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F L O R I D A H O U S E O F R E P R E S E N T A T I V E S
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; amending s. 409.974, 16
F.S.; requiring the CMS pr ogram to transfer operation 17
of certain managed care contracts from the department 18
to the agency effective on a specified date; requiring 19
the CMS program to conduct clinical eligibility 20
screening for certain children and youth with special 21
health care needs; requiring the program to provide 22
ongoing consultation to the agency for a specified 23
purpose; requiring the agency to establish specific 24
measures for evaluation of services provided to 25
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children and youth with special health care needs; 26
requiring the agency to contract with an independent 27
evaluator to conduct the evaluation of services 28
provided; specifying requirements for the evaluation; 29
requiring the agency to submit the results of the 30
evaluation to the Governor and the Legislature by a 31
specified date; amending s. 391.016, F.S.; revising 32
the purposes and functions of the CMS program; 33
amending s. 391.021, F.S.; revising definitions; 34
amending s. 391.025, F.S.; revising the scope of the 35
CMS program; amending s. 391.026, F.S.; revising the 36
powers and duties of the department to conform to 37
changes made by the act; providing for the future 38
repeal of s. 391.026(8) through (11), F.S., relating 39
to the department's oversight and administration of 40
the CMS program; repealing s. 391.028, F.S., relating 41
to administration of the program; amending s. 391.029, 42
F.S.; revising program eligibility requirements; 43
conforming provisions to changes made by the act; 44
amending s. 391.0315, F.S.; conforming provisions to 45
changes made by the act; providing for future repeal 46
of specified provisions; repealing ss. 391.035, 47
391.037, 391.045, 391.047, 391.055, and 391.071, F.S., 48
relating to provider qualifications, physicians and 49
private sector services, provider reimbursements, 50
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third-party payments, service delivery systems under 51
the program, and quality of care requirements, 52
respectively; amending s. 391.097, F.S.; conforming a 53
provision to changes made by the act; repealing part 54
II of ch. 391, F.S., consisting of ss. 391.221 and 55
391.223, F.S., relating to Children's Medical Services 56
councils and panels; amending ss. 409.166, 409.811, 57
409.813, 409.8134, 409.814, 409.815, 409.8177, 58
409.818, 409.912, 409.9126, 409.9131, 409.920, 59
409.962, 409.968, and 409.972, F.S.; conforming 60
provisions to changes made by the act; requiring the 61
Agency for Health Care Administration to develop a 62
comprehensive plan to redesign the Florida Medicaid 63
Model Waiver for home and community -based services to 64
include children who receive private duty nursing 65
services; providing requirements for the redesign of 66
waiver program; requiring the Agency for Health Care 67
Administration to submit a report to the Governor, the 68
President of the Senate, and the Speaker of the House 69
of Representatives by a specified date; providing 70
effective dates. 71
72
Be It Enacted by the Legislature o f the State of Florida: 73
74
Section 1. Transfer of operation of the Children's Medical 75
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Services Managed Care Plan. — 76
(1) Effective July 1, 2025, all statutory powers, duties, 77
functions, records, personnel, pending issues, existing 78
contracts, administrati ve authority, administrative rules, and 79
unexpended balances of appropriations, allocations, and other 80
funds for the operation of the Department of Health's Children's 81
Medical Services Managed Care Plan are transferred to the Agency 82
for Health Care Administ ration. 83
(2) The transfer of operations of the Children's Medical 84
Services Managed Care Plan does not affect the validity of any 85
judicial or administrative action pending as of 11:59 p.m. on 86
the day before the effective date of the transfer to which the 87
Department of Health's Children's Medical Services Managed Care 88
Plan is at that time a party, and the Agency for Health Care 89
Administration shall be substituted as a party in interest in 90
any such action. 91
(3) The Department of Health's Children's Medical S ervices 92
program shall collaborate with the Agency for Health Care 93
Administration in the care of children and youth with special 94
health care needs. The Department of Health's Children's Medical 95
Services program shall do all of the following: 96
(a) Conduct clinical eligibility screening for children 97
and youth with special health care needs who are eligible for or 98
enrolled in Medicaid or the Children's Health Insurance Program. 99
(b) Provide ongoing consultation to the Agency for Health 100
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Care Administration to ensure high-quality, family-centered, 101
coordinated health services within an effective system of care 102
for children and youth with special health care needs. 103
Section 2. Paragraph (d) of subsection (13) of section 104
