Medicaid-eligible persons are exempt from
720 mandatory managed care enrollment required by s. 409.965, and
721 may voluntarily choose to participate in the managed medical
722 assistance program:
723 (g) Children receiving services in a prescribed pediatric
724 extended care center.
725 Section 35. Paragraph (a) of subsection (3) and subsection
726 (9) of section 400.4765, Florida Statutes, are amended, and
727 subsection (10) is added to that section, to read:
728 400.4765 Home health aide for medically fragile children
729 program.—
730 (3) TRAINING.—
731 (a) The agency, in consultation with the Board of Nursing,
732 shall approve home health aide for medically fragile children
733 training programs developed by home health agencies in
734 accordance with 42 C.F.R. ss. 483.151-483.154 and 484.80 to
735 train family caregivers as home health aides for medically
736 fragile children to increase the health care provider workforce
737 and to authorize persons to provide trained nursing services as
738 delegated by a registered nurse to eligible relatives. The
739 program must include consist of at least 85 hours of training,
740 including, but need not be limited to, all of the following:
741 1. A minimum of 20 40 hours of theoretical instruction in
742 nursing, including, but not limited to, instruction on all of
743 the following:
744 a. Person-centered care.
745 b. Communication and interpersonal skills.
746 c. Infection control.
747 d. Safety and emergency procedures.
748 e. Assistance with activities of daily living.
749 f. Mental health and social service needs.
750 g. Care of cognitively impaired individuals.
751 h. Basic restorative care and rehabilitation.
752 i. Patient rights and confidentiality of personal
753 information and medical records.
754 j. Relevant legal and ethical issues.
755
756 Such instruction must be offered in various formats, and any
757 interactive instruction must be provided during various times of
758 the day.
759 2. Up to A minimum of 20 hours of skills training on basic
760 nursing skills, tailored to the child’s care needs as specified
761 in the ordering provider’s plan of care, which may include
762 training on the following topics, as applicable including, but
763 not limited to:
764 a. Hygiene, grooming, and toileting.
765 b. Skin care and pressure sore prevention.
766 c. Nutrition and hydration.
767 d. Measuring vital signs, height, and weight.
768 e. Safe lifting, positioning, and moving of patients.
769 f. Wound care.
770 g. Portable Oxygen use and safety and other respiratory
771 procedures.
772 h. Tracheostomy care.
773 i. Enteral care and therapy.
774 j. Peripheral Intravenous assistive activities and
775 alternative feeding methods.
776 k. Urinary catheterization and care and ostomy care.
777 3. Up to At least 16 hours of clinical training related to
778 the specific needs of the eligible relative, under direct
779 supervision of a licensed registered nurse.
780 4. Training concerning HIV infections and AIDS. and is
781 required to obtain and maintain
782 5. Obtaining and maintaining a current certificate in
783 cardiopulmonary resuscitation.
784 (9) FEE SCHEDULE.—The agency shall modify any state
785 Medicaid plans and implement any federal waivers necessary to
786 implement this section and shall establish a Medicaid fee
787 schedule for home health agencies employing a home health aide
788 for medically fragile children at a minimum rate of $25 per hour
789 with a utilization cap of no more than 12 8 hours per day per
790 medically fragile child. If a home health aide for medically
791 fragile children works more than 40 hours per week,
792 justification must be provided as to why there is no other
793 qualified provider available, and the request must be approved
794 by the home health agency and the managed care plan.
795 (10) FEDERAL APPROVAL.—Within 30 days after this act
796 becomes a law, the agency shall seek federal approval through
797 any necessary Medicaid waiver or state plan amendment to:
798 (a) Allow Medicaid private duty nursing specialty providers
799 and home health services providers to participate in and receive
800 reimbursement for services rendered under the program.
801 (b) Establish that the income earned under the program by a
802 home health aide for medically fragile children must be
803 disregarded in eligibility considerations for public assistance
804 as defined in s. 414.0252.
805 Section 36. Section 400.54, Florida Statutes, is amended to
806 read:
807 400.54 Annual assessment of the home health aide for
808 medically fragile children program.—The agency shall conduct an
809 annual assessment of the home health aide for medically fragile
810 children program. The assessment must report caregiver
811 satisfaction with the program and, identify additional support
812 that may be needed by the home health aide for medically fragile
813 children. The managed care plan shall provide to the agency the
814 data necessary to, and assess the rate and extent of
815 hospitalization of children in home health services who are
816 attended by a home health aide for medically fragile children
817 compared to those in home health services provided by a
818 registered nurse or licensed practical nurse without a home
819 health aide for medically fragile children. The agency shall
820 include in the assessment data on any adverse incident occurring
821 under the care of a home health aide for medically fragile
822 children. By January 1 of each year, beginning January 1, 2025,
823 the agency shall report its findings to the Governor, the
824 President of the Senate, and the Speaker of the House of
825 Representatives.
826 Section 37. The Division of Law Revision is directed to
827 replace the phrase “this act becomes a law” wherever it occurs
828 in this act with the date this act becomes a law.
829 Section 38. Except as otherwise expressly provided in this
830 act, this act shall take effect upon becoming a law.
