HB 1085 — Children's Medical Services Program

hb1085-02-c2hb1085-01-c1 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 CS/CS/HBCS/HB 1085 2025 Statutes,the Children's Medical Services Network shall be pursuant to a single, statewide contract with the agency that is amendednot subject to read:the procurement requirements or regional plan number limits of this section.

The Children's Medical Services Network must meet all other plan requirements for the managed medical assistance program.

Section 4.

Subsection (1) of section 391.016, Florida Statutes, is amended to read:

Section 4.5.

(1)(2) "Children and youth with special health care needs" meansPage those8 children and youth younger than 21 years of age29 whoCODING: have chronic and serious physical, developmental, behavioral, or emotional conditions and who require health care and related services of a type or amount beyond that which is generally required by children and youth.

(4) "Eligible individual" means a child or youth with a special health care need or a female with a high-risk pregnancy, Page 7 of 27 CODING:

hb1085-02-c2hb1085-01-c1 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 CS/CS/HBCS/HB 1085 2025 means those children and youth younger than 21 years of age who meetshave thechronic financialand serious physical, developmental, behavioral, or emotional conditions and medicalwho eligibilityrequire standardshealth establishedcare inand s.related services of a type or amount beyond that which is generally required by children and youth.

(4) "Eligible individual" means a child or youth with a special health care need or a female with a high-risk pregnancy, who meets the financial and medical eligibility standards established in s.

Section 5.6.

(f)Page The9 Medicalof Foster29 CareCODING: Program.

Words stricken are deletions;

words underlined are additions.

hb1085-01-c1 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 CS/HB 1085 2025 (f) The Medical Foster Care Program.

(j) The State Child Abuse Death Review Committee and local Pagechild 8abuse ofdeath 27review CODING:committees established in s.

Words stricken are deletions;

words underlined are additions.

hb1085-02-c2 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 CS/CS/HB 1085 2025 child abuse death review committees established in s.

Section 6.7.

(6)Page To10 initiateof and29 coordinateCODING: applications to federal agencies and private organizations for funds, services, or commodities relating to children's medical programs.

(7) To sponsor or promote grants for projects, programs, education, or research in the field of children and youth with special health care needs, with an emphasis on early diagnosis and treatment.

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hb1085-02-c2hb1085-01-c1 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 CS/CS/HBCS/HB 1085 2025 (8)(6) To overseeinitiate and operatecoordinate theapplications Children'sto Medicalfederal Servicesagencies Managedand Careprivate Planorganizations throughfor thefunds, endservices, ofor Junecommodities 30,relating 2025to network.children's medical programs.

(7) To sponsor or promote grants for projects, programs, education, or research in the field of children and youth with special health care needs, with an emphasis on early diagnosis and treatment.

(8) To oversee and operate the Children's Medical Services Managed Care Plan through the end of June 30, 2025 network.

(15)Page To11 maintainof program29 integrityCODING: in the Children's Medical Services program.

(11)(16) To receive and manage health care premiums, capitation payments, and funds from federal, state, local, and private entities for the program.

The department may contract with a third-party administrator for processing claims, monitoring medical expenses, and other related services Page 10 of 27 CODING:

hb1085-02-c2hb1085-01-c1 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 CS/CS/HBCS/HB 1085 2025 necessary(15) toTo themaintain efficientprogram andintegrity cost-effectivein operation of the Children's Medical Services Managedprogram. Care Plan through the end of June 30, 2025 network.

(11)(16) To receive and manage health care premiums, capitation payments, and funds from federal, state, local, and private entities for the program.

The department may contract with a third-party administrator for processing claims, monitoring medical expenses, and other related services necessary to the efficient and cost-effective operation of the Children's Medical Services Managed Care Plan through the end of June 30, 2025 network.

(15)Page To12 administer the Medical Foster Care Program, including all of the29 following:CODING:

(a) Recruitment, training, assessment, and monitoring for the Medical Foster Care Program.

(b) Monitoring access and facilitating admissions of eligible children and youth to the program and designated medical foster care homes.

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hb1085-02-c2hb1085-01-c1 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 CS/CS/HBCS/HB 1085 2025 (c)(15) CoordinationTo withadminister the DepartmentMedical ofFoster ChildrenCare andProgram, Familiesincluding andall of the Agencyfollowing: for Health Care Administration or their designees.

