STORAGE NAME: h1085b.HCB
DATE: 4/14/2025
1
FLORIDA HOUSE OF REPRESENTATIVES
BILL ANALYSIS
This bill analysis was prepared by nonpartisan committee staff and does not constitute an official statement of legislative intent.
BILL #: CS/HB 1085
TITLE: Children's Medical Services Program
SPONSOR(S): Oliver
COMPANION BILL: CS/SB 1490 (Harrell)
LINKED BILLS: None
RELATED BILLS: SB 1166 (Harrell)
Committee References
Health Care Facilities & Systems
14 Y, 3 N, As CS
Health Care Budget
Health & Human Services
SUMMARY
Effect of the Bill:
CS/HB 1085 requires the Department of Health (DOH) to transfer all of the Children’s Medical Services (CMS)
Managed Care Plan contracts, which serve children and youth with special health care needs (CYSHCN), to the
Agency for Health Care Administration (AHCA), beginning in the 2025-2026 fiscal year. The bill requires AHCA to
redesign the Medicaid Model Waiver to include a new tiered service array for CYSHCN receiving private duty
nursing services. The bill shifts prescribed pediatric extended care services from a fee-for-service delivery model to
a managed care delivery model. The bill requires a multiyear evaluation that analyzes the state’s current health
care model of service for medically fragile children.
Fiscal or Economic Impact:
The transfer of staff from DOH’s CMS Division to AHCA is budget neutral. The redesign of the Medicaid Model
Wavier has an indeterminate fiscal impact that will depend on the ultimate program design and the enrollment
level funded by the legislature. The transfer of prescribed pediatric extended care services from a fee-for-service
delivery system to a managed care delivery system has an indeterminate impact.
JUMP TO SUMMARY ANALYSIS RELEVANT INFORMATION BILL HISTORY
ANALYSIS
EFFECT OF THE BILL:
Florida Medicaid
Children’s Medical Services Managed Care Plan
The Agency for Health Care Administration (AHCA) is responsible for the administration of the Florida Medicaid
program, which includes administration of the Statewide Medicaid Managed Care (SMMC) program, by which
AHCA contracts with managed care plans to deliver health care services to Medicaid recipients. Each plan in the
SMMC program delivers comprehensive, integrated services. The Department of Health (DOH), through its
Children’s Medical Services (CMS) Division, currently administers a specialty Medicaid managed care program for
children and youth with special health care needs (CYSHCN), under AHCA’s SMMC program.
CS/HB 1085 requires DOH to transfer all of the CMS Managed Care Plan contracts to AHCA, beginning with the
2025-2026 fiscal year. Along with the contracts, the bill requires the DOH CMS Division to transfer all statutory
powers, duties, responsibilities, functions, records, personnel, pending issues, existing contracts, administrative
authority, administrative rules, and unexpended balances of appropriations, allocations, and other funds for the
operation of DOH CMS Managed Care Plan to AHCA, beginning with the 2025-2026 fiscal year. The bill replaces
DOH with AHCA, effective July 1, 2025, as the party of interest in the outstanding judicial and administrative
actions to which the CMS Managed Care Plan is a party. (Sections 1 and 3).
JUMP TO SUMMARY ANALYSIS RELEVANT INFORMATION BILL HISTORY
2
While AHCA will administer the CMS Managed Care Plan under the bill, the CMS Division at DOH will continue to
make clinical eligibility determinations for enrollment in the CMS Managed Care Plan. (Sections 1 and 3).
The bill makes numerous conforming changes in the CMS Division statutes to reflect these changes. (Sections 5, 7,
8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, and 32).
Medicaid Model Waiver
Currently, the Medicaid program administers a “Model Waiver” which authorizes Florida to provide home and
community-based services (HCBS), and to avoid institutional care, for children 20 years of age or younger who
either have a degenerative spinocerebellar disease diagnosis or have resided in a pediatric nursing facility for at
least 60 consecutive days, require hospital level care, and are medically fragile. However, this Medicaid waiver
program caps enrollment slots at 20 and excludes certain children receiving private duty nursing services.
The bill requires AHCA to develop a comprehensive plan to redesign the Medicaid Model Waiver for HCBS to serve
children who receive private duty nursing (PDN). The bill requires the plan to propose an array of tiered services
for this population group, with the intention to keep certain medically fragile children from institutional care so
that they can remain at home or in a community-based setting. The bill requires AHCA to work inclusively with
private sector stakeholders, which must, at a minimum, include the families of children who are either Medicaid
Model Waiver enrollees or PDN recipients, advocates for children, PDN service providers, and the SMMC plans.
The bill authorizes AHCA to contract with necessary experts for assistance in the development of the
comprehensive plan. (Section 35).
By September 30, 2025, the bill requires AHCA to submit a report, which must describe certain proposed decisions
made about the redesign of the Medicaid Model Wavier, to the Governor, the President of the Senate, and the
Speaker of the House. This bill requires the report to address, at a minimum, seven decision points:
The purpose, rationale, and expected benefits of the redesigned waiver plan.
The proposed eligibility criteria for clients and service benefit package that the managed care plans
participating in the SMMC program must provide under the redesigned Medicaid Model Waiver.
The proposed implementation plan and timeline for the redesigned Medicaid Model Waiver, which must
include, but is not limited to, recommendations for the number of clients served at initial rollout, changes
over time and recommendations for any per-client benefit caps.
The estimated, actuarially-sound, fiscal impact for Year 1 (implementation year) and for Years 2-6 of the
redesigned Medicaid Model Wavier.
A market analysis that estimates the anticipated availability of services and service providers under the
redesigned Medical Model Wavier and that proposes recommendations, if necessary, to increase the
availability of services.
A list of all public and private stakeholders who AHCA consulted or contacted in the development of the
comprehensive plan to redesign the Medicaid Model Waiver. (Section 35).
