Florida Senate - 2025 SB 1490 By Senator Harrell 31-00791A-25 20251490__ 1 A bill to be entitled 2 An act relating to the Childrens Medical Services 3 program; transferring operation of the Childrens 4 Medical Services Managed Care Plan from the Department 5 of Health to the Agency for Health Care 6 Administration, effective on a specified date; 7 providing construction as to judicial and 8 administrative actions pending as of a specified date 9 and time; requiring the departments Childrens 10 Medical Services (CMS) program to collaborate with the 11 agency in the care of children and youth with special 12 health care needs; requiring the CMS program to 13 conduct certain clinical eligibility screenings and 14 provide ongoing consultation to the agency for a 15 specified purpose; amending s. 409.906, F.S.; 16 conforming a cross-reference; requiring the agency to 17 seek federal approval to amend the states Medicaid 18 Model Waiver for home and community-based services to 19 include certain services; requiring the agency to 20 implement the approved waiver amendment subject to 21 certain conditions; authorizing the agency to adopt 22 rules; amending s. 409.974, F.S.; requiring the CMS 23 program to transfer operation of certain managed care 24 contracts from the department to the agency effective 25 on a specified date; requiring the CMS program to 26 conduct clinical eligibility screening for certain 27 children and youth with special health care needs; 28 requiring the program to provide ongoing consultation 29 to the agency for a specified purpose; requiring the 30 agency to establish specific measures for evaluation 31 of services provided to children and youth with 32 special health care needs; requiring the agency to 33 contract with an independent evaluator to conduct the 34 evaluation of services provided; specifying 35 requirements for the evaluation; requiring the agency 36 to submit the results of the evaluation to the 37 Governor and the Legislature by a specified date; 38 amending s. 391.016, F.S.; revising the purposes and 39 functions of the CMS program; amending s. 391.021, 40 F.S.; revising definitions; amending s. 391.025, F.S.; 41 revising the scope of the CMS program; amending s. 42 391.026, F.S.; revising the powers and duties of the 43 department to conform to changes made by the act; 44 providing for the future repeal of s. 391.026(8) 45 through (11), F.S., relating to the departments 46 oversight and administration of the CMS program; 47 repealing s. 391.028, F.S., relating to administration 48 of the program; amending s. 391.029, F.S.; revising 49 program eligibility requirements; conforming 50 provisions to changes made by the act; amending s. 51 391.0315, F.S.; conforming provisions to changes made 52 by the act; providing for future repeal of specified 53 provisions; repealing ss. 391.035, 391.037, 391.045, 54 391.047, 391.055, and 391.071, F.S., relating to 55 provider qualifications; physicians and private sector 56 services; provider reimbursements; third-party 57 payments; service delivery systems under the program; 58 and quality of care requirements, respectively; 59 amending s. 391.097, F.S.; conforming a provision to 60 changes made by the act; repealing part II of ch. 391, 61 F.S., consisting of ss. 391.221 and 391.223, F.S., 62 relating to the Statewide Childrens Medical Services 63 Network Advisory Council and technical advisory 64 panels, respectively; amending ss. 409.166, 409.811, 65 409.813, 409.8134, 409.814, 409.815, 409.8177, 66 409.818, 409.912, 409.9126, 409.9131, 409.920, 67 409.962, 409.968, and 409.972, F.S.; conforming 68 provisions to changes made by the act; 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 Childrens Medical 74 Services Managed Care Plan. 75 (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 appropriations, allocations, and other 79 funds for the operation of the Department of Healths Childrens 80 Medical Services Managed Care Plan are transferred to the Agency 81 for Health Care Administration. 82 (2)The transfer of operations of the Childrens 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 Healths Childrens 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 Healths Childrens 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 Healths Childrens Medical 94 Services program shall do all of the following: 95 (a)Conduct clinical eligibility screening for children and 96 youth with special health care needs who are eligible for or 97 enrolled in Medicaid or the Childrens Health Insurance Program. 