409.906, Florida Statutes, is amended to read: 105
409.906 Optional Medicaid services. —Subject to specific 106
appropriations, the agency may make payments for services which 107
are optional to the state under Title XIX of the Social Security 108
Act and are furnished by Medicaid providers to recipients who 109
are determined to be eligible on the dates on which the services 110
were provided. Any optional service that is provided shall be 111
provided only when medically necessary and in accordance with 112
state and federal law. Optional services rendered by providers 113
in mobile units to Medicaid recipients may be restricted or 114
prohibited by the agency. Nothing in this section shall be 115
construed to prevent or limit the agency from adjusting fees, 116
reimbursement rates, lengths of stay, number of visits, or 117
number of services, o r making any other adjustments necessary to 118
comply with the availability of moneys and any limitations or 119
directions provided for in the General Appropriations Act or 120
chapter 216. If necessary to safeguard the state's systems of 121
providing services to elder ly and disabled persons and subject 122
to the notice and review provisions of s. 216.177, the Governor 123
may direct the Agency for Health Care Administration to amend 124
the Medicaid state plan to delete the optional Medicaid service 125
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known as "Intermediate Care Fa cilities for the Developmentally 126
Disabled." Optional services may include: 127
(13) HOME AND COMMUNITY -BASED SERVICES.— 128
(d) The agency shall seek federal approval to pay for 129
flexible services for persons with severe mental illness or 130
substance use disorder s, including, but not limited to, 131
temporary housing assistance. Payments may be made as enhanced 132
capitation rates or incentive payments to managed care plans 133
that meet the requirements of s. 409.968(3) s. 409.968(4). 134
Section 3. Subsection (4) of sectio n 409.974, Florida 135
Statutes, is amended to read: 136
409.974 Eligible plans. — 137
(4) CHILDREN'S MEDICAL SERVICES NETWORK.— 138
(a) The Department of Health's Children's Medical Services 139
program shall do all of the following: 140
1. Effective July 1, 2025, transfer to the agency the 141
operation of managed care contracts procured by the department 142
for Medicaid and Children's Health Insurance Program services 143
provided to children and youth with special health care needs 144
who are enrolled in the Children's Medical Services Managed Care 145
Plan. 146
2. Conduct clinical eligibility screening for children and 147
youth with special health care needs who are eligible for or are 148
enrolled in Medicaid or the Children's Health Insurance Program. 149
3. Provide ongoing consultation to the agency to ensure 150
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high-quality, family-centered, coordinated health services are 151
provided within an effective system of care for children and 152
youth with special health care needs. 153
(b) The agency shall establish specific measures of 154
access, quality, and costs of providing health care services to 155
children and youth with special health care needs. The agency 156
shall contract with an independent evaluator to conduct an 157
evaluation of services provided. The evaluation must include, 158
but need not be limited to, all of the following: 159
1. A performance comparison of plans contracted to provide 160
services to children and youth with special health care needs as 161
well as plans contracted to serve a broader population of 162
Managed Medical Assistance enrollees. The perform ance comparison 163
must be based on the measures established by the agency and 164
differentiated based on the age and medical condition or 165
diagnosis of patients receiving services under each plan. 166
2. For each plan, an assessment of cost savings, patient 167
choice, access to services, coordination of care, person -168
centered planning, health and quality -of-life outcomes, patient 169
and provider satisfaction, and provider networks and quality of 170
care. 171
172
The agency shall submit the results of the evaluation to the 173
Governor, the President of the Senate, and the Speaker of the 174
House of Representatives by January 15, 2028 Participation by 175
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the Children's Medical Services Network shall be pursuant to a 176
single, statewide contract with the agency that is not subject 177
to the procurement requirements or regional plan number limits 178
of this section. The Children's Medical Services Network must 179
meet all other plan requirements for the managed medical 180
assistance program. 181
Section 4. Subsection (1) of section 391.016, Florida 182
Statutes, is amended to read: 183
391.016 Purposes and functions. —The Children's Medical 184
Services program is established for the following purposes and 185
authorized to perform the following functions: 186
(1) Provide to children and youth with special health care 187
needs a family-centered, comprehensive, and coordinated 188
statewide managed system of care that links community -based 189