Medicaid Managed Care Performance Measures
Current law requires AHCA to establish performance measures and standards for SMMC plans, including network
adequacy, financial accountability, and patient outcome metrics. AHCA is required to use the federal Healthcare
Effectiveness Data and Information Set (HEDIS), other federally-established metrics, and other metrics established
by the agency to hold plans accountable for patient outcomes.
1 AHCA has broad authority in current law to
establish any patient outcome performance metric.
The bill requires AHCA to establish specific metrics for healthcare access, quality, and costs regarding medically
fragile children, and evaluate plan performance based on those metrics. (Section 3).
In addition, AHCA must contract with an independent evaluator to perform a multi-year comparative analysis of
managed care plans serving medically fragile children in the SMMC program, factoring variables of age and medical
1 S. 409.967, F.S. JUMP TO SUMMARY ANALYSIS RELEVANT INFORMATION BILL HISTORY
3
condition and diagnosis. The comparative analysis must also assess cost savings, patient choice, access to services,
care coordination, person-centered planning, health and quality-of-life outcomes, patient and provider satisfaction,
and provider networks and quality of care. The bill requires AHCA to submit the results of the independent
evaluation to the Governor, the President of the Senate, and the Speaker of the House by January 15, 2028. (Section
3).
Prescribed Pediatric Extended Care
Prescribed Pediatric Extended Care (PPEC) centers provide skilled nursing supervision and therapeutic
interventions in a non-residential setting to medically dependent or technologically dependent recipients.
Currently, Medicaid covers PPEC services using a fee-for-service model; these services are not included in the
SMMC program.
2
The bill eliminates the current fee-for-service carveout for PPEC centers, allowing Medicaid to cover PPEC services
under the managed care delivery model within the SMMC program. (Section 33). Under the bill, PPEC providers
will need to contract with SMMC managed care plans to receive reimbursement, and these services will be
integrated with the larger Medicaid program. To conform to this change, the bill eliminates the exemption for
children receiving PPEC services from enrollment in managed care.
3 (Section 34).
Department of Health Children’s Medical Services Division
The Children’s Medical Services Act of 1978 established the Children’s Medical Services (CMS) Division within the
Department of Health (DOH) to provide medical services to children with special health care needs, particularly
those with chronic, crippling or potentially crippling, and physically disabling diseases or conditions.
4 Current law
advises the CMS Division to provide essential preventative, evaluative, and early intervention services for children
at risk for or having special health care needs, in order to prevent or reduce long-term disabilities.
5
Although the CMS Division has an organizing statute, s. 391.025, F.S., that itemizes its various service programs,
this organizing statute does not include every service program the CMS Division administers.
The CMS Division organizing statute, s. 391.025, F.S., includes the following medical service programs:
A newborn screening program to identify metabolic disorders, other hereditary and congenital disorders,
and environmental risk factors.
6
A regional perinatal intensive care center program to provide a full range of health services to certain
women experiencing high-risk pregnancies and certain newborn infants requiring intensive care.
7
The “Early Steps Program” to provide evaluations and early interventions to infants and toddlers at risk of
developmental disabilities and developmental delays.
8
The Children’s Medical Services (CMS) Managed Care Plan
9 to serve children and youth with special health
care needs in a family-centered, comprehensive, and coordinated statewide managed system of care. The
CMS unit links community-based health care with multidisciplinary, regional, and tertiary pediatric
specialty care while prioritizing consistent medical homes for these children.
10
Florida law codifies other CMS Division medical service programs outside of the CMS organizing statute, s. 391.025,
F.S., which includes the following medical service programs:
2 S. 409.968, F.S.
3 S. 409.972, F.S.
4 Ch. 78-106, L.O.F. See Sections 1 and 2.
5 S. 391.016, F.S.
6 S. 383.14, F.S.
7 S. 383.16, F.S., s. 383.17, F.S.
8 S. 391.301, F.S., s. 391.308, F.S.
9
Chapter 391 refers to the CMS Managed Care Plan as the CMS Network. DOH previously administered the CMS managed care plan as a
provider-based fee-for-service program. In August 2014, the CMS program transformed into a managed care plan within AHCA’s statewide
managed care model. However, DOH remains responsible for administering the CMS program. Department of Health, Agency Analysis of
2023 House Bill 1503, see p. 5, (Feb. 24, 2023).
10 S. 391.016, F.S. JUMP TO SUMMARY ANALYSIS RELEVANT INFORMATION BILL HISTORY
4
The state and local Child Abuse Death Review program to understand and address the causes and
contributing factors of deaths resulting from child abuse, to identify service delivery gaps, and to
recommend and implement changes in law, rule, or public policy.
11
The Child Protection Team program to provide specialized diagnostic assessments, medical evaluations,
expert testimony in court cases, and case managers to develop treatment plans for children referred by the
Department of Children and Families.
12
The Poison Information Center Network program to provide 24/7 emergency poison information through
a toll-free hotline. CMS coordinates all of the regional poison control centers.
13
A sexual abuse treatment program to provide specialized therapeutic treatment (i.e., crisis intervention,
clinical treatment, and therapy) that assists a victim’s recovery from sexual abuse, prevents developmental
impairment, restores the child’s developmental functioning, and promotes healthy, non-abusive
relationships.
14
A Title V block-grant-supported program to serve children and youth with chronic and serious physical,
developmental, behavioral, or emotional conditions.
15
The Safety Net program to serve children with chronic health conditions who do not qualify for Florida
Medicaid or KidCare on a first-come, first-served basis, subject to appropriations.
16
The CMS Division also administers two programs without express statutory authority, pursuant to its general
directives under the Children’s Medical Services Act:
The Children’s Multidisciplinary Assessment Team (CMAT) interagency program to assess the level of care
that a child with special health care needs, with due consideration to medical, emotional, psychosocial, and
environmental factors, and to determine the appropriateness of pediatric nursing facility admission.