Section(a) 7.Recruitment, training, assessment, and monitoring for the Medical Foster Care Program.

Effective(b) July,Monitoring 1,access 2025,and subsectionsfacilitating (8)admissions throughof (11)eligible ofchildren sectionand 391.026,youth Floridato Statutes,the asprogram amendedand bydesignated thismedical act,foster arecare repealed.homes.

(c) Coordination with the Department of Children and Families and the Agency for Health Care Administration or their designees.

Effective JulyJuly, 1, 2025, subsections (8) through (11) of section 391.028,391.026, Florida Statutes, isas amended by this act, are repealed.

Effective July 1, 2025, section 391.028, Florida Statutes, is repealed.

Section 10.

(b) Children and youth with serious special health care needs from birth to 21 years of age who are enrolled in Medicaid.Page 13 of 29 CODING:

(c) Children and youth with serious special health care needs from birth to 19 years of age who are enrolled in a program under Title XXI of the Social Security Act.

(3) Subject to the availability of funds, the following individuals may receive services through the Children's Medical Services Safety Net program:

Page 12 of 27 CODING:

hb1085-02-c2hb1085-01-c1 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 CS/CS/HBCS/HB 1085 2025 (a)Medicaid. Children and youth with serious special health care needs from birth to 21 years of age who do not qualify for Medicaid or Title XXI of the Social Security Act but who are unable to access, due to lack of providers or lack of financial resources, specialized services that are medically necessary or essential family support services.

(c) Children and youth with serious special health care needs from birth to 19 years of age who are enrolled in a program under Title XXI of the Social Security Act.

(3) Subject to the availability of funds, the following individuals may receive services through the Children's Medical Services Safety Net program:

(a) Children and youth with serious special health care needs from birth to 21 years of age who do not qualify for Medicaid or Title XXI of the Social Security Act but who are unable to access, due to lack of providers or lack of financial resources, specialized services that are medically necessary or essential family support services.

Section 10.11.

Section 391.0315, Florida Statutes, is amended toPage read:14 of 29 CODING:

391.0315 Benefits.—Benefits provided under the Children's Medical Services Managed Care Plan program for children with special health care needs shall be equivalent to benefits provided to children as specified in ss.

409.905 and 409.906.

The department may offer additional benefits through Children's Medical Services programs for early intervention services, Page 13 of 27 CODING:

hb1085-02-c2hb1085-01-c1 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 CS/CS/HBCS/HB 1085 2025 respite services, genetic testing, genetic and nutritional counseling, and parent support services, if such services are determined to beread: medically necessary.

391.0315 Benefits.—Benefits provided under the Children's Medical Services Managed Care Plan program for children with special health care needs shall be equivalent to benefits provided to children as specified in ss.

409.905 and 409.906.

The department may offer additional benefits through Children's Medical Services programs for early intervention services, respite services, genetic testing, genetic and nutritional counseling, and parent support services, if such services are determined to be medically necessary.

Section 11.

Section 391.035, Florida Statutes, is repealed.

EffectiveSection January391.035, 1, 2026, section 391.037, Florida Statutes, is repealed.

SectionEffective 391.045,January 1, 2026, section 391.037, Florida Statutes, is repealed.

EffectiveSection January391.045, 1, 2026, section 391.047, Florida Statutes, is repealed.

Effective January 1, 2026, section 391.055,391.047, Florida Statutes, is repealed.

Effective January 1, 2026, section 391.071,391.055, Florida Statutes, is repealed.

Effective January 1, 2026, section 391.071, Florida Statutes, is repealed.

Section 18.

391.097Page Research15 and evaluation.— (1) The department may initiate, fund, and conduct research and evaluation projects to improve the delivery of children's29 medicalCODING: services.

The department may cooperate with public and private agencies engaged in work of a similar nature.

(2) The Children's Medical Services network shall be included in any evaluation conducted in accordance with the Page 14 of 27 CODING:

hb1085-02-c2hb1085-01-c1 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 CS/CS/HBCS/HB 1085 2025 provisions391.097 ofResearch Titleand XXIevaluation.— of(1) theThe Socialdepartment Securitymay Actinitiate, asfund, enactedand byconduct research and evaluation projects to improve the Legislature.delivery of children's medical services.

