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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. 409.974, F.S.; 15
requiring the CMS program to transfer operation of 16
certain managed care contr acts from the department to 17
the agency effective on a specified date; requiring 18
the CMS program to conduct clinical eligibility 19
screening for certain children and youth with special 20
health care needs; requiring the program to provide 21
ongoing consultation t o the agency for a specified 22
purpose; requiring the agency to establish specific 23
measures for evaluation of services provided to 24
children and youth with special health care needs; 25
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requiring the agency to contract with an independent 26
evaluator to conduct th e evaluation of services 27
provided; specifying requirements for the evaluation; 28
requiring the agency to submit the results of the 29
evaluation to the Governor and the Legislature by a 30
specified date; amending s. 391.016, F.S.; revising 31
the purposes and functi ons of the CMS program; 32
amending s. 391.021, F.S.; revising definitions; 33
amending s. 391.025, F.S.; revising the scope of the 34
CMS program; amending s. 391.026, F.S.; revising the 35
powers and duties of the department to conform to 36
changes made by the act; pr oviding for the future 37
repeal of s. 391.026(8) through (11), F.S., relating 38
to the department's oversight and administration of 39
the CMS program; repealing s. 391.028, F.S., relating 40
to administration of the program; amending s. 391.029, 41
F.S.; revising program eligibility requirements; 42
conforming provisions to changes made by the act; 43
amending s. 391.0315, F.S.; conforming provisions to 44
changes made by the act; providing for future repeal 45
of specified provisions; repealing ss. 391.035, 46
391.037, 391.045, 391. 047, 391.055, and 391.071, F.S., 47
relating to provider qualifications, physicians and 48
private sector services, provider reimbursements, 49
third-party payments, service delivery systems under 50
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the program, and quality of care requirements, 51
respectively; amendin g s. 391.097, F.S.; conforming a 52
provision to changes made by the act; repealing part 53
II of ch. 391, F.S., consisting of ss. 391.221 and 54
391.223, F.S., relating to Children's Medical Services 55
councils and panels; amending ss. 409.166, 409.811, 56
409.813, 409.8134, 409.814, 409.815, 409.8177, 57
409.818, 409.912, 409.9126, 409.9131, 409.920, and 58
409.962, F.S.; conforming provisions to changes made 59
by the act; requiring the Agency for Health Care 60
Administration to develop a comprehensive plan to 61
redesign the Florida Medicaid Model Waiver for home 62
and community-based services to include children who 63
receive private duty nursing services; providing 64
requirements for the redesign of waiver program; 65
requiring the Agency for Health Care Administration to 66
submit a report to the Governor, the President of the 67
Senate, and the Speaker of the House of 68
Representatives by a specified date; providing 69
effective dates. 70
71
Be It Enacted by the Legislature of the State of Florida: 72
73
Section 1. Transfer of operation of the Childr en's Medical 74
Services Managed Care Plan. — 75
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(1) Effective July 1, 2025, all statutory powers, duties, 76
functions, records, personnel, pending issues, existing 77
contracts, administrative authority, administrative rules, and 78
unexpended balances of appropriatio ns, allocations, and other 79
funds for the operation of the Department of Health's Children's 80
Medical Services Managed Care Plan are transferred to the Agency 81
for Health Care Administration. 82
(2) The transfer of operations of the Children's Medical 83
Services Managed Care Plan does not affect the validity of any 84
judicial or administrative action pending as of 11:59 p.m. on 85
the day before the effective date of the transfer to which the 86
Department of Health's Children's Medical Services Managed Care 87
Plan is at that time a party, and the Agency for Health Care 88
Administration shall be substituted as a party in interest in 89
any such action. 90
(3) The Department of Health's Children's Medical Services 91
program shall collaborate with the Agency for Health Care 92
Administration in the care of children and youth with special 93
health care needs. The Department of Health's Children's Medical 94
Services program shall do all of the following: 95
(a) Conduct clinical eligibility screening for children 96
and youth with special health ca re needs who are eligible for or 97
enrolled in Medicaid or the Children's Health Insurance Program. 98
(b) Provide ongoing consultation to the Agency for Health 99