health care with multidisciplinary, regional, and tertiary 190
pediatric specialty care. The program shall coordinate and 191
maintain a consistent medical h ome for participating children. 192
Section 5. Subsections (1), (2), and (4) of section 193
391.021, Florida Statutes, are amended to read: 194
391.021 Definitions. —When used in this act, the term: 195
(2)(1) "Children's Medical Services Managed Care Plan 196
network" or "plan network" means a statewide managed care 197
service system that includes health care providers, as defined 198
in this section. 199
(1)(2) "Children and youth with special health care needs" 200
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means those children and youth younger than 21 years of age who 201
have chronic and serious physical, developmental, behavioral, or 202
emotional conditions and who require health care and related 203
services of a type or amount beyond that which is generally 204
required by children and youth. 205
(4) "Eligible individual" means a child or youth with a 206
special health care need or a female with a high -risk pregnancy, 207
who meets the financial and medical eligibility standards 208
established in s. 391.029. 209
Section 6. Subsection (1) of section 391.025, Florida 210
Statutes, is amended to read: 211
391.025 Applicability and scope. — 212
(1) The Children's Medical Services program consists of 213
the following components: 214
(a) The newborn screening program established in s. 383.14 215
and the newborn, infant, and toddler hearing screening program 216
established in s. 383.145 . 217
(b) The regional perinatal intensive care centers program 218
established in ss. 383.15 -383.19. 219
(c) The developmental evaluation and intervention program, 220
including the Early Steps Program established in ss. 391.301-221
391.308. 222
(d) The Children's Medical Services Managed Care Plan 223
through the end of June 30, 2025 network. 224
(e) The Children's Multidisciplinary Assessment Team. 225
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(f) The Medical Foster Care Program. 226
(g) The Title V Children and Youth wit h Special Health 227
Care Needs program. 228
(h) The Safety Net Program. 229
(i) Child Protection Teams and sexual abuse treatment 230
programs established under s. 39.303. 231
(j) The State Child Abuse Death Review Committee and local 232
child abuse death review committees established in s. 383.402. 233
Section 7. Section 391.026, Florida Statutes, is amended 234
to read: 235
391.026 Powers and duties of the department. —The 236
department shall have the following powers, duties, and 237
responsibilities: 238
(1) To provide or con tract for the provision of health 239
services to eligible individuals. 240
(2) To provide services to abused and neglected children 241
through Child Protection Teams pursuant to s. 39.303. 242
(3) To determine the medical and financial eligibility of 243
individuals seeking health services from the program. 244
(4) To coordinate a comprehensive delivery system for 245
eligible individuals to take maximum advantage of all available 246
funds. 247
(5) To coordinate with programs relating to children's 248
medical services in cooperation w ith other public and private 249
agencies. 250
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(6) To initiate and coordinate applications to federal 251
agencies and private organizations for funds, services, or 252
commodities relating to children's medical programs. 253
(7) To sponsor or promote grants for projects, programs, 254
education, or research in the field of children and youth with 255
special health care needs, with an emphasis on early diagnosis 256
and treatment. 257
(8) To oversee and operate the Children's Medical Services 258
Managed Care Plan through the end of June 3 0, 2025 network. 259
(9) To establish reimbursement mechanisms for the 260
Children's Medical Services network. 261
(10) To establish Children's Medical Services network 262
standards and credentialing requirements for health care 263
providers and health care services. 264
(11) To serve as a provider and principal case manager for 265
children with special health care needs under Titles XIX and XXI 266
of the Social Security Act. 267
(9)(12) To monitor the provision of health services in the 268
program, including the utilization and qua lity of health 269
services. 270
(10)(13) To administer the Children and Youth with Special 271
Health Care Needs program in accordance with Title V of the 272
Social Security Act. 273
(14) To establish and operate a grievance resolution 274
process for participants and healt h care providers. 275
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(15) To maintain program integrity in the Children's 276
Medical Services program. 277
(11)(16) To receive and manage health care premiums, 278
capitation payments, and funds from federal, state, local, and 279
private entities for the program. The d epartment may contract 280
with a third-party administrator for processing claims, 281
monitoring medical expenses, and other related services 282
necessary to the efficient and cost -effective operation of the 283
