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A bill to be entitled 1
An act relating to the Children's Medical Services 2
program; transferring operation of the Children's 3
Medical Services Managed Care Plan from the Department 4
of Health to the Agency for Health Care 5
Administration, effective on a specified date; 6
providing construction as to judicial and 7
administrative actions pending as of a specified date 8
and time; requiring the department's Children's 9
Medical Services (CMS) program to collaborate with the 10
agency in the care of children and youth with special 11
health care needs; requiring the CMS program to 12
conduct certain clinical eligibility screenings and 13
provide ongoing consultation to the agency for a 14
specified purpose; amending s. 409.906, F.S.; 15
conforming a cross-reference; requiring the agency to 16
seek federal approval t o amend the state's Medicaid 17
Model Waiver for home and community -based services to 18
include certain services; requiring the agency to 19
implement the approved waiver amendment subject to 20
certain conditions; authorizing the agency to adopt 21
rules; amending s. 4 09.974, F.S.; requiring the CMS 22
program to transfer operation of certain managed care 23
contracts from the department to the agency effective 24
on a specified date; requiring the CMS program to 25
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conduct clinical eligibility screening for certain 26
children and youth with special health care needs; 27
requiring the program to provide ongoing consultation 28
to the agency for a specified purpose; requiring the 29
agency to establish specific measures for evaluation 30
of services provided to children and youth with 31
special health care needs; requiring the agency to 32
contract with an independent evaluator to conduct the 33
evaluation of services provided; specifying 34
requirements for the evaluation; requiring the agency 35
to submit the results of the evaluation to the 36
Governor and the Legislature by a specified date; 37
amending s. 391.016, F.S.; revising the purposes and 38
functions of the CMS program; amending s. 391.021, 39
F.S.; revising definitions; amending s. 391.025, F.S.; 40
revising the scope of the CMS program; amending s. 41
391.026, F.S.; revising the powers and duties of the 42
department to conform to changes made by the act; 43
providing for the future repeal of s. 391.026(8) 44
through (11), F.S., relating to the department's 45
oversight and administration of the CMS program; 46
repealing s. 391.028 , F.S., relating to administration 47
of the program; amending s. 391.029, F.S.; revising 48
program eligibility requirements; conforming 49
provisions to changes made by the act; amending s. 50
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391.0315, F.S.; conforming provisions to changes made 51
by the act; providing for future repeal of specified 52
provisions; repealing ss. 391.035, 391.037, 391.045, 53
391.047, 391.055, and 391.071, F.S., relating to 54
provider qualifications, physicians and private sector 55
services, provider reimbursements, third -party 56
payments, service delivery systems under the program, 57
and quality of care requirements, respectively; 58
amending s. 391.097, F.S.; conforming a provision to 59
changes made by the act; repealing part II of ch. 391, 60
F.S., consisting of ss. 391.221 and 391.223, F.S., 61
relating to Children's Medical Services councils and 62
panels; amending ss. 409.166, 409.811, 409.813, 63
409.8134, 409.814, 409.815, 409.8177, 409.818, 64
409.912, 409.9126, 409.9131, 409.920, 409.962, 65
409.968, and 409.972, F.S.; conforming provisions to 66
changes made by the a ct; providing effective dates. 67
68
Be It Enacted by the Legislature of the State of Florida: 69
70
Section 1. Transfer of operation of the Children's Medical 71
Services Managed Care Plan. — 72
(1) Effective July 1, 2025, all statutory powers, duties, 73
functions, records, personnel, pending issues, existing 74
contracts, administrative authority, administrative rules, and 75
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unexpended balances of appropriations, allocations, and other 76
funds for the operation of the Department of Health's Children's 77
Medical Services Managed Care Plan are transferred to the Agency 78
for Health Care Administration. 79
(2) The transfer of operations of the Children's Medical 80
Services Managed Care Plan does not affect the validity of any 81
judicial or administrative action pending as of 11:59 p.m. on 82
the day before the effective date of the transfer to which the 83
Department of Health's Children's Medical Services Managed Care 84
Plan is at that time a party, and the Agency for Health Care 85
Administration shall be substituted as a party in interest i n 86
any such action. 87
(3) The Department of Health's Children's Medical Services 88
program shall collaborate with the Agency for Health Care 89
Administration in the care of children and youth with special 90
health care needs. The Department of Health's Children's Medical 91