However, AHCA regulations speak to the requirement of the CMAT to make recommendations for the
placement of a Medicaid applicant or recipient.
17 There is no reciprocal DOH regulation and no statute for
DOH to implement this program.
The Medical Foster Care program to offer medical support, care coordination, and referrals to children
residing in a family-based medical foster home. However, this program refers to medical family foster
homes, which are licensed by the Department of Children and Families. and are certified by AHCA.
18 There
is no clearly identifiable statutory authority for CMS to participate in the administration of the medical
foster care program.
The bill codifies, within the CMS Division organizing statute, s. 391.025, F.S., the six CMS Division programs that
current law authorizes elsewhere in the Florida Statutes: the state and local Child Abuse Death Review program,
the Child Protection Team program, the Poison Information Center Network, the sexual abuse treatment program,
Title V block-grant-supported program, and the Safety Net program. (Section 6).
The bill establishes, within the CMS Division organizing statute, s. 391.025, F.S., the two CMS Division programs
that current law does not expressly authorize: the Children’s Multidisciplinary Assessment Team program and the
Medical Foster Care program. (Sections 6). The bill vests the CMS Division with the responsibility to perform the
11 S. 383.402(1), F.S.
12 S. 39.303(3), F.S.
13 S. 395.1027(4), F.S. Florida Poison Control Centers, Mission & Services, https://floridapoisoncontrol.org/about-the-network/mission-
services/ (last visited April 11, 2025).
14 S. 39.303(10), F.S.
15 s. 391.026(13), F.S. Department of Health, CMS Title V Program, (last updated Nov. 10, 2021) https://www.floridahealth.gov/programs-
and-services/childrens-health/cms-specialty-programs/title-5-program/index.html (last visited April 11, 2025).
16 S. 391.029(3)(a), F.S., Rule 64C-2.004, F.A.C., Florida Department of Health, Safety Net Program, (last updated Mar. 16, 2023)
https://www.floridahealth.gov/programs-and-services/childrens-health/cms-specialty-programs/safety-net/index.html (last visited April
11, 2025).
17 Rule 59A-4.1295(3)(b), F.A.C. Current law requires AHCA to make rules setting minimum standards of care and minimum staffing
requirements for nursing homes serving children and youth. AHCA must collaborate with the CMS Division to exercise AHCA rulemaking
authority. See s. 400.23(5), F.S.
18 See Rule 59G-4.197, F.A.C., See s. 409.903, F.S., See s. 409.175(5)(a)5. Department of Health, Medical Foster Care, (last updated Feb. 6,
2025) https://www.floridahealth.gov/programs-and-services/childrens-health/cms-specialty-programs/medical-foster-care/index.html
(last visited April 11, 2025). See Department of Children and Families, Foster Home Licensing: Levels of Foster Care Licensure,
https://www.myflfamilies.com/services/licensing/foster-care-licensing (last visited April 11, 2025). License Level V is the Medical Foster
Home license. JUMP TO SUMMARY ANALYSIS RELEVANT INFORMATION BILL HISTORY
5
following components of the Medical Foster Care program: recruitment, training, program assessment, program
monitoring, access monitoring so that eligible children receive medical foster care, admission assistance enter the
medical foster care program, and coordination with the Department of Children and Families and the AHCA.
(Section 7).
The effective date of the bill, unless otherwise expressly provided, is upon the bill becoming a law. (Section 36).
RULEMAKING:
The bill expands the DOH CMS Division’s existing rulemaking authority under s. 391.026(18), F.S., to administer
the Children’s Medical Services Act, specifically to adopt rules to administer the Children’s Multidisciplinary
Assessment Team program, the Medical Foster Care program, the Title V Children and Youth for Special Health
Care Needs program, the Safety Net program, the Child Protection Team program, the sexual abuse treatment
program, and the state and local Child Abuse Death Review committees. (Section 6).
Lawmaking is a legislative power; however, the Legislature may delegate a portion of such power to executive
branch agencies to create rules that have the force of law. To exercise this delegated power, an agency must
have a grant of rulemaking authority and a law to implement.
FISCAL OR ECONOMIC IMPACT:
STATE GOVERNMENT:
According to AHCA, the transfer of the CMS plan from DOH to AHCA will require the transfer of four full-time
equivalent (FTE) positions with associated salary rate of 253,800 and associated budget authority of $385,458 in
multiple appropriation categories to support the transfer of 4 FTEs from DOH to AHCA.
19 The transfer of FTE,
associated salary rate and funding are provided for this purpose in HB 5001, the House of Representatives General
Appropriations Act.
The redesign of the Medicaid Model Wavier has an indeterminate fiscal impact that will depend on the ultimate
program design and the enrollment level funded by the legislature.
AHCA anticipates an indeterminate costs savings to the state for transferring PPEC from the fee-for-service only
delivery system to the managed care delivery system, as Medicaid managed care plans are paid a fixed per-
member-per-month (PMPM) payment to provide care for their enrollees. While managed care plans have
incentives to control costs through coordinated care, preventative services, and managing chronic conditions, they
also have the flexibility to pay higher rates for services than the Medicaid FFS delivery system.
20
RELEVANT INFORMATION
SUBJECT OVERVIEW:
Florida Medicaid
Medicaid is the health care safety net for low-income Floridians. Medicaid is a partnership of the federal and state
governments established to provide coverage for health services for eligible persons. The Agency for Health Care
Administration (AHCA) is responsible for administering the Medicaid Program, licensing and regulating health
facilities, and providing health care quality and price information to Floridians.
21 The Department of Children and
Families makes Medicaid eligibility determinations.