98 (b)Provide ongoing consultation to the Agency for Health 99 Care Administration to ensure high-quality, family-centered, 100 coordinated health services within an effective system of care 101 for children and youth with special health care needs. 102 Section 2.Paragraph (d) of subsection (13) of section 103 409.906, Florida Statutes, is amended, and paragraph (e) is 104 added to that subsection, to read: 105 409.906Optional 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, or 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 states systems of 121 providing services to elderly 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 known as Intermediate Care Facilities 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 disorders, 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 (e)The agency shall seek federal approval to amend 135 Floridas Medicaid Model Waiver for home and community-based 136 services to include children who receive private duty nursing 137 services. The amended waiver must provide an array of tiered 138 services to more broadly serve medically fragile children who 139 receive private duty nursing services and must ensure that 140 institutional care is avoided so children can remain in the home 141 or community setting. Services provided under the waiver must be 142 provided by health plans participating in the Statewide Medicaid 143 Managed Care program. The agency shall implement the approved 144 waiver amendment subject to the availability of funds and any 145 limitations provided in the General Appropriations Act, 146 including a limitation on the number of enrollees in the revised 147 waiver. The agency may adopt rules to implement this paragraph. 148 Section 3.Subsection (4) of section 409.974, Florida 149 Statutes, is amended to read: 150 409.974Eligible plans. 151 (4)CHILDRENS MEDICAL SERVICES NETWORK. 152 (a)The Department of Healths Childrens Medical Services 153 program shall do all of the following: 154 1.Effective July 1, 2025, transfer to the agency the 155 operation of managed care contracts procured by the department 156 for Medicaid and Childrens Health Insurance Program services 157 provided to children and youth with special health care needs 158 who are enrolled in the Childrens Medical Services Managed Care 159 Plan. 160 2.Conduct clinical eligibility screening for children and 161 youth with special health care needs who are eligible for or are 162 enrolled in Medicaid or the Childrens Health Insurance Program. 163 3.Provide ongoing consultation to the agency to ensure 164 high-quality, family-centered, coordinated health services are 165 provided within an effective system of care for children and 166 youth with special health care needs. 167 (b)The agency shall establish specific measures of access, 168 quality, and costs of providing health care services to children 169 and youth with special health care needs. The agency shall 170 contract with an independent evaluator to conduct an evaluation 171 of services provided. The evaluation must include, but need not 172 be limited to, all of the following: 173 1.A performance comparison of plans contracted to provide 174 services to children and youth with special health care needs as 175 well as plans contracted to serve a broader population of 176 Managed Medical Assistance enrollees. The performance comparison 177 must be based on the measures established by the agency and 178 differentiated based on the age and medical condition or 179 diagnosis of patients receiving services under each plan. 180 2.For each plan, an assessment of cost savings, patient 181 choice, access to services, coordination of care, person 182 centered planning, health and quality-of-life outcomes, patient 183 and provider satisfaction, and provider networks and quality of 184 care. 185 186 The agency shall submit the results of the evaluation to the 187 Governor, the President of the Senate, and the Speaker of the 188 House of Representatives by January 15, 2028 Participation by 189 the Childrens Medical Services Network shall be pursuant to a 190 single, statewide contract with the agency that is not subject 191 to the procurement requirements or regional plan number limits 192 of this section. The Childrens Medical Services Network must 193 meet all other plan requirements for the managed medical 194 assistance program. 