Care Administration to ensure high -quality, family-centered, 100
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coordinated health services within an effective system of care 101
for children and youth with special health care needs. 102
Section 2. Subsection (4) of section 409.974, Florida 103
Statutes, is amended to read: 104
409.974 Eligible plans. — 105
(4) CHILDREN'S MEDICAL SERVICES NETWORK.— 106
(a) The Department of Health's Children's Medical Services 107
program shall do all of the following: 108
1. Effective July 1, 2025, transfer to the agency the 109
operation of managed care contracts procured by the department 110
for Medicaid and Children's Health Insurance Program services 111
provided to children and youth with special health care needs 112
who are enrolled in the Children's Medical Services Managed Care 113
Plan. 114
2. Conduct clinical eligibility screening for children and 115
youth with special health care needs who are eligible for or are 116
enrolled in Medicaid or the Children's Health Insurance Program. 117
3. Provide ongoing consultation to the agency to ensure 118
high-quality, family-centered, coordinated health services are 119
provided within an effective system of care for children and 120
youth with special health care needs. 121
(b) The agency shall establish specific measures of 122
access, quality, and costs of providing health care services to 123
children and youth with special health care needs. The agency 124
shall contract with an independent evaluator to conduct an 125
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evaluation of services provided. The evaluation must include, 126
but need not be limited to, all of the following: 127
1. A performance comparison of plans contracted to provide 128
services to children and youth with special health care ne eds as 129
well as plans contracted to serve a broader population of 130
Managed Medical Assistance enrollees. The performance comparison 131
must be based on the measures established by the agency and 132
differentiated based on the age and medical condition or 133
diagnosis of patients receiving services under each plan. 134
2. For each plan, an assessment of cost savings, patient 135
choice, access to services, coordination of care, person -136
centered planning, health and quality -of-life outcomes, patient 137
and provider satisfaction, and provider networks and quality of 138
care. 139
140
The agency shall submit the results of the evaluation to the 141
Governor, the President of the Senate, and the Speaker of the 142
House of Representatives by January 15, 2028 Participation by 143
the Children's Medical Serv ices Network shall be pursuant to a 144
single, statewide contract with the agency that is not subject 145
to the procurement requirements or regional plan number limits 146
of this section. The Children's Medical Services Network must 147
meet all other plan requirements for the managed medical 148
assistance program. 149
Section 3. Subsection (1) of section 391.016, Florida 150
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Statutes, is amended to read: 151
391.016 Purposes and functions. —The Children's Medical 152
Services program is established for the following purposes and 153
authorized to perform the following functions: 154
(1) Provide to children and youth with special health care 155
needs a family-centered, comprehensive, and coordinated 156
statewide managed system of care that links community -based 157
health care with multidisciplinary, regional, and tertiary 158
pediatric specialty care. The program shall coordinate and 159
maintain a consistent medical home for participating children. 160
Section 4. Subsections (1), (2), and (4) of section 161
391.021, Florida Statutes, are amended to read: 162
391.021 Definitions.—When used in this act, the term: 163
(2)(1) "Children's Medical Services Managed Care Plan 164
network" or "plan network" means a statewide managed care 165
service system that includes health care providers, as defined 166
in this section. 167
(1)(2) "Children and youth with special health care needs" 168
means those children and youth younger than 21 years of age who 169
have chronic and serious physical, developmental, behavioral, or 170
emotional conditions and who require health care and related 171
services of a type or amount beyond that which is generally 172
required by children and youth. 173
(4) "Eligible individual" means a child or youth with a 174
special health care need or a female with a high -risk pregnancy, 175
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who meets the financial and medical eligibility standards 176
established in s. 391.029. 177
Section 5. Subsection (1) of section 391.025, Florida 178
Statutes, is amended to read: 179