22
19 Agency for Health Care Administration, Agency Analysis of 2025 House Bill 1085, pp. 1, 7-8 (Mar. 3, 2025).
20 Agency for Health Care Administration, Agency Analysis of 2025 House Bill 1085, pp. 1, 7-8 (Mar. 3, 2025).
21
Office of Program Policy Analysis and Government Accountability, Agency for Health Care Administration,
https://oppaga.fl.gov/ProgramSummary/ProgramDetail?programNumber=5048 (last visited April 11, 2025).
22 Agency for Health Care Administration, Agency Analysis of 2025 House Bill 1085, pp. 1 (Mar. 3, 2025). JUMP TO SUMMARY ANALYSIS RELEVANT INFORMATION BILL HISTORY
6
The structure of each state’s Medicaid program varies, but what states must pay for is largely determined by the
federal government, as a condition of receiving federal funds.
23 The federal government also sets the minimum
mandatory benefits to be covered in every state’s Medicaid program.
24
As of January 2025, Florida Medicaid recorded an enrollment total of 4,213,073 people, with 71% enrolled in
managed care plans, 28% enrolled in fee-for-service plans, and 1% enrolled in the Program of All-Inclusive Care for
the Elderly (PACE).
25, 26
Medicaid Managed Care
States may deliver Medicaid services to most enrollees through state-level contracts with comprehensive, risk-
based managed care plans, which are often administered by private insurance companies. Instead of the traditional
Medicaid fee-for-service model, states pay managed care organizations a fixed per member per month payment for
primary care and acute services.
27
States can use a managed care delivery system by getting a state plan amendment approved by the federal
government. While the state plan authority does not have an expiration date, this authority does not allow states to
require dual eligible persons, indigenous groups, or children with special health care needs to enroll in a managed
care program.
28
Alternatively, states may select waiver vehicles, subject to federal approval, to test new or existing ways to deliver
and pay for health care services in Medicaid and the Children’s Health Insurance Program (CHIP).
29
Section 1115 of the Social Security Act allows states to implement demonstrations of innovative service
delivery systems that improve care, increase efficiency, and reduce costs. These laws allow HHS to waive
federal requirements to expand populations or services, or to try new ways of service delivery.
Demonstrations must be “budget neutral" to the federal government, and states commonly request and
receive additional 5-year extension approvals.
30
Section 1915(a) of the Social Security Act allows states to implement a voluntary managed care delivery
system by contract through competitive procurement.
31
Section 1915(b) of the Social Security Act allows states to implement a mandatory managed care delivery
system using a freedom of choice waiver (to restrict service array), an enrollment broker waiver (to use a
centralized broker), a Non-Medicaid services waiver (to direct cost-savings towards add-on benefits for
23 Title 42 U.S.C. §§ 1396-1396w -5; Title 42 C.F.R. Part 430-456 (§§ 430.0-456.725).
24 S. 409.905, F.S. Florida Medicaid Managed Care sets a minimum benefit package that build on top of the federal minimum benefits
package. S. 409.973, F.S.
25 The Program of All-Inclusive Care for the Elderly (PACE) is a Medicare and Medicaid program that helps people meet their health care
needs in the community instead of going to a nursing home or other care facility. Medicaid, PACE, https://www.medicare.gov/health-drug-
plans/health-plans/your-coverage-options/other-medicare-health-plans/PACE (last visited April 11, 2025).
26 Florida Agency for Health Care Administration, Current Comprehensive Medicaid Managed Care Enrollment Reports, (Jan. 2025)
https://ahca.myflorida.com/medicaid/medicaid-finance-and-analytics/medicaid-data-analytics/medicaid-monthly-enrollment-report (last
visited April 11, 2025). Select the “Medicaid” tab on the lower toolbar of the Excel Spreadsheet.
27 Robin Rudowitz, Jennifer Tolbert, Alice Burns, Elizabeth Hinton, and Anna Mudumala, Medicaid 101, KFF (May 28, 2024)
https://www.kff.org/health-policy-101-medicaid/?entry=table-of-contents-how-are-medicaid-services-delivered (last visited April 11,
2023). Scroll to the “How Are Medicaid Services Delivered?” section.
28 Medicaid, Managed Care Authorities: 1932(a) State Plan Basics, https://www.medicaid.gov/medicaid/managed-care/managed-care-
authorities/index.html (last visited April 11, 2025).
29 Medicaid, State Waivers List: Florida, Centers for Medicare & Medicaid Services, https://www.medicaid.gov/medicaid/section-1115-
demo/demonstration-and-waiver-
list/index.html?f%5B0%5D=state_waiver_status_facet%3A1561&f%5B1%5D=waiver_state_facet%3A756#content (last visited April 11,
2025).
30 Elizabeth Hinton and Amaya Diana, Medicaid Section 1115 Waivers: The Basics, KFF (Jan. 24, 2025) https://www.kff.org/medicaid/issue-
brief/medicaid-section-1115-waivers-the-basics/ (last visited April 11, 2025); Medicaid, About Section 1115 Demonstrations,
https://www.medicaid.gov/medicaid/section-1115-demonstrations/about-section-1115-demonstrations/index.html (last visited April 11,
2025).
31 Medicaid, Managed Care Authorities: 1915(a) Waiver Basics, https://www.medicaid.gov/medicaid/managed-care/managed-care-
authorities/index.html (last visited April 11, 2025). JUMP TO SUMMARY ANALYSIS RELEVANT INFORMATION BILL HISTORY
7
enrollees), and a selective contracting waiver (to restrict the provider network). 1915(b) waivers are valid
for two-year renewable terms.
32
Section 1915(c) of the Social Security Act allows states to implement home and community-based services
(HCBS) for certain population groups by waiving Medicaid rules governing institutional care.