195 Section 4.Subsection (1) of section 391.016, Florida 196 Statutes, is amended to read: 197 391.016Purposes and functions.The Childrens Medical 198 Services program is established for the following purposes and 199 authorized to perform the following functions: 200 (1)Provide to children and youth with special health care 201 needs a family-centered, comprehensive, and coordinated 202 statewide managed system of care that links community-based 203 health care with multidisciplinary, regional, and tertiary 204 pediatric specialty care. The program shall coordinate and 205 maintain a consistent medical home for participating children. 206 Section 5.Subsections (1), (2), and (4) of section 207 391.021, Florida Statutes, are reordered and amended to read: 208 391.021Definitions.When used in this act, the term: 209 (2)(1)Childrens Medical Services Managed Care Plan 210 network or plan network means a statewide managed care 211 service system that includes health care providers, as defined 212 in this section. 213 (1)(2)Children and youth with special health care needs 214 means those children and youth younger than 21 years of age who 215 have chronic and serious physical, developmental, behavioral, or 216 emotional conditions and who require health care and related 217 services of a type or amount beyond that which is generally 218 required by children and youth. 219 (4)Eligible individual means a child or youth with a 220 special health care need or a female with a high-risk pregnancy, 221 who meets the financial and medical eligibility standards 222 established in s. 391.029. 223 Section 6.Subsection (1) of section 391.025, Florida 224 Statutes, is amended to read: 225 391.025Applicability and scope. 226 (1)The Childrens Medical Services program consists of the 227 following components: 228 (a)The newborn screening program established in s. 383.14 229 and the newborn, infant, and toddler hearing screening program 230 established in s. 383.145. 231 (b)The regional perinatal intensive care centers program 232 established in ss. 383.15-383.19. 233 (c)The developmental evaluation and intervention program, 234 including the Early Steps Program established in ss. 391.301 235 391.308. 236 (d)The Childrens Medical Services Managed Care Plan 237 through the end of June 30, 2025 network. 238 (e)The Childrens Multidisciplinary Assessment Team. 239 (f)The Medical Foster Care Program. 240 (g)The Title V Children and Youth with Special Health Care 241 Needs program. 242 (h)The Safety Net Program. 243 (i)Child Protection Teams and sexual abuse treatment 244 programs established under s. 39.303. 245 (j)The State Child Abuse Death Review Committee and local 246 child abuse death review committees established in s. 383.402. 247 Section 7.Section 391.026, Florida Statutes, is amended to 248 read: 249 391.026Powers and duties of the department.The department 250 shall have the following powers, duties, and responsibilities: 251 (1)To provide or contract for the provision of health 252 services to eligible individuals. 253 (2)To provide services to abused and neglected children 254 through Child Protection Teams pursuant to s. 39.303. 255 (3)To determine the medical and financial eligibility of 256 individuals seeking health services from the program. 257 (4)To coordinate a comprehensive delivery system for 258 eligible individuals to take maximum advantage of all available 259 funds. 260 (5)To coordinate with programs relating to childrens 261 medical services in cooperation with other public and private 262 agencies. 263 (6)To initiate and coordinate applications to federal 264 agencies and private organizations for funds, services, or 265 commodities relating to childrens medical programs. 266 (7)To sponsor or promote grants for projects, programs, 267 education, or research in the field of children and youth with 268 special health care needs, with an emphasis on early diagnosis 269 and treatment. 270 (8)To oversee and operate the Childrens Medical Services 271 Managed Care Plan through the end of June 30, 2025 network. 272 (9)To establish reimbursement mechanisms for the 273 Childrens Medical Services network. 274 (10)To establish Childrens Medical Services network 275 standards and credentialing requirements for health care 276 providers and health care services. 277 (11)To serve as a provider and principal case manager for 278 children with special health care needs under Titles XIX and XXI 279 of the Social Security Act. 280 (12)To monitor the provision of health services in the 281 program, including the utilization and quality of health 282 services. 283 (10)(13)To administer the Children and Youth with Special 284 Health Care Needs program in accordance with Title V of the 285 Social Security Act. 286 (14)To establish and operate a grievance resolution 287 process for participants and health care providers. 288 (15)To maintain program integrity in the Childrens 289 Medical Services program. 