SectionThe 18.department may cooperate with public and private agencies engaged in work of a similar nature.

(2) The Children's Medical Services network shall be included in any evaluation conducted in accordance with the provisions of Title XXI of the Social Security Act as enacted by the Legislature.

Section 19.

Section 19.20.

SectionPage 20.16 of 29 CODING:

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words underlined are additions.

hb1085-01-c1 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 CS/HB 1085 2025 Section 21.

PageSection 1522. of 27 CODING:

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words underlined are additions.

hb1085-02-c2 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 CS/CS/HB 1085 2025 Section 21.

Section 22.23.

Effective July 1, 2025, subsection (3) of sectionPage 409.8134,17 Floridaof Statutes,29 isCODING: amended to read:

409.8134 Program expenditure ceiling;

enrollment.— (3) Upon determination by the Social Services Estimating Conference that there are insufficient funds to finance the current enrollment in the Florida Kidcare program within current appropriations, the program shall initiate disenrollment procedures to remove enrollees, except those children enrolled Page 16 of 27 CODING:

hb1085-02-c2hb1085-01-c1 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 CS/CS/HBCS/HB 1085 2025 insection a409.8134, planFlorida underStatutes, contractis withamended the agency to serveread: children with special health care needs the Children's Medical Services Network, on a last-in, first-out basis until the expenditure and appropriation levels are balanced.

Section409.8134 23.Program expenditure ceiling;

enrollment.— (3) Upon determination by the Social Services Estimating Conference that there are insufficient funds to finance the current enrollment in the Florida Kidcare program within current appropriations, the program shall initiate disenrollment procedures to remove enrollees, except those children enrolled in a plan under contract with the agency to serve children with special health care needs the Children's Medical Services Network, on a last-in, first-out basis until the expenditure and appropriation levels are balanced.

Section 24.

(3) A Title XXI-funded child who is eligible for the Florida Kidcare program who is a child with special health care needs, as determined through a medical or behavioral screening instrument, is eligible for health benefits coverage from and shall be assigned to and may opt out of a plan under contract withPage the18 agencyof to29 serveCODING: children with special health care needs the Children's Medical Services Network.

(10) In determining the eligibility of a child, an assets test is not required.

If eligibility for the Florida Kidcare program cannot be verified using reliable data sources in accordance with federal requirements, each applicant shall provide documentation during the application process and the Page 17 of 27 CODING:

hb1085-02-c2hb1085-01-c1 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 CS/CS/HBCS/HB 1085 2025 redeterminationwith process,the including,agency butto notserve limitedchildren to,with special health care needs the following:Children's Medical Services Network.

(10) In determining the eligibility of a child, an assets test is not required.

If eligibility for the Florida Kidcare program cannot be verified using reliable data sources in accordance with federal requirements, each applicant shall provide documentation during the application process and the redetermination process, including, but not limited to, the following:

Section 24.25.

This section sets the minimum benefits that must be included in any health benefits coverage, other than Medicaid or MedikidsPage coverage,19 offeredof under29 ss.CODING:

Words stricken are deletions;

words underlined are additions.

hb1085-01-c1 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 CS/HB 1085 2025 Medikids coverage, offered under ss.

PageExcept 18for a plan under contract with the agency to serve children with special health care needs the Children's Medical Services Network, the agency may not increase the premium assistance payment for either additional benefits provided beyond the minimum benefits described in this section or the imposition of 27less CODING:restrictive service limitations.

WordsSection stricken26. are deletions;

words underlined are additions.

hb1085-02-c2 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 CS/CS/HB 1085 2025 Except for a plan under contract with the agency to serve children with special health care needs the Children's Medical Services Network, the agency may not increase the premium assistance payment for either additional benefits provided beyond the minimum benefits described in this section or the imposition of less restrictive service limitations.

Section 25.