Children's Medical Services Managed Care Plan through the end of 284
June 30, 2025 network. The department is authorized to maintain 285
a minimum reserve for the Children's Medical Services network in 286
an amount that is the greater of: 287
(a) Ten percent of total projected expenditures for Title 288
XIX-funded and Title XXI -funded children; or 289
(b) Two percent of total annualized payments from the 290
Agency for Health Care Administration for Title XIX and Title 291
XXI of the Social Security Act . 292
(12)(17) To provide or contract for peer review and other 293
quality-improvement activities. 294
(13)(18) To adopt rules pursuant to ss. 120.536(1) and 295
120.54 to administer the Children's Medical Services Act. 296
(14)(19) To serve as the lead agency in administering the 297
Early Steps Program pursuant to part C of the federal 298
Individuals with Disab ilities Education Act and part III of this 299
chapter. 300
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(15) To administer the Medical Foster Care Program, 301
including all of the following: 302
(a) Recruitment, training, assessment, and monitoring for 303
the Medical Foster Care Program. 304
(b) Monitoring access a nd facilitating admissions of 305
eligible children and youth to the program and designated 306
medical foster care homes. 307
(c) Coordination with the Department of Children and 308
Families and the Agency for Health Care Administration or their 309
designees. 310
Section 8. Effective July, 1, 2025, subsections (8) 311
through (11) of section 391.026, Florida Statutes, as amended by 312
this act, are repealed. 313
Section 9. Effective July 1, 2025, section 391.028, 314
Florida Statutes, is repealed. 315
Section 10. Subsections (2) and (3) of section 391.029, 316
Florida Statutes, are amended to read: 317
391.029 Program eligibility. — 318
(2) The following individuals are eligible to receive 319
services through the program: 320
(a) Related to the regional perinatal intensive care 321
centers, a high-risk pregnant female who is enrolled in 322
Medicaid. 323
(b) Children and youth with serious special health care 324
needs from birth to 21 years of age who are enrolled in 325
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Medicaid. 326
(c) Children and youth with serious special health care 327
needs from birth to 19 year s of age who are enrolled in a 328
program under Title XXI of the Social Security Act. 329
(3) Subject to the availability of funds, the following 330
individuals may receive services through the Children's Medical 331
Services Safety Net program: 332
(a) Children and youth with serious special health care 333
needs from birth to 21 years of age who do not qualify for 334
Medicaid or Title XXI of the Social Security Act but who are 335
unable to access, due to lack of providers or lack of financial 336
resources, specialized services that are medically necessary or 337
essential family support services. Families shall participate 338
financially in the cost of care based on a sliding fee scale 339
established by the department. 340
(b) Children and youth with special health care needs from 341
birth to 21 years of age, as provided in Title V of the Social 342
Security Act. 343
(c) An infant who receives an award of compensation under 344
s. 766.31(1). The Florida Birth-Related Neurological Injury 345
Compensation Association shall reimburse the Children's Medical 346
Services Network the state's share of funding, which must 347
thereafter be used to obtain matching federal funds under Title 348
XXI of the Social Security Act. 349
Section 11. Section 391.0315, Florida Statutes, is amended 350
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to read: 351
391.0315 Benefits.—Benefits provided under the Children's 352
Medical Services Managed Care Plan program for children with 353
special health care needs shall be equivalent to benefits 354
provided to children as specified in ss. 409.905 and 409.906. 355
The department may offer additional benefits through Children's 356
Medical Services programs for early intervention services, 357
respite services, genetic testing, genetic and nutritional 358
counseling, and parent support services, if such services are 359
determined to be medically necessary. This section is repealed 360
on January 1, 2026. 361
Section 12. Section 391.035, Florida Statutes, is 362
repealed. 363
Section 13. Effective January 1, 2026, section 391.037, 364
Florida Statutes, is repealed. 365
Section 14. Section 391.045, Florida Statutes, is 366
repealed. 367
Section 15. Effective January 1, 2026, section 391.047, 368
Florida Statutes, is repealed. 369
Section 16. Effective January 1, 2026, section 391.055, 370
Florida Statutes, is repealed. 371
Section 17. Effective January 1, 2026, section 391.071, 372
Florida Statutes, is repealed. 373
Section 18. Section 391.097, Florida Statutes, is amended 374
to read: 375
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391.097 Research and evaluation. — 376
(1) The department may initiate, fund, and conduct 377
research and evaluation projects to improve the delivery of 378
children's medical services. The depar tment may cooperate with 379