391.025 Applicability and scope. — 180
(1) The Children's Medical Services program consists of 181
the following components: 182
(a) The newborn scr eening program established in s. 383.14 183
and the newborn, infant, and toddler hearing screening program 184
established in s. 383.145 . 185
(b) The regional perinatal intensive care centers program 186
established in ss. 383.15 -383.19. 187
(c) The developmental evaluation and intervention program, 188
including the Early Steps Program established in ss. 391.301 -189
391.308. 190
(d) The Children's Medical Services Managed Care Plan 191
through the end of June 30, 2025 network. 192
(e) The Children's Multidi sciplinary Assessment Team. 193
(f) The Medical Foster Care Program. 194
(g) The Title V Children and Youth with Special Health 195
Care Needs program. 196
(h) The Safety Net Program. 197
(i) Child Protection Teams and sexual abuse treatment 198
programs established under s. 39.303. 199
(j) The State Child Abuse Death Review Committee and local 200
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child abuse death review committees established in s. 383.402. 201
Section 6. Section 391.026, Florida Statutes, is amended 202
to read: 203
391.026 Powers and duties of the department. —The 204
department shall have the following powers, duties, and 205
responsibilities: 206
(1) To provide or contract for the provision of health 207
services to eligible individuals. 208
(2) To provide services to abused and neglected children 209
through Child Protection Teams pursuant to s. 39.303. 210
(3) To determine the medical and financial eligibility of 211
individuals seeking health services from the program. 212
(4) To coordinate a comprehensive delivery system for 213
eligible individuals to take maximum advantage of all available 214
funds. 215
(5) To coordinate with programs relating to children's 216
medical services in cooperation with other public and private 217
agencies. 218
(6) To initiate and coordinate applications to federal 219
agencies and private organizations for funds, services, or 220
commodities relating to children's medical programs. 221
(7) To sponsor or promote grants for projects, programs, 222
education, or research in the field of children and youth with 223
special health care needs, with an emphasis on early diagnosis 224
and treatment. 225
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(8) To oversee and operate the Children's Medical Services 226
Managed Care Plan through the end of June 30, 2025 network. 227
(9) To establish reimbursement mechanisms for the 228
Children's Medical Services network. 229
(10) To establish Children's Medical Services netw ork 230
standards and credentialing requirements for health care 231
providers and health care services. 232
(11) To serve as a provider and principal case manager for 233
children with special health care needs under Titles XIX and XXI 234
of the Social Security Act. 235
(9)(12) To monitor the provision of health services in the 236
program, including the utilization and quality of health 237
services. 238
(10)(13) To administer the Children and Youth with Special 239
Health Care Needs program in accordance with Title V of the 240
Social Security Act. 241
(14) To establish and operate a grievance resolution 242
process for participants and health care providers. 243
(15) To maintain program integrity in the Children's 244
Medical Services program. 245
(11)(16) To receive and manage health care premiums, 246
capitation payments, and funds from federal, state, local, and 247
private entities for the program. The department may contract 248
with a third-party administrator for processing claims, 249
monitoring medical expenses, and other related services 250
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necessary to the effici ent and cost-effective operation of the 251
Children's Medical Services Managed Care Plan through the end of 252
June 30, 2025 network. The department is authorized to maintain 253
a minimum reserve for the Children's Medical Services network in 254
an amount that is the greater of: 255
(a) Ten percent of total projected expenditures for Title 256
XIX-funded and Title XXI -funded children; or 257
(b) Two percent of total annualized payments from the 258
Agency for Health Care Administration for Title XIX and Title 259
XXI of the Social Sec urity Act. 260
(12)(17) To provide or contract for peer review and other 261
quality-improvement activities. 262
(13)(18) To adopt rules pursuant to ss. 120.536(1) and 263
120.54 to administer the Children's Medical Services Act. 264
(14)(19) To serve as the lead agency in administering the 265
Early Steps Program pursuant to part C of the federal 266
Individuals with Disabilities Education Act and part III of this 267
chapter. 268
(15) To administer the Medical Foster Care Program, 269