33
Managed Medical Assistance
The Managed Medical Assistance program is a Section 1115 waiver, valid through June 30, 2030, that authorizes
Florida to use a comprehensive Statewide Medicaid Managed Care (SMMC) delivery model for primary and acute
care services.
34 In addition to standard managed care, specialty plans serve distinct populations, such as the
Children’s Medical Services Managed Care Plan for children with special health care needs, or those in the child
welfare system. Medicaid recipients with HIV/AIDS, serious mental illness, dual enrollment with Medicare, chronic
obstructive pulmonary disease, congestive heart failure, or cardiovascular disease may also select from specialized
plans.
On February 1, 2025, AHCA consolidated 11 SMMC regions into 9 SMMC regions, and the map below illustrates the
9 new SMMC regions.
35
On February 1, 2025, AHCA entered into new managed care contracts with health and dental plans, which the chart
below depicts.
36
32 Medicaid, Managed Care Authorities: 1915(b) Waiver Basics, https://www.medicaid.gov/medicaid/managed-care/managed-care-
authorities/index.html (last visited April 11, 2025).
33 Medicaid, Home & Community Based Services Authorities, https://www.medicaid.gov/medicaid/home-community-based-services/home-
community-based-services-authorities/index.html (last visited April 11, 2025).
34 See s. 409.964, F.S. See s. 409.971, F.S. See KKF, Medicaid Waiver Tracker: Approved and Pending Section 1115 Waivers by State, KFF (last
updated Feb. 7, 2025) https://www.kff.org/medicaid/issue-brief/medicaid-waiver-tracker-approved-and-pending-section-1115-waivers-
by-state/ (last visited April 11, 2025). Find Table 4 entitled “Approved Section 1115 Medicaid Waivers”.
35 Agency for Health Care Administration, New Statewide Medicaid Managed Care Regions, https://ahca.myflorida.com/medicaid/statewide-
medicaid-managed-care/new-smmc-regions (last visited April 11, 2025).
36 Agency for Health Care Administration, Statewide Medicaid Managed Care Plan Poster,
https://ahca.myflorida.com/content/download/25039/file/27061%20SMMC%20Plan%20Poster%2002042025.pdf (last visited April 11,
2025). COMP+ = Comprehensive Long-Term Care Plus Plan; MMA+ = Managed Medical Assistance Plus Plan; Select Comp = Select
Comprehensive Plan; Specialty Services = C (Child Welfare), H (HIV/AIDS), and S (Serious Mental Health Illness). JUMP TO SUMMARY ANALYSIS RELEVANT INFORMATION BILL HISTORY
8
Children’s Medical Services Managed Care Plan
Current law vests the Department of Health (DOH) with the power, duty, and responsibility to provide, or contract
for, the Children’s Medical Services (CMS) Managed Care Plan.
37 Although DOH has the ultimate authority to
establish CMS Managed Care Plan standards, credentialing requirements for health care providers and health
services, reimbursement mechanisms, and a minimum reserve of rainy-day funds,
38 DOH contracts with AHCA to
administer the CMS Managed Care Plan.
However, DOH continues to make the clinical eligibility determinations for the CMS Managed Care Plan.
39 DOH
remains responsible for vendor oversight in the areas of clinical operations, compliance, performance
management, family level grievance remedies, and provider technical assistance.
40
The CMS Managed Care Plan, currently operated by Sunshine State Health Plan, Inc. (Sunshine Health), includes a
network of primary care physicians, specialty care providers, and case management service providers that serve
children and youth under the age of 21 who are Medicaid-eligible and have special healthcare needs that require
extensive preventative and ongoing care.
These enrollees do not pay a monthly premium.
41
According to AHCA’s Medicaid enrollment numbers for January 2025, the Sunshine Health CMS managed care plan
served 93,217 children and youth, which represents 3% of all SMMC enrollees.
42
Home and Community Based Services
Medicaid home and community-based care services (HCBS) are medical and supportive services to help people
with the activities of daily living (such as eating and bathing) and the instrumental activities of daily living (such as
preparing meals and managing medications). Medicaid HCBS is self-directed care, meaning participants exercise
greater autonomy over their service array and their selection of service providers, which in some cases includes
paid family caregivers. Beyond paying for their caregiving, Medicaid supports family caregivers with services such
37 See s. 391.025(1)(d), F.S., see s. 391.026(1), F.S.
38 S. 391.026, F.S.
39 S. 391.029(1), F.S.
40 S. 391.035, F.S., s. 391.037, F.S., s. 391.071, F.S., s. 391.081, F.S., s. 391.097, F.S.
41 S. 391.055(2), F.S. Sunshine Health, Children’s Medical Services Health Plan (Medicaid)
https://www.sunshinehealth.com/members/cms.html (last visited April 11, 2025). Sunshine Health is a subsidiary of Centene Corporation.
Sunshine Health’s KidCare enrollees pay a monthly premium.
42
Agency for Health Care Administration, Current Comprehensive Medicaid Managed Care Enrollment Reports, (Jan. 2025)
https://ahca.myflorida.com/medicaid/medicaid-finance-and-analytics/medicaid-data-analytics/medicaid-monthly-enrollment-report (last
visited April 11, 2025). Select the “Medicaid” tab on the lower toolbar of the Excel Spreadsheet. JUMP TO SUMMARY ANALYSIS RELEVANT INFORMATION BILL HISTORY
9
as training, support groups, and respite care (which is paid care that allows family caregivers to take a break from
their normal responsibilities).
43
Medicaid Model Waiver
The Medicaid Model Waiver is a Section 1915(c) waiver, valid through June 30, 2025,
44 that authorizes Florida to
provide HCBS to eligible children to delay or prevent institutionalization for the purpose of maintaining stable
health while living at home or in their community.