public and private agencies engaged in work of a similar nature. 380
(2) The Children's Medical Services network shall be 381
included in any evaluation conducted in accordance with the 382
provisions of Title XXI of the Social Security Act as enacted by 383
the Legislature. 384
Section 19. Part II of chapter 391, Florida Statutes, 385
consisting of ss. 391.221 and 391.223, Florida Statutes, is 386
repealed, and part III of that chapter is redesignated as part 387
II. 388
Section 20. Effective July 1, 2025, paragraph (b) of 389
subsection (5) of section 409.166, Florida Statutes, is amended 390
to read: 391
409.166 Children within the child welfare system; adoption 392
assistance program.— 393
(5) ELIGIBILITY FOR SERVICES. — 394
(b) A child who is handicapped at the time of ado ption is 395
shall be eligible for services through a plan under contract 396
with the agency to serve children and youth with special heath 397
care needs the Children's Medical Services network established 398
under part I of chapter 391 if the child was eligible for such 399
services before prior to the adoption. 400
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Section 21. Effective July 1, 2025, subsection (7) of 401
section 409.811, Florida Statutes, is amended to read: 402
409.811 Definitions relating to Florida Kidcare Act. —As 403
used in ss. 409.810-409.821, the term: 404
(7) "Children's Medical Services Network" or "network" 405
means a statewide managed care service system as defined in s. 406
391.021(1). 407
Section 22. Effective July 1, 2025, subsection (1) of 408
section 409.813, Florida Statutes, is amended to read: 409
409.813 Health benefits coverage; program components; 410
entitlement and nonentitlement. — 411
(1) The Florida Kidcare program includes health benefits 412
coverage provided to children through the following program 413
components, which shall be m arketed as the Florida Kidcare 414
program: 415
(a) Medicaid; 416
(b) Medikids as created in s. 409.8132; 417
(c) The Florida Healthy Kids Corporation as created in s. 418
624.91; 419
(d) Employer-sponsored group health insurance plans 420
approved under ss. 409.810 -409.821; and 421
(e) Plans under contract with the agency to serve children 422
and youth with special health care needs The Children's Medical 423
Services network established in chapter 391 . 424
Section 23. Effective July 1, 2025, subsection (3) of 425
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section 409.8134, Florid a Statutes, is amended to read: 426
409.8134 Program expenditure ceiling; enrollment. — 427
(3) Upon determination by the Social Services Estimating 428
Conference that there are insufficient funds to finance the 429
current enrollment in the Florida Kidcare program wi thin current 430
appropriations, the program shall initiate disenrollment 431
procedures to remove enrollees, except those children enrolled 432
in a plan under contract with the agency to serve children with 433
special health care needs the Children's Medical Services 434
Network, on a last-in, first-out basis until the expenditure and 435
appropriation levels are balanced. 436
Section 24. Subsection (3) and paragraph (c) of subsection 437
(10) of section 409.814, Florida Statutes, are amended to read: 438
409.814 Eligibility. —A child who has not reached 19 years 439
of age whose family income is equal to or below 300 percent of 440
the federal poverty level is eligible for the Florida Kidcare 441
program as provided in this section. If an enrolled individual 442
is determined to be ineligible for cov erage, he or she must be 443
immediately disenrolled from the respective Florida Kidcare 444
program component. 445
(3) A Title XXI-funded child who is eligible for the 446
Florida Kidcare program who is a child with special health care 447
needs, as determined through a me dical or behavioral screening 448
instrument, is eligible for health benefits coverage from and 449
shall be assigned to and may opt out of a plan under contract 450
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with the agency to serve children with special health care needs 451
the Children's Medical Services Netwo rk. 452
(10) In determining the eligibility of a child, an assets 453
test is not required. If eligibility for the Florida Kidcare 454
program cannot be verified using reliable data sources in 455
accordance with federal requirements, each applicant shall 456
provide documentation during the application process and the 457
redetermination process, including, but not limited to, the 458
following: 459
(c) To enroll in a plan under contract with the agency to 460
service children with special health care needs the Children's 461
Medical Services Network, a completed application, including a 462
Children's Medical Services clinical screening. 463
Section 25. Effective July 1, 2025, paragraph (t) of 464
subsection (2) of section 409.815, Florida Statutes, is amended 465
to read: 466
409.815 Health benefits cove rage; limitations.— 467
(2) BENCHMARK BENEFITS. —In order for health benefits 468
coverage to qualify for premium assistance payments for an 469
eligible child under ss. 409.810 -409.821, the health benefits 470