Services program shall do all of the following: 92
(a) Conduct clinical eligibility screening for children 93
and youth with special health care needs who are eligible for or 94
enrolled in Medicaid or the Children's Health Insurance Program. 95
(b) Provide ongoing consultation to the Agency for Health 96
Care Administration to ensure high -quality, family-centered, 97
coordinated health services within an effective system of care 98
for children and youth with special health care needs. 99
Section 2. Paragraph (d) of subsection (13) of section 100
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409.906, Florida Statutes, is amended, and paragraph (e) is 101
added to that subsection, to read: 102
409.906 Optional Medicaid services. —Subject to specific 103
appropriations, the agency may make payments for services which 104
are optional to the state under Title XIX of the Social Security 105
Act and are furnished by Medicaid providers to recipients who 106
are determined to be eligible on the dates on which the services 107
were provided. Any optional service that is provided shall be 108
provided only when medically necessary and in accordance with 109
state and federal law. Optional services rendered by providers 110
in mobile units to Medicaid recipients may be restricted or 111
prohibited by the agency. Nothing in this section shall be 112
construed to prevent o r limit the agency from adjusting fees, 113
reimbursement rates, lengths of stay, number of visits, or 114
number of services, or making any other adjustments necessary to 115
comply with the availability of moneys and any limitations or 116
directions provided for in the General Appropriations Act or 117
chapter 216. If necessary to safeguard the state's systems of 118
providing services to elderly and disabled persons and subject 119
to the notice and review provisions of s. 216.177, the Governor 120
may direct the Agency for Health Car e Administration to amend 121
the Medicaid state plan to delete the optional Medicaid service 122
known as "Intermediate Care Facilities for the Developmentally 123
Disabled." Optional services may include: 124
(13) HOME AND COMMUNITY -BASED SERVICES.— 125
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(d) The agency shall seek federal approval to pay for 126
flexible services for persons with severe mental illness or 127
substance use disorders, including, but not limited to, 128
temporary housing assistance. Payments may be made as enhanced 129
capitation rates or incentive payments to managed care plans 130
that meet the requirements of s. 409.968(3) s. 409.968(4). 131
(e) The agency shall seek federal approval to amend 132
Florida's Medicaid Model Waiver for home and community -based 133
services to include children who receive private duty nursin g 134
services. The amended waiver must provide an array of tiered 135
services to more broadly serve medically fragile children who 136
receive private duty nursing services and must ensure that 137
institutional care is avoided so children can remain in the home 138
or community setting. Services provided under the waiver must be 139
provided by health plans participating in the Statewide Medicaid 140
Managed Care program. The agency shall implement the approved 141
waiver amendment subject to the availability of funds and any 142
limitations provided in the General Appropriations Act, 143
including a limitation on the number of enrollees in the revised 144
waiver. The agency may adopt rules to implement this paragraph. 145
Section 3. Subsection (4) of section 409.974, Florida 146
Statutes, is amended t o read: 147
409.974 Eligible plans. — 148
(4) CHILDREN'S MEDICAL SERVICES NETWORK.— 149
(a) The Department of Health's Children's Medical Services 150
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program shall do all of the following: 151
1. Effective July 1, 2025, transfer to the agency the 152
operation of managed care contracts procured by the department 153
for Medicaid and Children's Health Insurance Program services 154
provided to children and youth with special health care needs 155
who are enrolled in the Children's Medical Services Managed Care 156
Plan. 157
2. Conduct clinical eligibility screening for children and 158
youth with special health care needs who are eligible for or are 159
enrolled in Medicaid or the Children's Health Insurance Program. 160
3. Provide ongoing consultation to the agency to ensure 161
high-quality, family-centered, coordinated health services are 162
provided within an effective system of care for children and 163
youth with special health care needs. 164
(b) The agency shall establish specific measures of 165
access, quality, and costs of providing health care services to 166
children and youth with special health care needs. The agency 167
shall contract with an independent evaluator to conduct an 168
evaluation of services provided. The evaluation must include, 169
but need not be limited to, all of the following: 170
1. A performance compar ison of plans contracted to provide 171
services to children and youth with special health care needs as 172