including all of the following: 270
(a) Recruitment, training, assessment, and monitoring for 271
the Medical Foster Care Program. 272
(b) Monitoring access and facilitating admissions of 273
eligible children and youth to the program and designated 274
medical foster care homes. 275
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(c) Coordination with the Department of C hildren and 276
Families and the Agency for Health Care Administration or their 277
designees. 278
Section 7. Effective July, 1, 2025, subsections (8) 279
through (11) of section 391.026, Florida Statutes, as amended by 280
this act, are repealed. 281
Section 8. Effective July 1, 2025, section 391.028, 282
Florida Statutes, is repealed. 283
Section 9. Subsections (2) and (3) of section 391.029, 284
Florida Statutes, are amended to read: 285
391.029 Program eligibility. — 286
(2) The following individuals are eligible to receive 287
services through the program: 288
(a) Related to the regional perinatal intensive care 289
centers, a high-risk pregnant female who is enrolled in 290
Medicaid. 291
(b) Children and youth with serious special health care 292
needs from birth to 21 years of age who are enr olled in 293
Medicaid. 294
(c) Children and youth with serious special health care 295
needs from birth to 19 years of age who are enrolled in a 296
program under Title XXI of the Social Security Act. 297
(3) Subject to the availability of funds, the following 298
individuals may receive services through the Children's Medical 299
Services Safety Net program: 300
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(a) Children and youth with serious special health care 301
needs from birth to 21 years of age who do not qualify for 302
Medicaid or Title XXI of the Social Security Act but who are 303
unable to access, due to lack of providers or lack of financial 304
resources, specialized services that are medically necessary or 305
essential family support services. Families shall participate 306
financially in the cost of care based on a sliding fee scale 307
established by the department. 308
(b) Children and youth with special health care needs from 309
birth to 21 years of age, as provided in Title V of the Social 310
Security Act. 311
(c) An infant who receives an award of compensation under 312
s. 766.31(1). The Florida Birth-Related Neurological Injury 313
Compensation Association shall reimburse the Children's Medical 314
Services Network the state's share of funding, which must 315
thereafter be used to obtain matching federal funds under Title 316
XXI of the Social Security Act. 317
Section 10. Section 391.0315, Florida Statutes, is amended 318
to read: 319
391.0315 Benefits.—Benefits provided under the Children's 320
Medical Services Managed Care Plan program for children with 321
special health care needs shall be equivalent to benefits 322
provided to children as specified in ss. 409.905 and 409.906. 323
The department may offer additional benefits through Children's 324
Medical Services programs for early intervention services, 325
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respite services, genetic testing, genetic and nutritional 326
counseling, and parent support services, if such services are 327
determined to be medically necessary. This section is repealed 328
on January 1, 2026. 329
Section 11. Section 391.035, Florida Statutes, is 330
repealed. 331
Section 12. Effective January 1, 2026, section 391.037, 332
Florida Statutes, is repealed. 333
Section 13. Section 391.045, Florida Statutes, is 334
repealed. 335
Section 14. Effective January 1, 2026, section 391.047, 336
Florida Statutes, is repealed. 337
Section 15. Effective January 1, 2026, section 391.055, 338
Florida Statutes, is repealed. 339
Section 16. Effective January 1, 2026, section 391.071, 340
Florida Statutes, is repealed. 341
Section 17. Section 391.097, Florida Statutes, is amended 342
to read: 343
391.097 Research and evaluation. — 344
(1) The department may initiate, fund, and co nduct 345
research and evaluation projects to improve the delivery of 346
children's medical services. The department may cooperate with 347
public and private agencies engaged in work of a similar nature. 348
(2) The Children's Medical Services network shall be 349
included in any evaluation conducted in accordance with the 350
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provisions of Title XXI of the Social Security Act as enacted by 351
the Legislature. 352
Section 18. Part II of chapter 391, Florida Statutes, 353
consisting of ss. 391.221 and 391.223, Florida Statutes, is 354
repealed, and part III of that chapter is redesignated as part 355
II. 356
Section 19. Effective July 1, 2025, paragraph (b) of 357
subsection (5) of section 409.166, Florida Statutes, is amended 358
to read: 359