coverage, except for coverage under Medicaid and Medikids, m ust 471
include the following minimum benefits, as medically necessary. 472
(t) Enhancements to minimum requirements. — 473
1. This section sets the minimum benefits that must be 474
included in any health benefits coverage, other than Medicaid or 475
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Medikids coverage, of fered under ss. 409.810 -409.821. Health 476
benefits coverage may include additional benefits not included 477
under this subsection, but may not include benefits excluded 478
under paragraph (r). 479
2. Health benefits coverage may extend any limitations 480
beyond the minimum benefits described in this section. 481
482
Except for a plan under contract with the agency to serve 483
children with special health care needs the Children's Medical 484
Services Network, the agency may not increase the premium 485
assistance payment for either addit ional benefits provided 486
beyond the minimum benefits described in this section or the 487
imposition of less restrictive service limitations. 488
Section 26. Effective July 1, 2025, paragraph (i) of 489
subsection (1) of section 409.8177, Florida Statutes, is amend ed 490
to read: 491
409.8177 Program evaluation. — 492
(1) The agency, in consultation with the Department of 493
Health, the Department of Children and Families, and the Florida 494
Healthy Kids Corporation, shall contract for an evaluation of 495
the Florida Kidcare program and shall by January 1 of each year 496
submit to the Governor, the President of the Senate, and the 497
Speaker of the House of Representatives a report of the program. 498
In addition to the items specified under s. 2108 of Title XXI of 499
the Social Security Act, the report shall include an assessment 500
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of crowd-out and access to health care, as well as the 501
following: 502
(i) An assessment of the effectiveness of the Florida 503
Kidcare program, including Medicaid, the Florida Healthy Kids 504
program, Medikids, and the plans under contract with the agency 505
to serve children with special health care needs Children's 506
Medical Services network , and other public and private programs 507
in the state in increasing the availability of affordable 508
quality health insurance and health care fo r children. 509
Section 27. Effective July 1, 2025, subsection (4) of 510
section 409.818, Florida Statutes, is amended to read: 511
409.818 Administration. —In order to implement ss. 409.810 -512
409.821, the following agencies shall have the following duties: 513
(4) The Office of Insurance Regulation shall certify that 514
health benefits coverage plans that seek to provide services 515
under the Florida Kidcare program, except those offered through 516
the Florida Healthy Kids Corporation or the Children's Medical 517
Services Network, meet, exceed, or are actuarially equivalent to 518
the benchmark benefit plan and that health insurance plans will 519
be offered at an approved rate. In determining actuarial 520
equivalence of benefits coverage, the Office of Insurance 521
Regulation and health insu rance plans must comply with the 522
requirements of s. 2103 of Title XXI of the Social Security Act. 523
The department shall adopt rules necessary for certifying health 524
benefits coverage plans. 525
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Section 28. Effective July 1, 2025, subsection (11) of 526
section 409.912, Florida Statutes, is amended to read: 527
409.912 Cost-effective purchasing of health care. —The 528
agency shall purchase goods and services for Medicaid recipients 529
in the most cost-effective manner consistent with the delivery 530
of quality medical care. T o ensure that medical services are 531
effectively utilized, the agency may, in any case, require a 532
confirmation or second physician's opinion of the correct 533
diagnosis for purposes of authorizing future services under the 534
Medicaid program. This section does no t restrict access to 535
emergency services or poststabilization care services as defined 536
in 42 C.F.R. s. 438.114. Such confirmation or second opinion 537
shall be rendered in a manner approved by the agency. The agency 538
shall maximize the use of prepaid per capita and prepaid 539
aggregate fixed-sum basis services when appropriate and other 540
alternative service delivery and reimbursement methodologies, 541
including competitive bidding pursuant to s. 287.057, designed 542
to facilitate the cost -effective purchase of a case -managed 543
continuum of care. The agency shall also require providers to 544
minimize the exposure of recipients to the need for acute 545
inpatient, custodial, and other institutional care and the 546
inappropriate or unnecessary use of high -cost services. The 547
agency shall contract with a vendor to monitor and evaluate the 548
clinical practice patterns of providers in order to identify 549
trends that are outside the normal practice patterns of a 550
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provider's professional peers or the national guidelines of a 551
provider's professional association. The vendor must be able to 552