well as plans contracted to serve a broader population of 173
Managed Medical Assistance enrollees. The performance comparison 174
must be based on the measures es tablished by the agency and 175
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differentiated based on the age and medical condition or 176
diagnosis of patients receiving services under each plan. 177
2. For each plan, an assessment of cost savings, patient 178
choice, access to services, coordination of care, pers on-179
centered planning, health and quality -of-life outcomes, patient 180
and provider satisfaction, and provider networks and quality of 181
care. 182
183
The agency shall submit the results of the evaluation to the 184
Governor, the President of the Senate, and the Speaker of the 185
House of Representatives by January 15, 2028 Participation by 186
the Children's Medical Services Network shall be pursuant to a 187
single, statewide contract with the agency that is not subject 188
to the procurement requirements or regional plan number limits 189
of this section. The Children's Medical Services Network must 190
meet all other plan requirements for the managed medical 191
assistance program. 192
Section 4. Subsection (1) of section 391.016, Florida 193
Statutes, is amended to read: 194
391.016 Purposes and functi ons.—The Children's Medical 195
Services program is established for the following purposes and 196
authorized to perform the following functions: 197
(1) Provide to children and youth with special health care 198
needs a family-centered, comprehensive, and coordinated 199
statewide managed system of care that links community -based 200
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health care with multidisciplinary, regional, and tertiary 201
pediatric specialty care. The program shall coordinate and 202
maintain a consistent medical home for participating children. 203
Section 5. Subsections (1), (2), and (4) of section 204
391.021, Florida Statutes, are amended to read: 205
391.021 Definitions. —When used in this act, the term: 206
(2)(1) "Children's Medical Services Managed Care Plan 207
network" or "plan network" means a statewide managed car e 208
service system that includes health care providers, as defined 209
in this section. 210
(1)(2) "Children and youth with special health care needs" 211
means those children and youth younger than 21 years of age who 212
have chronic and serious physical, developmental, behavioral, or 213
emotional conditions and who require health care and related 214
services of a type or amount beyond that which is generally 215
required by children and youth. 216
(4) "Eligible individual" means a child or youth with a 217
special health care need or a female with a high -risk pregnancy, 218
who meets the financial and medical eligibility standards 219
established in s. 391.029. 220
Section 6. Subsection (1) of section 391.025, Florida 221
Statutes, is amended to read: 222
391.025 Applicability and scope. — 223
(1) The Children's Medical Services program consists of 224
the following components: 225
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(a) The newborn screening program established in s. 383.14 226
and the newborn, infant, and toddler hearing screening program 227
established in s. 383. 145. 228
(b) The regional perinatal intensive care centers program 229
established in ss. 383.15 -383.19. 230
(c) The developmental evaluation and intervention program, 231
including the Early Steps Program established in ss. 391.301 -232
391.308. 233
(d) The Children's Medic al Services Managed Care Plan 234
through the end of June 30, 2025 network. 235
(e) The Children's Multidisciplinary Assessment Team. 236
(f) The Medical Foster Care Program. 237
(g) The Title V Children and Youth with Special Health 238
Care Needs program. 239
(h) The Safety Net Program. 240
(i) Child Protection Teams and sexual abuse treatment 241
programs established under s. 39.303. 242
(j) The State Child Abuse Death Review Committee and local 243
child abuse death review committees established in s. 383.402. 244
Section 7. Section 391.026, Florida Statutes, is amended 245
to read: 246
391.026 Powers and duties of the department. —The 247
department shall have the following powers, duties, and 248
responsibilities: 249
(1) To provide or contract for the provision of health 250
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services to eligible i ndividuals. 251
(2) To provide services to abused and neglected children 252
through Child Protection Teams pursuant to s. 39.303. 253
(3) To determine the medical and financial eligibility of 254
individuals seeking health services from the program. 255
(4) To coordinate a comprehensive delivery system for 256
eligible individuals to take maximum advantage of all available 257
funds. 258
(5) To coordinate with programs relating to children's 259
medical services in cooperation with other public and private 260
agencies. 261
(6) To initiate and coordinate applications to federal 262
agencies and private organizations for funds, services, or 263