409.166 Children within the child welfare system; adoption 360
assistance program.— 361
(5) ELIGIBILITY FOR SERVICES. — 362
(b) A child who is handicapped at the time of adoption is 363
shall be eligible for services through a plan under contract 364
with the agency to serve children and youth with special heath 365
care needs the Children's Medical Services network established 366
under part I of chapter 391 if the child was eligible for such 367
services before prior to the adoption. 368
Section 20. Effective July 1, 2025, subsection (7) of 369
section 409.811, Florida Statutes, is amended to read: 370
409.811 Definitions relating to Florida Kidcare Act. —As 371
used in ss. 409.810-409.821, the term: 372
(7) "Children's Medical Services Network" or "network" 373
means a statewide managed care service system as defined in s. 374
391.021(1). 375
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Section 21. Effective July 1, 2025, subsection (1) of 376
section 409.813, Florida Statutes, is amended to read: 377
409.813 Health benefits coverage; program components; 378
entitlement and nonentitlement. — 379
(1) The Florida Kidcare program includes health benefits 380
coverage provided to children through the following program 381
components, which shall be marketed as the Florida Kidcare 382
program: 383
(a) Medicaid; 384
(b) Medikids as created in s. 409.8132; 385
(c) The Florida Healthy Kids Corporation as created in s. 386
624.91; 387
(d) Employer-sponsored group health insurance plans 388
approved under ss. 409.810 -409.821; and 389
(e) Plans under contract with the agency to serve children 390
and youth with special health care needs The Children's Medical 391
Services network established in chapter 391 . 392
Section 22. Effective July 1, 2025, subsection (3) of 393
section 409.8134, Florida Statutes, is amended to read: 394
409.8134 Program expenditure ceiling; enrollment. — 395
(3) Upon determination by the Social Services Estimating 396
Conference that there are insuffi cient funds to finance the 397
current enrollment in the Florida Kidcare program within current 398
appropriations, the program shall initiate disenrollment 399
procedures to remove enrollees, except those children enrolled 400
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in a plan under contract with the agency to serve children with 401
special health care needs the Children's Medical Services 402
Network, on a last-in, first-out basis until the expenditure and 403
appropriation levels are balanced. 404
Section 23. Subsection (3) and paragraph (c) of subsection 405
(10) of section 409.814, Florida Statutes, are amended to read: 406
409.814 Eligibility. —A child who has not reached 19 years 407
of age whose family income is equal to or below 300 percent of 408
the federal poverty level is eligible for the Florida Kidcare 409
program as provided in this section. If an enrolled individual 410
is determined to be ineligible for coverage, he or she must be 411
immediately disenrolled from the respective Florida Kidcare 412
program component. 413
(3) A Title XXI-funded child who is eligible for the 414
Florida Kidcare program who is a child with special health care 415
needs, as determined through a medical or behavioral screening 416
instrument, is eligible for health benefits coverage from and 417
shall be assigned to and may opt out of a plan under contract 418
with the agency to serv e children with special health care needs 419
the Children's Medical Services Network . 420
(10) In determining the eligibility of a child, an assets 421
test is not required. If eligibility for the Florida Kidcare 422
program cannot be verified using reliable data sourc es in 423
accordance with federal requirements, each applicant shall 424
provide documentation during the application process and the 425
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redetermination process, including, but not limited to, the 426
following: 427
(c) To enroll in a plan under contract with the agency to 428
service children with special health care needs the Children's 429
Medical Services Network , a completed application, including a 430
Children's Medical Services clinical screening. 431
Section 24. Effective July 1, 2025, paragraph (t) of 432
subsection (2) of sectio n 409.815, Florida Statutes, is amended 433
to read: 434
409.815 Health benefits coverage; limitations. — 435
(2) BENCHMARK BENEFITS. —In order for health benefits 436
coverage to qualify for premium assistance payments for an 437
eligible child under ss. 409.810 -409.821, the health benefits 438
coverage, except for coverage under Medicaid and Medikids, must 439
include the following minimum benefits, as medically necessary. 440
(t) Enhancements to minimum requirements. — 441
1. This section sets the minimum benefits that must be 442