provide information and counseling to a provider whose practice 553
patterns are outside the norms, in consultation with the agency, 554
to improve patient care and reduce inappropriate utilization. 555
The agency may mandate pr ior authorization, drug therapy 556
management, or disease management participation for certain 557
populations of Medicaid beneficiaries, certain drug classes, or 558
particular drugs to prevent fraud, abuse, overuse, and possible 559
dangerous drug interactions. The Pha rmaceutical and Therapeutics 560
Committee shall make recommendations to the agency on drugs for 561
which prior authorization is required. The agency shall inform 562
the Pharmaceutical and Therapeutics Committee of its decisions 563
regarding drugs subject to prior auth orization. The agency is 564
authorized to limit the entities it contracts with or enrolls as 565
Medicaid providers by developing a provider network through 566
provider credentialing. The agency may competitively bid single -567
source-provider contracts if procurement o f goods or services 568
results in demonstrated cost savings to the state without 569
limiting access to care. The agency may limit its network based 570
on the assessment of beneficiary access to care, provider 571
availability, provider quality standards, time and dista nce 572
standards for access to care, the cultural competence of the 573
provider network, demographic characteristics of Medicaid 574
beneficiaries, practice and provider -to-beneficiary standards, 575
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appointment wait times, beneficiary use of services, provider 576
turnover, provider profiling, provider licensure history, 577
previous program integrity investigations and findings, peer 578
review, provider Medicaid policy and billing compliance records, 579
clinical and medical record audits, and other factors. Providers 580
are not entitled to enrollment in the Medicaid provider network. 581
The agency shall determine instances in which allowing Medicaid 582
beneficiaries to purchase durable medical equipment and other 583
goods is less expensive to the Medicaid program than long -term 584
rental of the equipment or goods. The agency may establish rules 585
to facilitate purchases in lieu of long -term rentals in order to 586
protect against fraud and abuse in the Medicaid program as 587
defined in s. 409.913. The agency may seek federal waivers 588
necessary to administer t hese policies. 589
(11) The agency shall implement a program of all -inclusive 590
care for children. The program of all -inclusive care for 591
children shall be established to provide in -home hospice-like 592
support services to children diagnosed with a life -threatening 593
illness and enrolled in the Children's Medical Services network 594
to reduce hospitalizations as appropriate. The agency, in 595
consultation with the Department of Health, may implement the 596
program of all-inclusive care for children after obtaining 597
approval from the Centers for Medicare and Medicaid Services. 598
Section 29. Effective July 1, 2025, subsection (1) of 599
section 409.9126, Florida Statutes, is amended to read: 600
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409.9126 Children with special health care needs. — 601
(1) Except as provided in subsection (4), children 602
eligible for the Children's Medical Services program who receive 603
Medicaid benefits, and other Medicaid -eligible children with 604
special health care needs, are shall be exempt from the 605
provisions of s. 409.9122 and shall be served through the 606
Children's Medical Services network established in chapter 391 . 607
Section 30. Effective July 1, 2025, paragraph (a) of 608
subsection (5) of section 409.9131, Florida Statutes, is amended 609
to read: 610
409.9131 Special provisions relating to integrity of the 611
Medicaid program.— 612
(5) DETERMINATIONS OF OVERPAYMENT. —In making a 613
determination of overpayment to a physician, the agency must: 614
(a) Use accepted and valid auditing, accounting, 615
analytical, statistical, or peer -review methods, or combinations 616
thereof. Appropriate statistical methods may include, but are 617
not limited to, sampling and extension to the population, 618
parametric and nonparametric statistics, tests of hypotheses, 619
other generally accepted statistical methods, review of medical 620
records, and a conside ration of the physician's client case mix. 621
Before performing a review of the physician's Medicaid records, 622
however, the agency shall make every effort to consider the 623
physician's patient case mix, including, but not limited to, 624
patient age and whether individual patients are clients of the 625
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Children's Medical Services Network established in chapter 391 . 626
In meeting its burden of proof in any administrative or court 627
proceeding, the agency may introduce the results of such 628
statistical methods and its other audi t findings as evidence of 629
overpayment. 630
Section 31. Effective July 1, 2025, paragraph (e) of 631
subsection (1) of section 409.920, Florida Statutes, is amended 632
to read: 633
409.920 Medicaid provider fraud. — 634