45 Specifically, this waiver covers respite care, environmental
accessibility adaptations, and transition case management services to children 20 years of age or younger with a
degenerative spinocerebellar disease
46 diagnosis and to children 20 years of age or younger who are medically
fragile and have already resided in a skilled nursing facility for at least 60 consecutive days and meet an “at risk for
hospitalization” level of care.
47
The Medicaid Model Wavier currently has 20 enrollment slots (5 for the degenerative spinocerebellar disease
population group and 15 for the medically fragile population group). There are no enrollment spots for children
that receive private duty nursing (PDN) services without a diagnosis of a degenerative spinocerebellar disease.
48
Private Duty Nursing Services / Family Home Health Aide Services
Medicaid private duty nursing (PDN) and family home health aide services provide full-time medically necessary
skilled nursing and family home health aide services to recipients under the age of 21 whose medical condition,
illness, or injury requires the delivery of health care within the recipient’s home or community.
49
SMMC plans reimburse eligible providers offering PDN services or family home health aide services.
PDN services may only be offered by licensed practical nurses (LPNs) and licensed registered nurses (RNs)
who work within their respective scope of practice. LPNs and RNs may either work for a licensed home
health agency or be physician-directed and monitored.
50
Family home health aides must be trained by a home health agency and serve only his or her dependent
under the age of 21 with an underlying physical, mental, or cognitive impairment that prevents the
dependent from safely living independently.
51
Federal law requires a Medicaid state plan to provide medical assistance (i.e., private duty nursing services and
home health care services) for eligible children under the age of 21 who request screening services and require
43 Alice Burns, Abby Wolk, Molly O’Malley Watts, and Maiss Mohamed, How Do Medicaid Care Programs Support Family Caregivers? KKF,
(Jan. 13, 2025) https://www.kff.org/medicaid/issue-brief/how-do-medicaid-home-care-programs-support-family-caregivers/ (last visited
April 11, 2025).
44 Florida first implemented this HCBS waiver in 1991, according to statutory authority for HCBS coverage found in s. 409.906(13), F.S.
Medicaid, FL Model Waiver (40166.R06.00), Centers for Medicare & Medicaid Service, https://www.medicaid.gov/medicaid/section-1115-
demo/demonstration-and-waiver-list/81361 (last visited April 11, 2025).
45 Agency for Health Care Administration, Agency Analysis of 2025 House Bill 1085, pp. 3 (Mar. 3, 2025). This waiver permits Florida to
disregard family income for certain children when determining HCBS waiver eligibility.
46 Spinocerebellar ataxia (SCA) is a group of inherited brain disorders affecting the cerebellum, a part of the brain vital to coordination of
physical movement and the spinal cord. Spinocerebellar Ataxia, Cleveland Clinic, (last reviewed Aug. 29, 2022)
https://my.clevelandclinic.org/health/diseases/24077-spinocerebellar-ataxia (last visited April 11, 2025).
47 Agency for Health Care Administration, Agency Analysis of 2025 House Bill 1085, pp. 3 (Mar. 3, 2025); Medicaid, Florida Waiver
Description Fact Sheet, https://www.medicaid.gov/medicaid/section-1115-demo/demonstration-and-waiver-list/Waiver-Descript-
Factsheet/FL#40166 (last visited April 11, 2025). The Department of Health’s Children Medical Services program, the Children’s
Multidisciplinary Assessment Team, determines the “at risk for hospitalization” level care.
48 Agency for Health Care Administration, Agency Analysis of 2025 House Bill 1085, pp. 3 (Mar. 3, 2025).
49 Florida Medicaid, Private Duty Nursing and Family Home Health Aide Services Coverage Policy, Agency for Health Care Administration,
(Sept. 2024) https://ahca.myflorida.com/content/download/7036/file/59G-
4.261%20Private%20Duty%20Nursing%20Services%20Coverage%20Policy_FINAL.pdf (last visited April 11, 2025).
50 Florida Medicaid, Private Duty Nursing and Family Home Health Aide Services Coverage Policy, Agency for Health Care Administration,
(Sept. 2024) https://ahca.myflorida.com/content/download/7036/file/59G-
4.261%20Private%20Duty%20Nursing%20Services%20Coverage%20Policy_FINAL.pdf (last visited April 11, 2025).
51 Ch. 2023-183, L.O.F., established the “Home Health Aides for Medically Fragile Children” program in response to the state’s HCBS provider
shortage and the shortage’s negative impact on medically fragile children and their family caregivers. JUMP TO SUMMARY ANALYSIS RELEVANT INFORMATION BILL HISTORY
10
corrective or ameliorative treatment.
52 While Florida Medicaid covers PDN services under the state plan, that
coverage does not extend to respite or home modifications.
53
The Healthcare Effectiveness Data and Information Set
The Healthcare Effectiveness Data and Information Set (HEDIS) is the National Committee for Quality Assurance
(NCQA)’s comparative analytical platform that competitively measures health plan performances. The Centers for
Medicare and Medicaid Services contracts with NCQA to assess the quality of health care provided to children and
adults through Medicaid and the Children’s Health Insurance Program.
54 NCQA publishes annual Health Plan
Report Cards to evaluate the health plans on the quality of care, patient satisfaction, and health plan’s efforts to
improve.
55 NCQA’s 2024 Medicaid health plan report card for Florida’s managed care plans is available for review.
56
Prescribed Pediatric Extended Care Eligibility and Coverage
Prescribed Pediatric Extended Care (PPEC) centers provide skilled nursing supervision and therapeutic
interventions in a non-residential setting to medically dependent or technologically dependent recipients.
Medicaid enrollees access PPEC services through a fee-for-service model, not a managed care model. In a fee-for-
service (FFS) system, AHCA establishes the fee levels for covered services and pays participating physicians,
clinics, hospitals, and other providers directly for each service they deliver to Medicaid beneficiaries. Beneficiaries
seeking care in the traditional FFS environment must identify providers who participate in Medicaid and accept
new patients. Except in the context of primary care case management programs, there is generally no organized
provider network in the FFS environment.