290 (11)(16)To receive and manage health care premiums, 291 capitation payments, and funds from federal, state, local, and 292 private entities for the program. The department may contract 293 with a third-party administrator for processing claims, 294 monitoring medical expenses, and other related services 295 necessary to the efficient and cost-effective operation of the 296 Childrens Medical Services Managed Care Plan through the end of 297 June 30, 2025 network. The department is authorized to maintain 298 a minimum reserve for the Childrens Medical Services network in 299 an amount that is the greater of: 300 (a)Ten percent of total projected expenditures for Title 301 XIX-funded and Title XXI-funded children; or 302 (b)Two percent of total annualized payments from the 303 Agency for Health Care Administration for Title XIX and Title 304 XXI of the Social Security Act. 305 (12)(17)To provide or contract for peer review and other 306 quality-improvement activities. 307 (13)(18)To adopt rules pursuant to ss. 120.536(1) and 308 120.54 to administer the Childrens Medical Services Act. 309 (14)(19)To serve as the lead agency in administering the 310 Early Steps Program pursuant to part C of the federal 311 Individuals with Disabilities Education Act and part III of this 312 chapter. 313 (15)To administer the Medical Foster Care Program, 314 including all of the following: 315 (a)Recruitment, training, assessment, and monitoring for 316 the Medical Foster Care Program. 317 (b)Monitoring access and facilitating admissions of 318 eligible children and youth to the program and designated 319 medical foster care homes. 320 (c)Coordination with the Department of Children and 321 Families and the Agency for Health Care Administration or their 322 designees. 323 Section 8.Effective July, 1, 2025, subsections (8) through 324 (11) of section 391.026, Florida Statutes, as amended by this 325 act, are repealed. 326 Section 9.Effective July 1, 2025, section 391.028, Florida 327 Statutes, is repealed. 328 Section 10.Subsections (2) and (3) of section 391.029, 329 Florida Statutes, are amended to read: 330 391.029Program eligibility. 331 (2)The following individuals are eligible to receive 332 services through the program: 333 (a)Related to the regional perinatal intensive care 334 centers, a high-risk pregnant female who is enrolled in 335 Medicaid. 336 (b)Children and youth with serious special health care 337 needs from birth to 21 years of age who are enrolled in 338 Medicaid. 339 (c)Children and youth with serious special health care 340 needs from birth to 19 years of age who are enrolled in a 341 program under Title XXI of the Social Security Act. 342 (3)Subject to the availability of funds, the following 343 individuals may receive services through the Childrens Medical 344 Services Safety Net program: 345 (a)Children and youth with serious special health care 346 needs from birth to 21 years of age who do not qualify for 347 Medicaid or Title XXI of the Social Security Act but who are 348 unable to access, due to lack of providers or lack of financial 349 resources, specialized services that are medically necessary or 350 essential family support services. Families shall participate 351 financially in the cost of care based on a sliding fee scale 352 established by the department. 353 (b)Children and youth with special health care needs from 354 birth to 21 years of age, as provided in Title V of the Social 355 Security Act. 356 (c)An infant who receives an award of compensation under 357 s. 766.31(1). The Florida Birth-Related Neurological Injury 358 Compensation Association shall reimburse the Childrens Medical 359 Services Network the states share of funding, which must 360 thereafter be used to obtain matching federal funds under Title 361 XXI of the Social Security Act. 362 Section 11.Section 391.0315, Florida Statutes, is amended 363 to read: 364 391.0315Benefits.Benefits provided under the Childrens 365 Medical Services Managed Care Plan program for children with 366 special health care needs shall be equivalent to benefits 367 provided to children as specified in ss. 409.905 and 409.906. 368 The department may offer additional benefits through Childrens 369 Medical Services programs for early intervention services, 370 respite services, genetic testing, genetic and nutritional 371 counseling, and parent support services, if such services are 372 determined to be medically necessary. This section is repealed 373 on January 1, 2026. 374 Section 12.Section 391.035, Florida Statutes, is repealed. 