commodities relating to children's medical programs. 264
(7) To sponsor or promote grants for projects, programs, 265
education, or research in the field of childr en and youth with 266
special health care needs, with an emphasis on early diagnosis 267
and treatment. 268
(8) To oversee and operate the Children's Medical Services 269
Managed Care Plan through the end of June 30, 2025 network. 270
(9) To establish reimbursement mechan isms for the 271
Children's Medical Services network. 272
(10) To establish Children's Medical Services network 273
standards and credentialing requirements for health care 274
providers and health care services. 275
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(11) To serve as a provider and principal case manager for 276
children with special health care needs under Titles XIX and XXI 277
of the Social Security Act. 278
(12) To monitor the provision of health services in the 279
program, including the utilization and quality of health 280
services. 281
(10)(13) To administer the Child ren and Youth with Special 282
Health Care Needs program in accordance with Title V of the 283
Social Security Act. 284
(14) To establish and operate a grievance resolution 285
process for participants and health care providers. 286
(15) To maintain program integrity in t he Children's 287
Medical Services program. 288
(11)(16) To receive and manage health care premiums, 289
capitation payments, and funds from federal, state, local, and 290
private entities for the program. The department may contract 291
with a third-party administrator for processing claims, 292
monitoring medical expenses, and other related services 293
necessary to the efficient and cost -effective operation of the 294
Children's Medical Services Managed Care Plan through the end of 295
June 30, 2025 network. The department is authorized to maintain 296
a minimum reserve for the Children's Medical Services network in 297
an amount that is the greater of: 298
(a) Ten percent of total projected expenditures for Title 299
XIX-funded and Title XXI -funded children; or 300
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(b) Two percent of total annualized pa yments from the 301
Agency for Health Care Administration for Title XIX and Title 302
XXI of the Social Security Act . 303
(12)(17) To provide or contract for peer review and other 304
quality-improvement activities. 305
(13)(18) To adopt rules pursuant to ss. 120.536(1) a nd 306
120.54 to administer the Children's Medical Services Act. 307
(14)(19) To serve as the lead agency in administering the 308
Early Steps Program pursuant to part C of the federal 309
Individuals with Disabilities Education Act and part III of this 310
chapter. 311
(15) To administer the Medical Foster Care Program, 312
including all of the following: 313
(a) Recruitment, training, assessment, and monitoring for 314
the Medical Foster Care Program. 315
(b) Monitoring access and facilitating admissions of 316
eligible children and youth t o the program and designated 317
medical foster care homes. 318
(c) Coordination with the Department of Children and 319
Families and the Agency for Health Care Administration or their 320
designees. 321
Section 8. Effective July, 1, 2025, subsections (8) 322
through (11) of section 391.026, Florida Statutes, as amended by 323
this act, are repealed. 324
Section 9. Effective July 1, 2025, section 391.028, 325
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Florida Statutes, is repealed. 326
Section 10. Subsections (2) and (3) of section 391.029, 327
Florida Statutes, are amended to read: 328
391.029 Program eligibility. — 329
(2) The following individuals are eligible to receive 330
services through the program: 331
(a) Related to the regional perinatal intensive care 332
centers, a high-risk pregnant female who is enrolled in 333
Medicaid. 334
(b) Children and youth with serious special health care 335
needs from birth to 21 years of age who are enrolled in 336
Medicaid. 337
(c) Children and youth with serious special health care 338
needs from birth to 19 years of age who are enrolled in a 339
program under Title XXI of the Social Security Act. 340
(3) Subject to the availability of funds, the following 341
individuals may receive services through the Children's Medical 342
Services Safety Net program: 343
(a) Children and youth with serious special health care 344
needs from birth to 21 years of age who do not qualify for 345
Medicaid or Title XXI of the Social Security Act but who are 346
unable to access, due to lack of providers or lack of financial 347
resources, specialized services that are medically necessary or 348
essential family support servi ces. Families shall participate 349
financially in the cost of care based on a sliding fee scale 350
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established by the department. 351
(b) Children and youth with special health care needs from 352
birth to 21 years of age, as provided in Title V of the Social 353
Security Act. 354
(c) An infant who receives an award of compensation under 355
s. 766.31(1). The Florida Birth-Related Neurological Injury 356