2108 of Title XXI of the Social Security Act, the report shall include an assessment ofPage crowd-out20 andof access29 toCODING: health care, as well as the following:

(i) An assessment of the effectiveness of the Florida Kidcare program, including Medicaid, the Florida Healthy Kids program, Medikids, and the plans under contract with the agency to serve children with special health care needs Children's Medical Services network, and other public and private programs Page 19 of 27 CODING:

hb1085-02-c2hb1085-01-c1 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 CS/CS/HBCS/HB 1085 2025 inof thecrowd-out stateand inaccess increasingto the availability of affordable quality health insurancecare, andas healthwell careas forthe children.following:

Section(i) 26.An assessment of the effectiveness of the Florida Kidcare program, including Medicaid, the Florida Healthy Kids program, Medikids, and the plans under contract with the agency to serve children with special health care needs Children's Medical Services network, and other public and private programs in the state in increasing the availability of affordable quality health insurance and health care for children.

Section 27.

SectionPage 27.21 of 29 CODING:

Effective July 1, 2025, subsection (11) of section 409.912, Florida Statutes, is amended to read:

409.912 Cost-effective purchasing of health care.—The agency shall purchase goods and services for Medicaid recipients in the most cost-effective manner consistent with the delivery of quality medical care.

To ensure that medical services are effectively utilized, the agency may, in any case, require a Page 20 of 27 CODING:

hb1085-02-c2hb1085-01-c1 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 CS/CS/HBCS/HB 1085 2025 confirmationSection or28. second physician's opinion of the correct diagnosis for purposes of authorizing future services under the Medicaid program.

Effective July 1, 2025, subsection (11) of section 409.912, Florida Statutes, is amended to read:

409.912 Cost-effective purchasing of health care.—The agency shall purchase goods and services for Medicaid recipients in the most cost-effective manner consistent with the delivery of quality medical care.

To ensure that medical services are effectively utilized, the agency may, in any case, require a confirmation or second physician's opinion of the correct diagnosis for purposes of authorizing future services under the Medicaid program.

The agency shall contract with a vendor to monitor and evaluate the clinical practice patterns of providers in order to identify trends that are outside the normal practice patterns of a provider'sPage professional22 peers or the national guidelines of a29 provider'sCODING: professional association.

The vendor must be able to provide information and counseling to a provider whose practice patterns are outside the norms, in consultation with the agency, to improve patient care and reduce inappropriate utilization.

The agency may mandate prior authorization, drug therapy management, or disease management participation for certain Page 21 of 27 CODING:

hb1085-02-c2hb1085-01-c1 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 CS/CS/HBCS/HB 1085 2025 populationsprovider's ofprofessional Medicaidpeers beneficiaries, certain drug classes, or particularthe drugsnational toguidelines preventof fraud,a abuse,provider's overuse,professional andassociation. possible dangerous drug interactions.

The vendor must be able to provide information and counseling to a provider whose practice patterns are outside the norms, in consultation with the agency, to improve patient care and reduce inappropriate utilization.

The agency may mandate prior authorization, drug therapy management, or disease management participation for certain populations of Medicaid beneficiaries, certain drug classes, or particular drugs to prevent fraud, abuse, overuse, and possible dangerous drug interactions.

The agency may limit its network based on the assessment of beneficiary access to care, provider availability, provider quality standards, time and distance standards for access to care, the cultural competence of the provider network, demographic characteristics of Medicaid beneficiaries, practice and provider-to-beneficiary standards, appointmentPage wait23 times, beneficiary use of services,29 providerCODING: turnover, provider profiling, provider licensure history, previous program integrity investigations and findings, peer review, provider Medicaid policy and billing compliance records, clinical and medical record audits, and other factors.

Providers are not entitled to enrollment in the Medicaid provider network.

The agency shall determine instances in which allowing Medicaid Page 22 of 27 CODING:

hb1085-02-c2hb1085-01-c1 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 CS/CS/HBCS/HB 1085 2025 beneficiariesappointment towait purchasetimes, durablebeneficiary medicaluse equipmentof andservices, otherprovider goodsturnover, isprovider lessprofiling, expensiveprovider tolicensure thehistory, Medicaidprevious program thanintegrity long-terminvestigations rentaland offindings, thepeer equipmentreview, orprovider goods.Medicaid policy and billing compliance records, clinical and medical record audits, and other factors.

Providers are not entitled to enrollment in the Medicaid provider network.

The agency shall determine instances in which allowing Medicaid beneficiaries to purchase durable medical equipment and other goods is less expensive to the Medicaid program than long-term rental of the equipment or goods.