375 Section 13.Effective January 1, 2026, section 391.037, 376 Florida Statutes, is repealed. 377 Section 14.Section 391.045, Florida Statutes, is repealed. 378 Section 15.Effective January 1, 2026, section 391.047, 379 Florida Statutes, is repealed. 380 Section 16.Effective January 1, 2026, section 391.055, 381 Florida Statutes, is repealed. 382 Section 17.Effective January 1, 2026, section 391.071, 383 Florida Statutes, is repealed. 384 Section 18.Section 391.097, Florida Statutes, is amended 385 to read: 386 391.097Research and evaluation. 387 (1)The department may initiate, fund, and conduct research 388 and evaluation projects to improve the delivery of childrens 389 medical services. The department may cooperate with public and 390 private agencies engaged in work of a similar nature. 391 (2)The Childrens Medical Services network shall be 392 included in any evaluation conducted in accordance with the 393 provisions of Title XXI of the Social Security Act as enacted by 394 the Legislature. 395 Section 19.Part II of chapter 391, Florida Statutes, 396 consisting of ss. 391.221 and 391.223, Florida Statutes, is 397 repealed, and part III of that chapter is redesignated as part 398 II. 399 Section 20.Effective July 1, 2025, paragraph (b) of 400 subsection (5) of section 409.166, Florida Statutes, is amended 401 to read: 402 409.166Children within the child welfare system; adoption 403 assistance program. 404 (5)ELIGIBILITY FOR SERVICES. 405 (b)A child who is handicapped at the time of adoption is 406 shall be eligible for services through a plan under contract 407 with the agency to serve children and youth with special heath 408 care needs the Childrens Medical Services network established 409 under part I of chapter 391 if the child was eligible for such 410 services before prior to the adoption. 411 Section 21.Effective July 1, 2025, subsection (7) of 412 section 409.811, Florida Statutes, is amended to read: 413 409.811Definitions relating to Florida Kidcare Act.As 414 used in ss. 409.810-409.821, the term: 415 (7)Childrens Medical Services Network or network 416 means a statewide managed care service system as defined in s. 417 391.021(1). 418 Section 22.Effective July 1, 2025, subsection (1) of 419 section 409.813, Florida Statutes, is amended to read: 420 409.813Health benefits coverage; program components; 421 entitlement and nonentitlement. 422 (1)The Florida Kidcare program includes health benefits 423 coverage provided to children through the following program 424 components, which shall be marketed as the Florida Kidcare 425 program: 426 (a)Medicaid; 427 (b)Medikids as created in s. 409.8132; 428 (c)The Florida Healthy Kids Corporation as created in s. 429 624.91; 430 (d)Employer-sponsored group health insurance plans 431 approved under ss. 409.810-409.821; and 432 (e)Plans under contract with the agency to serve children 433 and youth with special health care needs The Childrens Medical 434 Services network established in chapter 391. 435 Section 23.Effective July 1, 2025, subsection (3) of 436 section 409.8134, Florida Statutes, is amended to read: 437 409.8134Program expenditure ceiling; enrollment. 438 (3)Upon determination by the Social Services Estimating 439 Conference that there are insufficient funds to finance the 440 current enrollment in the Florida Kidcare program within current 441 appropriations, the program shall initiate disenrollment 442 procedures to remove enrollees, except those children enrolled 443 in a plan under contract with the agency to serve children with 444 special health care needs the Childrens Medical Services 445 Network, on a last-in, first-out basis until the expenditure and 446 appropriation levels are balanced. 447 Section 24.Subsection (3) and paragraph (c) of subsection 448 (10) of section 409.814, Florida Statutes, are amended to read: 449 409.814Eligibility.A child who has not reached 19 years 450 of age whose family income is equal to or below 300 percent of 451 the federal poverty level is eligible for the Florida Kidcare 452 program as provided in this section. If an enrolled individual 453 is determined to be ineligible for coverage, he or she must be 454 immediately disenrolled from the respective Florida Kidcare 455 program component. 456 (3)A Title XXI-funded child who is eligible for the 457 Florida Kidcare program who is a child with special health care 458 needs, as determined through a medical or behavioral screening 459 instrument, is eligible for health benefits coverage from and 460 shall be assigned to and may opt out of a plan under contract 461 with the agency to serve children with special health care needs 462 the Childrens Medical Services Network. 