Compensation Association shall reimburse the Children's Medical 357
Services Network the state's share of funding, which must 358
thereafter be used to obtain matching federal funds under Title 359
XXI of the Social Security Act. 360
Section 11. Section 391.0315, Florida Statutes, is amended 361
to read: 362
391.0315 Benefits.—Benefits provided under the Children's 363
Medical Services Managed Care Plan program for children with 364
special health care needs shall be equivalent to benefits 365
provided to children as specified in ss. 409.905 and 409.906. 366
The department may offer additional benefits through Children's 367
Medical Services programs for early interventio n services, 368
respite services, genetic testing, genetic and nutritional 369
counseling, and parent support services, if such services are 370
determined to be medically necessary. This section is repealed 371
on January 1, 2026. 372
Section 12. Section 391.035, Florida Statutes, is 373
repealed. 374
Section 13. Effective January 1, 2026, section 391.037, 375
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Florida Statutes, is repealed. 376
Section 14. Section 391.045, Florida Statutes, is 377
repealed. 378
Section 15. Effective January 1, 2026, section 391.047, 379
Florida Statutes, is repealed. 380
Section 16. Effective January 1, 2026, section 391.055, 381
Florida Statutes, is repealed. 382
Section 17. Effective January 1, 2026, section 391.071, 383
Florida Statutes, is repealed. 384
Section 18. Section 391.097, Florida Statutes, is amende d 385
to read: 386
391.097 Research and evaluation. — 387
(1) The department may initiate, fund, and conduct 388
research and evaluation projects to improve the delivery of 389
children's medical services. The department may cooperate with 390
public and private agencies engag ed in work of a similar nature. 391
(2) The Children's Medical Services network shall be 392
included in any evaluation conducted in accordance with the 393
provisions of Title XXI of the Social Security Act as enacted by 394
the Legislature. 395
Section 19. Part II of chapter 391, Florida Statutes, 396
consisting of ss. 391.221 and 391.223, Florida Statutes, is 397
repealed, and part III of that chapter is redesignated as part 398
II. 399
Section 20. Effective July 1, 2025, paragraph (b) of 400
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subsection (5) of section 409.166, Florid a Statutes, is amended 401
to read: 402
409.166 Children within the child welfare system; adoption 403
assistance program.— 404
(5) ELIGIBILITY FOR SERVICES. — 405
(b) A child who is handicapped at the time of adoption is 406
shall be eligible for services through a plan under contract 407
with the agency to serve children and youth with special heath 408
care needs the Children's Medical Services network established 409
under part I of chapter 391 if the child was eligible for such 410
services before prior to the adoption. 411
Section 21. Effective July 1, 2025, subsection (7) of 412
section 409.811, Florida Statutes, is amended to read: 413
409.811 Definitions relating to Florida Kidcare Act. —As 414
used in ss. 409.810-409.821, the term: 415
(7) "Children's Medical Services Network" or "network" 416
means a statewide managed care service system as defined in s. 417
391.021(1). 418
Section 22. Effective July 1, 2025, subsection (1) of 419
section 409.813, Florida Statutes, is amended to read: 420
409.813 Health benefits coverage; program components; 421
entitlement and nonentitlement.— 422
(1) The Florida Kidcare program includes health benefits 423
coverage provided to children through the following program 424
components, which shall be marketed as the Florida Kidcare 425
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program: 426
(a) Medicaid; 427
(b) Medikids as created in s. 409.8132; 428
(c) The Florida Healthy Kids Corporation as created in s. 429
624.91; 430
(d) Employer-sponsored group health insurance plans 431
approved under ss. 409.810 -409.821; and 432
(e) Plans under contract with the agency to serve children 433
and youth with special health care needs The Children's Medical 434
Services network established in chapter 391 . 435
Section 23. Effective July 1, 2025, subsection (3) of 436
section 409.8134, Florida Statutes, is amended to read: 437
409.8134 Program expenditure ceiling; enrollment. — 438
(3) Upon determination by the Social Services Estimating 439
Conference that there are insufficient funds to finance the 440
current enrollment in the Florida Kidcare program within current 441
appropriations, the program shall initiate disenrollment 442
procedures to remove enrollees, except those children enrolled 443
in a plan under contract with the agency to serve children with 444
special health care needs the Children's Medical Services 445
Network, on a last-in, first-out basis until the expenditure and 446
appropriation levels are balanced. 447
Section 24. Subsection (3) and paragraph (c) of subsection 448
(10) of section 409.814, Florida Statutes, are amended to read: 449