included in any health benefits coverage, other than Medicaid or 443
Medikids coverage, offered under ss. 409.810 -409.821. Health 444
benefits coverage may include additional benefits not included 445
under this subsection, but may not include benefits excluded 446
under paragraph (r). 447
2. Health benefits coverage may extend any limitations 448
beyond the minimum benefits described in this section. 449
450
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Except for a plan under contract with the agency to serve 451
children with special health care needs the Children's Medical 452
Services Network, the agency may not increase the premium 453
assistance payment for either additional benefits provided 454
beyond the minimum benefits described in this section or the 455
imposition of less restrictive service limitations. 456
Section 25. Effective July 1, 2025, paragraph (i) of 457
subsection (1) of section 409.8177, Florida Statutes, is amended 458
to read: 459
409.8177 Program evaluation. — 460
(1) The agency, in consultation with the Department of 461
Health, the Department of Children and Families, and the Florida 462
Healthy Kids Corporation, shall contract for an evaluation of 463
the Florida Kidcare program and shall by January 1 of each year 464
submit to the Governor, the President of the Senate, and the 465
Speaker of the House of Representatives a report of the program. 466
In addition to the items specified under s. 2108 of Title XXI of 467
the Social Security Act, the report shall include an assessment 468
of crowd-out and access to health care, as well as the 469
following: 470
(i) An assessment of the effectiveness of the Florida 471
Kidcare program, inc luding Medicaid, the Florida Healthy Kids 472
program, Medikids, and the plans under contract with the agency 473
to serve children with special health care needs Children's 474
Medical Services network , and other public and private programs 475
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in the state in increasing the availability of affordable 476
quality health insurance and health care for children. 477
Section 26. Effective July 1, 2025, subsection (4) of 478
section 409.818, Florida Statutes, is amended to read: 479
409.818 Administration. —In order to implement ss. 409. 810-480
409.821, the following agencies shall have the following duties: 481
(4) The Office of Insurance Regulation shall certify that 482
health benefits coverage plans that seek to provide services 483
under the Florida Kidcare program, except those offered through 484
the Florida Healthy Kids Corporation or the Children's Medical 485
Services Network, meet, exceed, or are actuarially equivalent to 486
the benchmark benefit plan and that health insurance plans will 487
be offered at an approved rate. In determining actuarial 488
equivalence of benefits coverage, the Office of Insurance 489
Regulation and health insurance plans must comply with the 490
requirements of s. 2103 of Title XXI of the Social Security Act. 491
The department shall adopt rules necessary for certifying health 492
benefits coverage plans. 493
Section 27. Effective July 1, 2025, subsection (11) of 494
section 409.912, Florida Statutes, is amended to read: 495
409.912 Cost-effective purchasing of health care. —The 496
agency shall purchase goods and services for Medicaid recipients 497
in the most cost-effective manner consistent with the delivery 498
of quality medical ca re. To ensure that medical services are 499
effectively utilized, the agency may, in any case, require a 500
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confirmation or second physician's opinion of the correct 501
diagnosis for purposes of authorizing future services under the 502
Medicaid program. This section do es not restrict access to 503
emergency services or poststabilization care services as defined 504
in 42 C.F.R. s. 438.114. Such confirmation or second opinion 505
shall be rendered in a manner approved by the agency. The agency 506
shall maximize the use of prepaid per c apita and prepaid 507
aggregate fixed-sum basis services when appropriate and other 508
alternative service delivery and reimbursement methodologies, 509
including competitive bidding pursuant to s. 287.057, designed 510
to facilitate the cost -effective purchase of a case -managed 511
continuum of care. The agency shall also require providers to 512
minimize the exposure of recipients to the need for acute 513
inpatient, custodial, and other institutional care and the 514
inappropriate or unnecessary use of high -cost services. The 515
agency shall contract with a vendor to monitor and evaluate the 516
clinical practice patterns of providers in order to identify 517
trends that are outside the normal practice patterns of a 518
provider's professional peers or the national guidelines of a 519