57
Medicaid reimburses PPEC services up to a maximum 12 hours per day.
58 The table below displays the current
2025 PPEC fee-for-service schedule.
59
Prescribed Pediatric Extended Care Services Fee Schedule (2025)
Code Description of Service Maximum Fee
T1025 Full Day PPEC Services (five to twelve hours)* $264.24
T1026 Partial Day PPEC Services (four hours or less per
day, billed in units by the hour)*
$41.96
* Any portion of the hour that exceeds 15 minutes may be rounded up to the next
hour after the first hour.
52 42 U.S.C. §§ 1396a(a)(43), 1396d(a)(7)-(8), 1396d(r)(5).
53 Agency for Health Care Administration, Agency Analysis of 2025 House Bill 1085, pp. 3 (Mar. 3, 2025).
54 See Office of Disease Prevention and Health Promotion, Healthcare Effectiveness Data and Information Set, United States Department of
Health and Human Services, https://odphp.health.gov/healthypeople/objectives-and-data/data-sources-and-methods/data-
sources/healthcare-effectiveness-data-and-information-set-hedis (last visited April 11, 2025).
55 Health Plan Ratings, National Committee for Quality Assurance, https://www.ncqa.org/hedis/health-plan-ratings/ (last visited April 11,
2025).
56 Health Plan Report Cards, National Committee for Quality Assurance (last updated Mar. 15, 2025) https://reportcards.ncqa.org/health-
plans?filter-state=Florida&filter-plan=Medicaid&pg=1&dropdown-state=Florida (last visited April 11, 2025). Select the filters for “Florida”
and “Medicaid” to discover health plan ratings and health plan accreditation status.
57 The Kaiser Commission on Medicaid and the Uninsured, Medicaid Delivery System and Payment Reform: A Guide to Key Terms and
Concepts, KFF, (Jun. 22, 2015) https://www.kff.org/medicaid/fact-sheet/medicaid-delivery-system-and-payment-reform-a-guide-to-key-
terms-and-concepts/ (last visited April 11, 2025).
58 S. 409.968(3), F.S. Florida Medicaid, Prescribed Pediatric Extended Care Services Coverage Policy, Agency for Health Care Administration,
(Feb. 2018) https://ahca.myflorida.com/content/download/5959/file/59G-4.260_PPEC.pdf (last visited April 11, 2025).
59 Agency for Health Care Administration, Rule 59G-4.002, Provider Reimbursement Schedules and Billing Codes,
https://ahca.myflorida.com/medicaid/rules/rule-59g-4.002-provider-reimbursement-schedules-and-billing-codes (last visited April 11,
2025). Find the “Updated Fee Schedule” for 2025 in the row for “Prescribed Pediatric Extended Care Services Fee Schedule. JUMP TO SUMMARY ANALYSIS RELEVANT INFORMATION BILL HISTORY
11
Medicaid covers PPEC services for recipients under the age of 21, so long as PPEC services are medically necessary,
the recipient is medically stable yet requires continuous therapeutic interventions or skilled nursing supervision,
and the recipient is not a threat to self or others.
60
As of June 2024, there were 3,638 children receiving PPEC services through Florida Medicaid. Of these children,
approximately 80% were enrolled in SMMC for non-PPEC services and 20% were receiving their Medicaid services
through the FFS delivery system.
61
Children’s Medical Services
The Children’s Medical Services Act of 1978 established the Children’s Medical Services (CMS) Division within the
Department of Health (DOH) to provide medical services to children with special health care needs, particularly
those with chronic, crippling or potentially crippling, and physically disabling diseases or conditions.
62 Current law
advises the CMS Division to provide essential preventative, evaluative, and early intervention services for children
at risk for or having special health care needs, in order to prevent or reduce long-term disabilities.
63
Although the CMS Division has an organizing statute, s. 391.025, F.S., that itemizes its various service programs,
this organizing statute does not include every service program the CMS Division administers.
The CMS Division organizing statute, s. 391.025, F.S., includes the following service programs:
A newborn screening program to identify metabolic disorders, other hereditary and congenital disorders,
and environmental risk factors.
64
A regional perinatal intensive care center program to provide a full range of health services to certain
women experiencing high-risk pregnancies and certain newborn infants requiring intensive care.
65
The “Early Steps Program” to provide evaluations and early interventions to infants and toddlers at risk of
developmental disabilities and developmental delays.
66
The Children’s Medical Services (CMS) Managed Care Plan
67 to serve children and youth with special health
care needs in a family-centered, comprehensive, and coordinated statewide managed system of care. The
CMS unit links community-based health care with multidisciplinary, regional, and tertiary pediatric
specialty care while prioritizing consistent medical homes for these children.
68
Florida law codifies other CMS Division service programs outside of the CMS organizing statute, s. 391.025, F.S.,
which includes the following service programs:
The state and local Child Abuse Death Review program to understand and address the causes and
contributing factors of deaths resulting from child abuse, to identify service delivery gaps, and to
recommend and implement changes in law, rule, or public policy.
69
The Child Protection Team program to provide specialized diagnostic assessments, medical evaluations,
expert testimony in court cases, and case managers to develop treatment plans for children referred by the
Department of Children and Families.
70
60 Florida Medicaid, Prescribed Pediatric Extended Care Services Coverage Policy, Agency for Health Care Administration, (Feb. 2018)
https://ahca.myflorida.com/content/download/5959/file/59G-4.260_PPEC.pdf (last visited April 11, 2025).