409.814 Eligibility. —A child who has not reached 19 years 450
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of age whose family income is equal to or below 300 percen t of 451
the federal poverty level is eligible for the Florida Kidcare 452
program as provided in this section. If an enrolled individual 453
is determined to be ineligible for coverage, he or she must be 454
immediately disenrolled from the respective Florida Kidcare 455
program component. 456
(3) A Title XXI-funded child who is eligible for the 457
Florida Kidcare program who is a child with special health care 458
needs, as determined through a medical or behavioral screening 459
instrument, is eligible for health benefits coverage from and 460
shall be assigned to and may opt out of a plan under contract 461
with the agency to serve children with special health care needs 462
the Children's Medical Services Network . 463
(10) In determining the eligibility of a child, an assets 464
test is not required. If eligibility for the Florida Kidcare 465
program cannot be verified using reliable data sources in 466
accordance with federal requirements, each applicant shall 467
provide documentation during the application process and the 468
redetermination process, including, but n ot limited to, the 469
following: 470
(c) To enroll in a plan under contract with the agency to 471
service children with special health care needs the Children's 472
Medical Services Network , a completed application, including a 473
Children's Medical Services clinical screening. 474
Section 25. Effective July 1, 2025, paragraph (t) of 475
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subsection (2) of section 409.815, Florida Statutes, is amended 476
to read: 477
409.815 Health benefits coverage; limitations. — 478
(2) BENCHMARK BENEFITS. —In order for health benefits 479
coverage to qualify for premium assistance payments for an 480
eligible child under ss. 409.810 -409.821, the health benefits 481
coverage, except for coverage under Medicaid and Medikids, must 482
include the following minimum benefits, as medically necessary. 483
(t) Enhancements to minimum requirements. — 484
1. This section sets the minimum benefits that must be 485
included in any health benefits coverage, other than Medicaid or 486
Medikids coverage, offered under ss. 409.810 -409.821. Health 487
benefits coverage may include additional benefit s not included 488
under this subsection, but may not include benefits excluded 489
under paragraph (r). 490
2. Health benefits coverage may extend any limitations 491
beyond the minimum benefits described in this section. 492
493
Except for a plan under contract with the agen cy to serve 494
children with special health care needs the Children's Medical 495
Services Network, the agency may not increase the premium 496
assistance payment for either additional benefits provided 497
beyond the minimum benefits described in this section or the 498
imposition of less restrictive service limitations. 499
Section 26. Effective July 1, 2025, paragraph (i) of 500
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subsection (1) of section 409.8177, Florida Statutes, is amended 501
to read: 502
409.8177 Program evaluation. — 503
(1) The agency, in consultation with the Department of 504
Health, the Department of Children and Families, and the Florida 505
Healthy Kids Corporation, shall contract for an evaluation of 506
the Florida Kidcare program and shall by January 1 of each year 507
submit to the Governor, the President of the Senate , and the 508
Speaker of the House of Representatives a report of the program. 509
In addition to the items specified under s. 2108 of Title XXI of 510
the Social Security Act, the report shall include an assessment 511
of crowd-out and access to health care, as well as t he 512
following: 513
(i) An assessment of the effectiveness of the Florida 514
Kidcare program, including Medicaid, the Florida Healthy Kids 515
program, Medikids, and the plans under contract with the agency 516
to serve children with special health care needs Children's 517
Medical Services network , and other public and private programs 518
in the state in increasing the availability of affordable 519
quality health insurance and health care for children. 520
Section 27. Effective July 1, 2025, subsection (4) of 521
section 409.818, Flor ida Statutes, is amended to read: 522
409.818 Administration. —In order to implement ss. 409.810 -523
409.821, the following agencies shall have the following duties: 524
(4) The Office of Insurance Regulation shall certify that 525
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health benefits coverage plans that s eek to provide services 526
under the Florida Kidcare program, except those offered through 527
the Florida Healthy Kids Corporation or the Children's Medical 528
Services Network, meet, exceed, or are actuarially equivalent to 529
the benchmark benefit plan and that heal th insurance plans will 530
be offered at an approved rate. In determining actuarial 531
equivalence of benefits coverage, the Office of Insurance 532