provider's professional association. The vendor must be able to 520
provide information and counseling to a provider whose practice 521
patterns are outside the norms, in consultation with the agency, 522
to improve patient care and reduce inappropriate utilization. 523
The agency may manda te prior authorization, drug therapy 524
management, or disease management participation for certain 525
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populations of Medicaid beneficiaries, certain drug classes, or 526
particular drugs to prevent fraud, abuse, overuse, and possible 527
dangerous drug interactions. Th e Pharmaceutical and Therapeutics 528
Committee shall make recommendations to the agency on drugs for 529
which prior authorization is required. The agency shall inform 530
the Pharmaceutical and Therapeutics Committee of its decisions 531
regarding drugs subject to prior authorization. The agency is 532
authorized to limit the entities it contracts with or enrolls as 533
Medicaid providers by developing a provider network through 534
provider credentialing. The agency may competitively bid single -535
source-provider contracts if procurem ent of goods or services 536
results in demonstrated cost savings to the state without 537
limiting access to care. The agency may limit its network based 538
on the assessment of beneficiary access to care, provider 539
availability, provider quality standards, time and distance 540
standards for access to care, the cultural competence of the 541
provider network, demographic characteristics of Medicaid 542
beneficiaries, practice and provider -to-beneficiary standards, 543
appointment wait times, beneficiary use of services, provider 544
turnover, provider profiling, provider licensure history, 545
previous program integrity investigations and findings, peer 546
review, provider Medicaid policy and billing compliance records, 547
clinical and medical record audits, and other factors. Providers 548
are not entitled to enrollment in the Medicaid provider network. 549
The agency shall determine instances in which allowing Medicaid 550
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beneficiaries to purchase durable medical equipment and other 551
goods is less expensive to the Medicaid program than long -term 552
rental of the equipment or goods. The agency may establish rules 553
to facilitate purchases in lieu of long -term rentals in order to 554
protect against fraud and abuse in the Medicaid program as 555
defined in s. 409.913. The agency may seek federal waivers 556
necessary to adminis ter these policies. 557
(11) The agency shall implement a program of all -inclusive 558
care for children. The program of all -inclusive care for 559
children shall be established to provide in -home hospice-like 560
support services to children diagnosed with a life -threatening 561
illness and enrolled in the Children's Medical Services network 562
to reduce hospitalizations as appropriate. The agency, in 563
consultation with the Department of Health, may implement the 564
program of all-inclusive care for children after obtaining 565
approval from the Centers for Medicare and Medicaid Services. 566
Section 28. Effective July 1, 2025, subsection (1) of 567
section 409.9126, Florida Statutes, is amended to read: 568
409.9126 Children with special health care needs. — 569
(1) Except as provided in subse ction (4), children 570
eligible for the Children's Medical Services program who receive 571
Medicaid benefits, and other Medicaid -eligible children with 572
special health care needs, are shall be exempt from the 573
provisions of s. 409.9122 and shall be served through the 574
Children's Medical Services network established in chapter 391 . 575
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Section 29. Effective July 1, 2025, paragraph (a) of 576
subsection (5) of section 409.9131, Florida Statutes, is amended 577
to read: 578
409.9131 Special provisions relating to integrity of the 579
Medicaid program.— 580
(5) DETERMINATIONS OF OVERPAYMENT. —In making a 581
determination of overpayment to a physician, the agency must: 582
(a) Use accepted and valid auditing, accounting, 583
analytical, statistical, or peer -review methods, or combinations 584
thereof. Appropriate statistical methods may include, but are 585
not limited to, sampling and extension to the population, 586
parametric and nonparametric statistics, tests of hypotheses, 587
other generally accepted statistical methods, review of medical 588
records, and a consideration of the physician's client case mix. 589
Before performing a review of the physician's Medicaid records, 590
however, the agency shall make every effort to consider the 591
physician's patient case mix, including, but not limited to, 592