463 (10)In determining the eligibility of a child, an assets 464 test is not required. If eligibility for the Florida Kidcare 465 program cannot be verified using reliable data sources in 466 accordance with federal requirements, each applicant shall 467 provide documentation during the application process and the 468 redetermination process, including, but not limited to, the 469 following: 470 (c)To enroll in a plan under contract with the agency to 471 service children with special health care needs the Childrens 472 Medical Services Network, a completed application, including a 473 Childrens Medical Services clinical screening. 474 Section 25.Effective July 1, 2025, paragraph (t) of 475 subsection (2) of section 409.815, Florida Statutes, is amended 476 to read: 477 409.815Health benefits coverage; limitations. 478 (2)BENCHMARK BENEFITS.In order for health benefits 479 coverage to qualify for premium assistance payments for an 480 eligible child under ss. 409.810-409.821, the health benefits 481 coverage, except for coverage under Medicaid and Medikids, must 482 include the following minimum benefits, as medically necessary. 483 (t)Enhancements to minimum requirements. 484 1.This section sets the minimum benefits that must be 485 included in any health benefits coverage, other than Medicaid or 486 Medikids coverage, offered under ss. 409.810-409.821. Health 487 benefits coverage may include additional benefits not included 488 under this subsection, but may not include benefits excluded 489 under paragraph (r). 490 2.Health benefits coverage may extend any limitations 491 beyond the minimum benefits described in this section. 492 493 Except for a plan under contract with the agency to serve 494 children with special health care needs the Childrens Medical 495 Services Network, the agency may not increase the premium 496 assistance payment for either additional benefits provided 497 beyond the minimum benefits described in this section or the 498 imposition of less restrictive service limitations. 499 Section 26.Effective July 1, 2025, paragraph (i) of 500 subsection (1) of section 409.8177, Florida Statutes, is amended 501 to read: 502 409.8177Program evaluation. 503 (1)The agency, in consultation with the Department of 504 Health, the Department of Children and Families, and the Florida 505 Healthy Kids Corporation, shall contract for an evaluation of 506 the Florida Kidcare program and shall by January 1 of each year 507 submit to the Governor, the President of the Senate, and the 508 Speaker of the House of Representatives a report of the program. 509 In addition to the items specified under s. 2108 of Title XXI of 510 the Social Security Act, the report shall include an assessment 511 of crowd-out and access to health care, as well as the 512 following: 513 (i)An assessment of the effectiveness of the Florida 514 Kidcare program, including Medicaid, the Florida Healthy Kids 515 program, Medikids, and the plans under contract with the agency 516 to serve children with special health care needs Childrens 517 Medical Services network, and other public and private programs 518 in the state in increasing the availability of affordable 519 quality health insurance and health care for children. 520 Section 27.Effective July 1, 2025, subsection (4) of 521 section 409.818, Florida Statutes, is amended to read: 522 409.818Administration.In order to implement ss. 409.810 523 409.821, the following agencies shall have the following duties: 524 (4)The Office of Insurance Regulation shall certify that 525 health benefits coverage plans that seek to provide services 526 under the Florida Kidcare program, except those offered through 527 the Florida Healthy Kids Corporation or the Childrens Medical 528 Services Network, meet, exceed, or are actuarially equivalent to 529 the benchmark benefit plan and that health insurance plans will 530 be offered at an approved rate. In determining actuarial 531 equivalence of benefits coverage, the Office of Insurance 532 Regulation and health insurance plans must comply with the 533 requirements of s. 2103 of Title XXI of the Social Security Act. 534 The department shall adopt rules necessary for certifying health 535 benefits coverage plans. 