Regulation and health insurance plans must comply with the 533
requirements of s. 2103 of Title XXI of the Social Securit y Act. 534
The department shall adopt rules necessary for certifying health 535
benefits coverage plans. 536
Section 28. Effective July 1, 2025, subsection (11) of 537
section 409.912, Florida Statutes, is amended to read: 538
409.912 Cost-effective purchasing of health care.—The 539
agency shall purchase goods and services for Medicaid recipients 540
in the most cost-effective manner consistent with the delivery 541
of quality medical care. To ensure that medical services are 542
effectively utilized, the agency may, in any case, requi re a 543
confirmation or second physician's opinion of the correct 544
diagnosis for purposes of authorizing future services under the 545
Medicaid program. This section does not restrict access to 546
emergency services or poststabilization care services as defined 547
in 42 C.F.R. s. 438.114. Such confirmation or second opinion 548
shall be rendered in a manner approved by the agency. The agency 549
shall maximize the use of prepaid per capita and prepaid 550
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aggregate fixed-sum basis services when appropriate and other 551
alternative service delivery and reimbursement methodologies, 552
including competitive bidding pursuant to s. 287.057, designed 553
to facilitate the cost -effective purchase of a case -managed 554
continuum of care. The agency shall also require providers to 555
minimize the exposure of recipients to the need for acute 556
inpatient, custodial, and other institutional care and the 557
inappropriate or unnecessary use of high -cost services. The 558
agency shall contract with a vendor to monitor and evaluate the 559
clinical practice patterns of providers in order to identify 560
trends that are outside the normal practice patterns of a 561
provider's professional peers or the national guidelines of a 562
provider's professional association. The vendor must be able to 563
provide information and counseling to a provider wh ose practice 564
patterns are outside the norms, in consultation with the agency, 565
to improve patient care and reduce inappropriate utilization. 566
The agency may mandate prior authorization, drug therapy 567
management, or disease management participation for certain 568
populations of Medicaid beneficiaries, certain drug classes, or 569
particular drugs to prevent fraud, abuse, overuse, and possible 570
dangerous drug interactions. The Pharmaceutical and Therapeutics 571
Committee shall make recommendations to the agency on drugs fo r 572
which prior authorization is required. The agency shall inform 573
the Pharmaceutical and Therapeutics Committee of its decisions 574
regarding drugs subject to prior authorization. The agency is 575
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authorized to limit the entities it contracts with or enrolls as 576
Medicaid providers by developing a provider network through 577
provider credentialing. The agency may competitively bid single -578
source-provider contracts if procurement of goods or services 579
results in demonstrated cost savings to the state without 580
limiting access to care. The agency may limit its network based 581
on the assessment of beneficiary access to care, provider 582
availability, provider quality standards, time and distance 583
standards for access to care, the cultural competence of the 584
provider network, demograp hic characteristics of Medicaid 585
beneficiaries, practice and provider -to-beneficiary standards, 586
appointment wait times, beneficiary use of services, provider 587
turnover, provider profiling, provider licensure history, 588
previous program integrity investigations and findings, peer 589
review, provider Medicaid policy and billing compliance records, 590
clinical and medical record audits, and other factors. Providers 591
are not entitled to enrollment in the Medicaid provider network. 592
The agency shall determine instances in w hich allowing Medicaid 593
beneficiaries to purchase durable medical equipment and other 594
goods is less expensive to the Medicaid program than long -term 595
rental of the equipment or goods. The agency may establish rules 596
to facilitate purchases in lieu of long -term rentals in order to 597
protect against fraud and abuse in the Medicaid program as 598
defined in s. 409.913. The agency may seek federal waivers 599
necessary to administer these policies. 600
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(11) The agency shall implement a program of all -inclusive 601
care for children. The program of all -inclusive care for 602
children shall be established to provide in -home hospice-like 603
support services to children diagnosed with a life -threatening 604
illness and enrolled in the Children's Medical Services network 605
to reduce hospitalization s as appropriate. The agency, in 606
consultation with the Department of Health, may implement the 607
program of all-inclusive care for children after obtaining 608