patient age and whether individual patients are clients of the 593
Children's Medical Services Network established in chapter 391 . 594
In meeting its burden of proof in any administrative or court 595
proceeding, the agency may introduce the results of such 596
statistical methods and its othe r audit findings as evidence of 597
overpayment. 598
Section 30. Effective July 1, 2025, paragraph (e) of 599
subsection (1) of section 409.920, Florida Statutes, is amended 600
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to read: 601
409.920 Medicaid provider fraud. — 602
(1) For the purposes of this section, the t erm: 603
(e) "Managed care plans" means a health insurer authorized 604
under chapter 624, an exclusive provider organization authorized 605
under chapter 627, a health maintenance organization authorized 606
under chapter 641, the Children's Medical Services Network 607
authorized under chapter 391 , a prepaid health plan authorized 608
under this chapter, a provider service network authorized under 609
this chapter, a minority physician network authorized under this 610
chapter, and an emergency department diversion program 611
authorized under this chapter or the General Appropriations Act, 612
providing health care services pursuant to a contract with the 613
Medicaid program. 614
Section 31. Effective July 1, 2025, subsection (7) of 615
section 409.962, Florida Statutes, is amended to read: 616
409.962 Definitions.—As used in this part, except as 617
otherwise specifically provided, the term: 618
(7) "Eligible plan" means a health insurer authorized 619
under chapter 624, an exclusive provider organization authorized 620
under chapter 627, a health maintenance organ ization authorized 621
under chapter 641, or a provider service network authorized 622
under s. 409.912(1) or an accountable care organization 623
authorized under federal law. For purposes of the managed 624
medical assistance program, the term also includes the 625
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Children's Medical Services Network authorized under chapter 391 626
and entities qualified under 42 C.F.R. part 422 as Medicare 627
Advantage Preferred Provider Organizations, Medicare Advantage 628
Provider-sponsored Organizations, Medicare Advantage Health 629
Maintenance Organizations, Medicare Advantage Coordinated Care 630
Plans, and Medicare Advantage Special Needs Plans, and the 631
Program of All-inclusive Care for the Elderly. 632
Section 32. The Agency for Health Care Administration 633
shall develop a comprehensive plan to redesig n the Florida 634
Medicaid Model Waiver for home and community -based services to 635
include children who receive private duty nursing services. The 636
plan must propose an array of tiered services with the goal of 637
ensuring that institutional care is avoided so child ren can 638
remain in the home or other community setting. The agency must 639
work with stakeholders in developing the plan, including, but 640
not limited to, families of children who are in the model waiver 641
or receiving private duty nursing, advocates for children, 642
providers of services to children receiving private duty 643
nursing, and Statewide Medicaid Managed Care plans. The agency 644
is authorized to contract with necessary experts to assist in 645
developing the plan. The agency must submit a report to the 646
Governor, the President of the Senate, and the Speaker of the 647
House of Representatives by September 30, 2025, addressing, at a 648
minimum, all of the following: 649
(1) The purpose, rationale, and expected benefits of the 650
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redesigned waiver plan. 651
(2) The proposed eligibili ty criteria for clients and 652
service benefit packages to be offered through the redesigned 653
waiver plan. Managed care plans participating in the Statewide 654
Medicaid Managed Care program must provide services under the 655
redesigned waiver plan. 656
(3) A proposed implementation plan and timeline, 657
including, but not limited to, recommendations for the number of 658
clients served by the redesigned waiver plan at initial 659
implementation, changes over time, and any per -client benefit 660
caps. 661
(4) The fiscal impact for the i mplementation year and 662
projections for the next 5 years determined on an actuarially 663
sound basis. 664
(5) An analysis of the availability of services and 665
service providers that would be offered under the redesigned 666
waiver plan and recommendations to increase availability of such 667
services, as applicable. 668
(6) A list of all stakeholders, public and private, who 669
were consulted or contacted the development of the plan. 670
Section 33. Except as otherwise expressly provided in this 671
act, this act shall take effect upon becoming a law. 672