Section 28.29.

409.9126Page Children24 with special health care needs.— (1) Except as provided in subsection (4), children eligible for the Children's Medical Services program who receive Medicaid benefits, and other Medicaid-eligible children with special health care needs, are shall be exempt from the provisions of s.29 CODING:

409.9122 and shall be served through the Children's Medical Services network established in chapter 391.

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hb1085-02-c2hb1085-01-c1 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 CS/CS/HBCS/HB 1085 2025 Section409.9126 29.Children with special health care needs.— (1) Except as provided in subsection (4), children eligible for the Children's Medical Services program who receive Medicaid benefits, and other Medicaid-eligible children with special health care needs, are shall be exempt from the provisions of s.

409.9122 and shall be served through the Children's Medical Services network established in chapter 391.

Section 30.

Before performing a review of the physician's Medicaid records, however, the agency shall make every effort to consider the physician's patient case mix, including, but not limited to, patient age and whether individual patients are clients of the Children'sPage Medical25 Servicesof Network29 establishedCODING: in chapter 391.

In meeting its burden of proof in any administrative or court proceeding, the agency may introduce the results of such statistical methods and its other audit findings as evidence of overpayment.

Section 30.

Effective July 1, 2025, paragraph (e) of subsection (1) of section 409.920, Florida Statutes, is amended Page 24 of 27 CODING:

hb1085-02-c2hb1085-01-c1 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 CS/CS/HBCS/HB 1085 2025 toChildren's read:Medical Services Network established in chapter 391.

In meeting its burden of proof in any administrative or court proceeding, the agency may introduce the results of such statistical methods and its other audit findings as evidence of overpayment.

Section 31.

Effective July 1, 2025, paragraph (e) of subsection (1) of section 409.920, Florida Statutes, is amended to read:

Section 31.32.

(7)Page "Eligible26 plan"of means29 aCODING: health insurer authorized under chapter 624, an exclusive provider organization authorized under chapter 627, a health maintenance organization authorized under chapter 641, or a provider service network authorized under s.

409.912(1) or an accountable care organization authorized under federal law.

For purposes of the managed medical assistance program, the term also includes the Page 25 of 27 CODING:

hb1085-02-c2hb1085-01-c1 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 CS/CS/HBCS/HB 1085 2025 Children's(7) Medical"Eligible Servicesplan" Networkmeans a health insurer authorized under chapter 391624, andan entitiesexclusive qualifiedprovider organization authorized under 42chapter C.F.R.627, a health maintenance organization authorized under chapter 641, or a provider service network authorized under s.

409.912(1) or an accountable care organization authorized under federal law.

For purposes of the managed medical assistance program, the term also includes the Children's Medical Services Network authorized under chapter 391 and entities qualified under 42 C.F.R.

Section 32.33.

Subsection (3) of section 409.968, Florida Statutes, is amended to read:

409.968 Managed care plan payments.— (3) Reimbursement for prescribed pediatric extended care services provided to children enrolled in a managed care plan under s.

409.972(1)(g) shall be paid to the prescribed pediatric extended care services provider by the agency on a fee-for- service basis.

Section 34.

Paragraph (g) of subsection (1) of section 409.972, Florida Statutes, is amended to read:

409.972 Mandatory and voluntary enrollment.— Page 27 of 29 CODING:

Words stricken are deletions;

words underlined are additions.

hb1085-01-c1 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 CS/HB 1085 2025 (1) The following Medicaid-eligible persons are exempt from mandatory managed care enrollment required by s.

409.965, and may voluntarily choose to participate in the managed medical assistance program:

(g) Children receiving services in a prescribed pediatric extended care center.

Section 35.

(1) The purpose, rationale, and expected benefits of the Pageredesigned 26waiver ofplan. 27 CODING:

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hb1085-02-c2hb1085-01-c1 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 CS/CS/HBCS/HB 1085 2025 (2) The proposed eligibility criteria for clients and service benefit packages to be offered through the redesigned waiver plan.

(2) The proposed eligibility criteria for clients and service benefit packages to be offered through the redesigned waiver plan.

Section 33.36.

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hb1085-02-c2hb1085-01-c1