536 Section 28.Effective July 1, 2025, subsection (11) of 537 section 409.912, Florida Statutes, is amended to read: 538 409.912Cost-effective purchasing of health care.The 539 agency shall purchase goods and services for Medicaid recipients 540 in the most cost-effective manner consistent with the delivery 541 of quality medical care. To ensure that medical services are 542 effectively utilized, the agency may, in any case, require a 543 confirmation or second physicians opinion of the correct 544 diagnosis for purposes of authorizing future services under the 545 Medicaid program. This section does not restrict access to 546 emergency services or poststabilization care services as defined 547 in 42 C.F.R. s. 438.114. Such confirmation or second opinion 548 shall be rendered in a manner approved by the agency. The agency 549 shall maximize the use of prepaid per capita and prepaid 550 aggregate fixed-sum basis services when appropriate and other 551 alternative service delivery and reimbursement methodologies, 552 including competitive bidding pursuant to s. 287.057, designed 553 to facilitate the cost-effective purchase of a case-managed 554 continuum of care. The agency shall also require providers to 555 minimize the exposure of recipients to the need for acute 556 inpatient, custodial, and other institutional care and the 557 inappropriate or unnecessary use of high-cost services. The 558 agency shall contract with a vendor to monitor and evaluate the 559 clinical practice patterns of providers in order to identify 560 trends that are outside the normal practice patterns of a 561 providers professional peers or the national guidelines of a 562 providers professional association. The vendor must be able to 563 provide information and counseling to a provider whose practice 564 patterns are outside the norms, in consultation with the agency, 565 to improve patient care and reduce inappropriate utilization. 566 The agency may mandate prior authorization, drug therapy 567 management, or disease management participation for certain 568 populations of Medicaid beneficiaries, certain drug classes, or 569 particular drugs to prevent fraud, abuse, overuse, and possible 570 dangerous drug interactions. The Pharmaceutical and Therapeutics 571 Committee shall make recommendations to the agency on drugs for 572 which prior authorization is required. The agency shall inform 573 the Pharmaceutical and Therapeutics Committee of its decisions 574 regarding drugs subject to prior authorization. The agency is 575 authorized to limit the entities it contracts with or enrolls as 576 Medicaid providers by developing a provider network through 577 provider credentialing. The agency may competitively bid single 578 source-provider contracts if procurement of goods or services 579 results in demonstrated cost savings to the state without 580 limiting access to care. The agency may limit its network based 581 on the assessment of beneficiary access to care, provider 582 availability, provider quality standards, time and distance 583 standards for access to care, the cultural competence of the 584 provider network, demographic characteristics of Medicaid 585 beneficiaries, practice and provider-to-beneficiary standards, 586 appointment wait times, beneficiary use of services, provider 587 turnover, provider profiling, provider licensure history, 588 previous program integrity investigations and findings, peer 589 review, provider Medicaid policy and billing compliance records, 590 clinical and medical record audits, and other factors. Providers 591 are not entitled to enrollment in the Medicaid provider network. 592 The agency shall determine instances in which allowing Medicaid 593 beneficiaries to purchase durable medical equipment and other 594 goods is less expensive to the Medicaid program than long-term 595 rental of the equipment or goods. The agency may establish rules 596 to facilitate purchases in lieu of long-term rentals in order to 597 protect against fraud and abuse in the Medicaid program as 598 defined in s. 409.913. The agency may seek federal waivers 599 necessary to administer these policies. 600 (11)The agency shall implement a program of all-inclusive 601 care for children. The program of all-inclusive care for 602 children shall be established to provide in-home hospice-like 603 support services to children diagnosed with a life-threatening 604 illness and enrolled in the Childrens Medical Services network 605 to reduce hospitalizations as appropriate. The agency, in 606 consultation with the Department of Health, may implement the 607 program of all-inclusive care for children after obtaining 608 approval from the Centers for Medicare and Medicaid Services. 609 Section 29.Effective July 1, 2025, subsection (1) of 610 section 409.9126, Florida Statutes, is amended to read: 611 409.9126Children with special health care needs. 