61 Agency for Health Care Administration, Agency Analysis of 2025 House Bill 1085, pp. 4 (Mar. 3, 2025).
62 Ch. 78-106, L.O.F. See Sections 1 and 2.
63 S. 391.016, F.S.
64 S. 383.14, F.S.
65 S. 383.16, F.S., s. 383.17, F.S.
66 S. 391.301, F.S., s. 391.308, F.S.
67
Chapter 391 refers to the CMS Managed Care Plan as the CMS Network. DOH previously administered the CMS managed care plan as a
provider-based fee-for-service program. In August 2014, the CMS program transformed into a managed care plan within AHCA’s statewide
managed care model. However, DOH remains responsible for administering the CMS program. Department of Health, Agency Analysis of
2023 House Bill 1503, see p. 5, (Feb. 24, 2023).
68 S. 391.016, F.S.
69 S. 383.402(1), F.S.
70 S. 39.303(3), F.S. JUMP TO SUMMARY ANALYSIS RELEVANT INFORMATION BILL HISTORY
12
The Poison Information Center Network program to provide 24/7 emergency poison information through
a toll-free hotline. CMS coordinates all of the regional poison control centers.
71
A sexual abuse treatment program to provide specialized therapeutic treatment (i.e., crisis intervention,
clinical treatment, and therapy) that assists a victim’s recovery from sexual abuse, prevents developmental
impairment, restores the child’s developmental functioning, and promotes healthy, non-abusive
relationships.
72
A Title V block-grant-supported program to serve children and youth with chronic and serious physical,
developmental, behavioral, or emotional conditions.
73
The Safety Net program to serve children with chronic health conditions who do not qualify for Medicaid or
KidCare on a first-come, first-served basis, subject to appropriations.
74
The CMS Division administers two programs without express statutory authority, pursuant to its general directives
under the Children Medical Services Act:
The Children’s Multidisciplinary Assessment Team (CMAT) interagency program to assess the level of care
that a child with special health care needs, with due consideration to medical, emotional, psychosocial, and
environmental factors, and to determine the appropriateness of pediatric nursing facility admission.
However, AHCA regulations speak to the requirement of the CMAT to make recommendations for the
placement of a Medicaid applicant or recipient.
75 There is no reciprocal DOH regulation and no statute for
DOH to implement this program.
The Medical Foster Care program to offer medical support, care coordination, and referrals to children
residing in a family-based medical foster home. However, this program refers to medical family foster
homes, which are licensed by the Department of Children and Families. and are certified by AHCA.
76 There
is no clearly identifiable statutory authority for CMS to participate in the administration of the medical
foster care program.
71 S. 395.1027(4), F.S. Florida Poison Control Centers, Mission & Services, https://floridapoisoncontrol.org/about-the-network/mission-
services/ (last visited April 11, 2025).
72 S. 39.303(10), F.S.
73 s. 391.026(13), F.S. Florida Department of Health, CMS Title V Program, (last updated Nov. 10, 2021)
https://www.floridahealth.gov/programs-and-services/childrens-health/cms-specialty-programs/title-5-program/index.html (last visited
April 11, 2025).
74 S. 391.029(3)(a), F.S., Rule 64C-2.004, F.A.C., Florida Department of Health, Safety Net Program, (last updated Mar. 16, 2023)
https://www.floridahealth.gov/programs-and-services/childrens-health/cms-specialty-programs/safety-net/index.html (last visited April
11, 2025).
75 Rule 59A-4.1295(3)(b), F.A.C. Current law requires AHCA to make rules setting minimum standards of care and minimum staffing
requirements for nursing homes serving children and youth. AHCA must collaborate with the CMS Division to exercise AHCA rulemaking
authority. See s. 400.23(5), F.S.
76 See Rule 59G-4.197, F.A.C., See s. 409.903, F.S., See s. 409.175(5)(a)5. Department of Health, Medical Foster Care, (last updated Feb. 6,
2025) https://www.floridahealth.gov/programs-and-services/childrens-health/cms-specialty-programs/medical-foster-care/index.html
(last visited April 11, 2025). See Florida Department of Children and Families, Foster Home Licensing: Levels of Foster Care Licensure,
https://www.myflfamilies.com/services/licensing/foster-care-licensing (last visited April 11, 2025). License Level V is the Medical Foster
Home license. JUMP TO SUMMARY ANALYSIS RELEVANT INFORMATION BILL HISTORY
13
RECENT LEGISLATION:
YEAR BILL # HOUSE SPONSOR(S) SENATE SPONSOR OTHER INFORMATION
2023 CS/CS/CS/HB
391
Tramont Harrell Became law on June 2, 2023.
2023 CS/SB 1548 Grant Bradley Passed Senate; Died in House
Messages on May 5, 2023).
OTHER RESOURCES:
Florida Managed Medical Assistance (MMA) Waiver
Florida Model Waiver
BILL HISTORY
COMMITTEE REFERENCE ACTION DATE
STAFF
DIRECTOR/
POLICY CHIEF
ANALYSIS
PREPARED BY
Health Care Facilities & Systems
Subcommittee
14 Y, 3 N, As CS 3/19/2025 Calamas DesRochers
THE CHANGES ADOPTED BY THE
COMMITTEE:
Removes the requirement that AHCA obtain federal approval
for, and implement, a redesign of the Medicaid Model Waiver
for home and community-based services, and instead requires
AHCA to develop a comprehensive plan to redesign that waiver.
Requires AHCA to include, in the redesign, a tiered service array
for certain children who receive private duty nursing services
so that they live in non-institutional settings.
Requires AHCA to submit a report that addresses certain details
about the comprehensive plan to redesign the Model Waiver to
the Governor, the President of the Senate, and the Speaker of
the House of Representatives by September 30, 2025.
Health Care Budget Subcommittee Clark Smith
Health & Human Services
Committee
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THIS BILL ANALYSIS HAS BEEN UPDATED TO INCORPORATE ALL OF THE CHANGES DESCRIBED ABOVE.
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