(1) For the purposes of this section, the term: 635
(e) "Managed care plans" means a health insurer authorized 636
under chapter 624, an exclusive provider organization authorized 637
under chapter 627, a health maintenance organization authorized 638
under chapter 641, the Children's Medical Services Network 639
authorized under chapter 391 , a prepaid health plan authorized 640
under this chapter, a provider service network authorized under 641
this chapter, a minority physician network authorized under this 642
chapter, and an emergency department diversion program 643
authorized under this chapter or the General Appropriations Act, 644
providing health care services pursuant to a contract with the 645
Medicaid program. 646
Section 32. Effective July 1, 2025, subsection (7) of 647
section 409.962, Florida Statutes, is amended to read: 648
409.962 Definitions.—As used in this part, except as 649
otherwise specifically provided, the term: 650
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(7) "Eligible plan" means a health insurer authorized 651
under chapter 624, an exclusive provider organization authorized 652
under chapter 627, a health maintenance organizatio n authorized 653
under chapter 641, or a provider service network authorized 654
under s. 409.912(1) or an accountable care organization 655
authorized under federal law. For purposes of the managed 656
medical assistance program, the term also includes the 657
Children's Medical Services Network authorized under chapter 391 658
and entities qualified under 42 C.F.R. part 422 as Medicare 659
Advantage Preferred Provider Organizations, Medicare Advantage 660
Provider-sponsored Organizations, Medicare Advantage Health 661
Maintenance Organizati ons, Medicare Advantage Coordinated Care 662
Plans, and Medicare Advantage Special Needs Plans, and the 663
Program of All-inclusive Care for the Elderly. 664
Section 33. Subsection (3) of section 409.968, Florida 665
Statutes, is amended to read: 666
409.968 Managed care plan payments.— 667
(3) Reimbursement for prescribed pediatric extended care 668
services provided to children enrolled in a managed care plan 669
under s. 409.972(1)(g) shall be paid to the prescribed pediatric 670
extended care services provider by the agency on a fee-for-671
service basis. 672
Section 34. Paragraph (g) of subsection (1) of section 673
409.972, Florida Statutes, is amended to read: 674
409.972 Mandatory and voluntary enrollment. — 675
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(1) The following Medicaid -eligible persons are exempt 676
from mandatory managed care enrollment required by s. 409.965, 677
and may voluntarily choose to participate in the managed medical 678
assistance program: 679
(g) Children receiving services in a prescribed pediatric 680
extended care center. 681
Section 35. The Agency for Health Care Admini stration 682
shall develop a comprehensive plan to redesign the Florida 683
Medicaid Model Waiver for home and community -based services to 684
include children who receive private duty nursing services. The 685
plan must propose an array of tiered services with the goal o f 686
ensuring that institutional care is avoided so children can 687
remain in the home or other community setting. The agency must 688
work with stakeholders in developing the plan, including, but 689
not limited to, families of children who are in the model waiver 690
or receiving private duty nursing, advocates for children, 691
providers of services to children receiving private duty 692
nursing, and Statewide Medicaid Managed Care plans. The agency 693
is authorized to contract with necessary experts to assist in 694
developing the plan. The agency must submit a report to the 695
Governor, the President of the Senate, and the Speaker of the 696
House of Representatives by September 30, 2025, addressing, at a 697
minimum, all of the following: 698
(1) The purpose, rationale, and expected benefits of the 699
redesigned waiver plan. 700
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(2) The proposed eligibility criteria for clients and 701
service benefit packages to be offered through the redesigned 702
waiver plan. Managed care plans participating in the Statewide 703
Medicaid Managed Care program must provide serv ices under the 704
redesigned waiver plan. 705
(3) A proposed implementation plan and timeline, 706
including, but not limited to, recommendations for the number of 707
clients served by the redesigned waiver plan at initial 708
implementation, changes over time, and any pe r-client benefit 709
caps. 710
(4) The fiscal impact for the implementation year and 711
projections for the next 5 years determined on an actuarially 712
sound basis. 713
(5) An analysis of the availability of services and 714
service providers that would be offered under th e redesigned 715
waiver plan and recommendations to increase availability of such 716
services, as applicable. 717
(6) A list of all stakeholders, public and private, who 718
were consulted or contacted the development of the plan. 719
Section 36. Except as otherwise ex pressly provided in this 720
act, this act shall take effect upon becoming a law. 721