612 (1)Except as provided in subsection (4), children eligible 613 for the Childrens Medical Services program who receive Medicaid 614 benefits, and other Medicaid-eligible children with special 615 health care needs, are shall be exempt from the provisions of s. 616 409.9122 and shall be served through the Childrens Medical 617 Services network established in chapter 391. 618 Section 30.Effective July 1, 2025, paragraph (a) of 619 subsection (5) of section 409.9131, Florida Statutes, is amended 620 to read: 621 409.9131Special provisions relating to integrity of the 622 Medicaid program. 623 (5)DETERMINATIONS OF OVERPAYMENT.In making a 624 determination of overpayment to a physician, the agency must: 625 (a)Use accepted and valid auditing, accounting, 626 analytical, statistical, or peer-review methods, or combinations 627 thereof. Appropriate statistical methods may include, but are 628 not limited to, sampling and extension to the population, 629 parametric and nonparametric statistics, tests of hypotheses, 630 other generally accepted statistical methods, review of medical 631 records, and a consideration of the physicians client case mix. 632 Before performing a review of the physicians Medicaid records, 633 however, the agency shall make every effort to consider the 634 physicians patient case mix, including, but not limited to, 635 patient age and whether individual patients are clients of the 636 Childrens Medical Services Network established in chapter 391. 637 In meeting its burden of proof in any administrative or court 638 proceeding, the agency may introduce the results of such 639 statistical methods and its other audit findings as evidence of 640 overpayment. 641 Section 31.Effective July 1, 2025, paragraph (e) of 642 subsection (1) of section 409.920, Florida Statutes, is amended 643 to read: 644 409.920Medicaid provider fraud. 645 (1)For the purposes of this section, the term: 646 (e)Managed care plans means a health insurer authorized 647 under chapter 624, an exclusive provider organization authorized 648 under chapter 627, a health maintenance organization authorized 649 under chapter 641, the Childrens Medical Services Network 650 authorized under chapter 391, a prepaid health plan authorized 651 under this chapter, a provider service network authorized under 652 this chapter, a minority physician network authorized under this 653 chapter, and an emergency department diversion program 654 authorized under this chapter or the General Appropriations Act, 655 providing health care services pursuant to a contract with the 656 Medicaid program. 657 Section 32.Effective July 1, 2025, subsection (7) of 658 section 409.962, Florida Statutes, is amended to read: 659 409.962Definitions.As used in this part, except as 660 otherwise specifically provided, the term: 661 (7)Eligible plan means a health insurer authorized under 662 chapter 624, an exclusive provider organization authorized under 663 chapter 627, a health maintenance organization authorized under 664 chapter 641, or a provider service network authorized under s. 665 409.912(1) or an accountable care organization authorized under 666 federal law. For purposes of the managed medical assistance 667 program, the term also includes the Childrens Medical Services 668 Network authorized under chapter 391 and entities qualified 669 under 42 C.F.R. part 422 as Medicare Advantage Preferred 670 Provider Organizations, Medicare Advantage Provider-sponsored 671 Organizations, Medicare Advantage Health Maintenance 672 Organizations, Medicare Advantage Coordinated Care Plans, and 673 Medicare Advantage Special Needs Plans, and the Program of All 674 inclusive Care for the Elderly. 675 Section 33.Subsection (3) of section 409.968, Florida 676 Statutes, is amended to read: 677 409.968Managed care plan payments. 678 (3)Reimbursement for prescribed pediatric extended care 679 services provided to children enrolled in a managed care plan 680 under s. 409.972(1)(g) shall be paid to the prescribed pediatric 681 extended care services provider by the agency on a fee-for 682 service basis. 683 Section 34.Paragraph (g) of subsection (1) of section 684 409.972, Florida Statutes, is amended to read: 685 409.972Mandatory and voluntary enrollment. 686 (1)The following Medicaid-eligible persons are exempt from 687 mandatory managed care enrollment required by s. 409.965, and 688 may voluntarily choose to participate in the managed medical 689 assistance program: 690 (g)Children receiving services in a prescribed pediatric 691 extended care center. 692 Section 35.Except as otherwise expressly provided in this 693 act, this act shall take effect upon becoming a law.