approval from the Centers for Medicare and Medicaid Services. 609
Section 29. Effective July 1, 2025, subsection (1) of 610
section 409.9126, Florida Statutes, is amended to read: 611
409.9126 Children with special health care needs. — 612
(1) Except as provided in subsection (4), children 613
eligible for the Children's Medical Services program who receive 614
Medicaid benefits, and other Medicaid -eligible children with 615
special health care needs, are shall be exempt from the 616
provisions of s. 409.9122 and shall be served through the 617
Children's Medical Services network established in chapter 391 . 618
Section 30. Effective July 1, 2025, paragraph (a) of 619
subsection (5) of section 409.9131, Florida Statutes, is amended 620
to read: 621
409.9131 Special provisions relating to integrity of the 622
Medicaid program.— 623
(5) DETERMINATIONS OF OVERPAYMENT. —In making a 624
determination of overpay ment to a physician, the agency must: 625
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(a) Use accepted and valid auditing, accounting, 626
analytical, statistical, or peer -review methods, or combinations 627
thereof. Appropriate statistical methods may include, but are 628
not limited to, sampling and extension t o the population, 629
parametric and nonparametric statistics, tests of hypotheses, 630
other generally accepted statistical methods, review of medical 631
records, and a consideration of the physician's client case mix. 632
Before performing a review of the physician's M edicaid records, 633
however, the agency shall make every effort to consider the 634
physician's patient case mix, including, but not limited to, 635
patient age and whether individual patients are clients of the 636
Children's Medical Services Network established in chap ter 391. 637
In meeting its burden of proof in any administrative or court 638
proceeding, the agency may introduce the results of such 639
statistical methods and its other audit findings as evidence of 640
overpayment. 641
Section 31. Effective July 1, 2025, paragraph ( e) of 642
subsection (1) of section 409.920, Florida Statutes, is amended 643
to read: 644
409.920 Medicaid provider fraud. — 645
(1) For the purposes of this section, the term: 646
(e) "Managed care plans" means a health insurer authorized 647
under chapter 624, an exclusiv e provider organization authorized 648
under chapter 627, a health maintenance organization authorized 649
under chapter 641, the Children's Medical Services Network 650
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authorized under chapter 391 , a prepaid health plan authorized 651
under this chapter, a provider serv ice network authorized under 652
this chapter, a minority physician network authorized under this 653
chapter, and an emergency department diversion program 654
authorized under this chapter or the General Appropriations Act, 655
providing health care services pursuant to a contract with the 656
Medicaid program. 657
Section 32. Effective July 1, 2025, subsection (7) of 658
section 409.962, Florida Statutes, is amended to read: 659
409.962 Definitions. —As used in this part, except as 660
otherwise specifically provided, the term: 661
(7) "Eligible plan" means a health insurer authorized 662
under chapter 624, an exclusive provider organization authorized 663
under chapter 627, a health maintenance organization authorized 664
under chapter 641, or a provider service network authorized 665
under s. 409.912(1) or an accountable care organization 666
authorized under federal law. For purposes of the managed 667
medical assistance program, the term also includes the 668
Children's Medical Services Network authorized under chapter 391 669
and entities qualified under 42 C.F.R. part 422 as Medicare 670
Advantage Preferred Provider Organizations, Medicare Advantage 671
Provider-sponsored Organizations, Medicare Advantage Health 672
Maintenance Organizations, Medicare Advantage Coordinated Care 673
Plans, and Medicare Advantage Special Needs Plans , and the 674
Program of All-inclusive Care for the Elderly. 675
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Section 33. Subsection (3) of section 409.968, Florida 676
Statutes, is amended to read: 677
409.968 Managed care plan payments. — 678
(3) Reimbursement for prescribed pediatric extended care 679
services provided to children enrolled in a managed care plan 680
under s. 409.972(1)(g) shall be paid to the prescribed pediatric 681
extended care services provider by the agency on a fee -for-682
service basis. 683
Section 34. Paragraph (g) of subsection (1) of section 684
409.972, Florida Statutes, is amended to read: 685
409.972 Mandatory and voluntary enrollment. — 686
(1) The following Medicaid -eligible persons are exempt 687
from mandatory managed care enrollment required by s. 409.965, 688
and may voluntarily choose to participate in the m anaged medical 689
assistance program: 690
(g) Children receiving services in a prescribed pediatric 691
extended care center. 692
Section 35. Except as otherwise expressly provided in this 693
act, this act shall take effect upon becoming a law. 694