THE BILL ITSELF
HB 1261
Medicaid Reimbursement for Private Duty Nursing Services
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A bill to be entitled
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An act relating to Medicaid reimbursement for private
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duty nursing services; amending s. 409.962, F.S.;
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defining the term "pediatric continuing care
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integrated community" for purposes of the state
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Medicaid program; amending s. 409.975, F.S.; defining
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the term "Medicaid region"; requiring Medicaid managed
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care plans to reimburse licensed home health agencies
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for private duty nursing services provided in a
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community residential group home at a certain rate;
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prohibiting Medicaid managed care plans from reducing
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reimbursement for such services under certain
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circumstances; requiring Medicaid managed care plans
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to negotiate rates with affiliated businesses at least
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annually; requiring Medicaid managed care plans, upon
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request by a provider, to provide certain written
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certification; requiring the Agency for Health Care
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Administration to seek federal approval within a
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specified timeframe; requiring the agency to implement
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the changes made by the act upon federal approval;
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providing effective dates.
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Be It Enacted by the Legislature of the State of Florida:
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Section 1. Effective July 1, 2026, present subsections
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(13) through (18) of section 409.962, Florida Statutes, are
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redesignated as subsections (14) through (19), respectively, and
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a new subsection (13) is added to that section, to read:
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409.962 Definitions.—As used in this part, except as
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otherwise specifically provided, the term:
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(13) "Pediatric continuing care integrated community"
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means a group of affiliated and integrated businesses that, as
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of July 1, 2026, are licensed or certified by the agency or the
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Agency for Persons with Disabilities and collectively provide
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coordinated care for Medicaid-eligible persons younger than 21
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years of age who are medically fragile, including those who are
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technology dependent. The term includes all of the following
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entities under common ownership:
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(a) A community residential group home licensed under
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chapter 393 providing residential care for medically complex
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children.
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(b) A home health agency licensed under part III of
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chapter 400 providing private duty nursing services by
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registered nurses or licensed practical nurses.
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(c) A prescribed pediatric extended care center licensed
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under part VI of chapter 400.
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(d) A home medical equipment provider licensed under part
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VII of chapter 400.
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(e) A health care clinic licensed under part X of chapter
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400 providing speech-language therapy, physical therapy, or
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occupational therapy.
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Section 2. Subsection (7) is added to section 409.975,
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Florida Statutes, to read:
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409.975 Managed care plan accountability.—In addition to
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the requirements of s. 409.967, plans and providers
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participating in the managed medical assistance program shall
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comply with the requirements of this section.
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(7) REIMBURSEMENT FOR SERVICES IN PEDIATRIC CONTINUING
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CARE INTEGRATED COMMUNITIES.—
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(a) As used in this subsection, the term "Medicaid region"
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means any of the regions established by the agency for the
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purpose of managed medical assistance.
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(b) Medicaid managed care plans shall reimburse home
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health agencies licensed under part III of chapter 400 for
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private duty nursing services, including services provided by
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registered nurses and licensed practical nurses, provided in a
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community residential group home at an amount no less than the
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Private Duty Nursing Fee Schedule set by the agency, regardless
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of the number of plan members who share a dwelling space within
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the community residential group home. However, mutually
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acceptable higher rates may be negotiated for medically complex
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care.
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(c) Reimbursement may not be reduced based on the number
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of Medicaid-eligible persons receiving private duty nursing
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services in the same dwelling space, or on the same day, within
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the community residential group home.
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(d) Managed care plans and the affiliated businesses shall
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negotiate rates at least annually for medical services provided
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within the pediatric continuing care integrated community.
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(e) Upon request by a provider, a Medicaid managed care
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plan must provide a written certification that the reimbursement
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rate offered for services within the pediatric continuing care
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integrated community is not less than the rate paid by that plan
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for private duty nursing services provided in private residences
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within the same Medicaid region.
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Section 3. Within 30 days after the effective date of this
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act, the Agency for Health Care Administration shall seek any
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necessary federal approval, including through any necessary
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state plan amendment or Medicaid waiver, to implement the
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changes made by this act. The agency shall implement this act
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upon receipt of federal approval.
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Section 4. Except as otherwise provided in this act, this
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act shall take effect upon becoming a law.