2010 Florida Statutes
CHILDREN'S MEDICAL SERVICES
CHILDREN’S MEDICAL SERVICES COUNCILS AND PANELS
DEVELOPMENTAL EVALUATION AND INTERVENTION PROGRAMS
The provisions of this chapter may be cited as the “Children’s Medical Services Act.”
s. 1, ch. 78-106; s. 2, ch. 98-288.
The Legislature intends that the Children’s Medical Services program:
Provide to children with special health care needs a family-centered, comprehensive, and coordinated statewide managed system of care that links community-based health care with multidisciplinary, regional, and tertiary pediatric specialty care. The program may provide for the coordination and maintenance of consistency of the medical home for children in families with a Children’s Medical Services program participant, in order to achieve family-centered care.
Provide essential preventive, evaluative, and early intervention services for children at risk for or having special health care needs, in order to prevent or reduce long-term disabilities.
Serve as a principal provider for children with special health care needs under Titles XIX and XXI of the Social Security Act.
Be complementary to children’s health training programs essential for the maintenance of a skilled pediatric health care workforce for all Floridians.
s. 2, ch. 78-106; s. 3, ch. 98-288.
When used in this act, unless the context clearly indicates otherwise:
“Children’s Medical Services network” or “network” means a statewide managed care service system that includes health care providers, as defined in this section.
“Children with special health care needs” means those children younger than 21 years of age who have chronic physical, developmental, behavioral, or emotional conditions and who also require health care and related services of a type or amount beyond that which is generally required by children.
“Department” means the Department of Health.
“Eligible individual” means a child 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. 391.029.
“Health care provider” means a health care professional, health care facility, or entity licensed or certified to provide health services in this state that meets the criteria as established by the department.
“Health services” includes the prevention, diagnosis, and treatment of human disease, pain, injury, deformity, or disabling conditions.
“Participant” means an eligible individual who is enrolled in the Children’s Medical Services program.
“Program” means the Children’s Medical Services program established in the department.
s. 3, ch. 78-106; s. 695, ch. 95-148; s. 87, ch. 97-101; s. 4, ch. 98-288; s. 43, ch. 99-397; s. 15, ch. 2004-350.
Applicability and scope.—
The Children’s Medical Services program consists of the following components:
The newborn screening program established in s. 383.14.
The regional perinatal intensive care centers program established in ss. 383.15-383.21.
A federal or state program authorized by the Legislature.
The developmental evaluation and intervention program, including the Florida Infants and Toddlers Early Intervention Program.
The Children’s Medical Services network.
The Children’s Medical Services program shall not be deemed an insurer and is not subject to the licensing requirements of the Florida Insurance Code or the rules adopted thereunder, when providing services to children who receive Medicaid benefits, other Medicaid-eligible children with special health care needs, and children participating in the Florida Kidcare program.
s. 5, ch. 98-288; s. 10, ch. 2000-253; s. 409, ch. 2003-261; s. 72, ch. 2003-416; s. 16, ch. 2004-350.
Powers and duties of the department.—
The department shall have the following powers, duties, and responsibilities:
To provide or contract for the provision of health services to eligible individuals.
To determine the medical and financial eligibility standards for the program and to determine the medical and financial eligibility of individuals seeking health services from the program.
To recommend priorities for the implementation of comprehensive plans and budgets.
To coordinate a comprehensive delivery system for eligible individuals to take maximum advantage of all available funds.
To promote, establish, and coordinate programs relating to children’s medical services in cooperation with other public and private agencies and to coordinate funding of health care programs with federal, state, or local indigent health care funding mechanisms.
To initiate, coordinate, and request review of applications to federal and state agencies for funds, services, or commodities relating to children’s medical programs.
To sponsor or promote grants for projects, programs, education, or research in the field of medical needs of children, with an emphasis on early diagnosis and treatment.
To oversee and operate the Children’s Medical Services network.
To establish reimbursement mechanisms for the Children’s Medical Services network.
To establish Children’s Medical Services network standards and credentialing requirements for health care providers and health care services.
To serve as a provider and principal case manager for children with special health care needs under Titles XIX and XXI of the Social Security Act.
To monitor the provision of health services in the program, including the utilization and quality of health services.
To administer the Children with Special Health Care Needs program in accordance with Title V of the Social Security Act.
To establish and operate a grievance resolution process for participants and health care providers.
To maintain program integrity in the Children’s Medical Services program.
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 network. The department is authorized to maintain a minimum reserve for the Children’s Medical Services network in an amount that is the greater of:
Ten percent of total projected expenditures for Title XIX-funded and Title XXI-funded children; or
Two percent of total annualized payments from the Agency for Health Care Administration for Title XIX and Title XXI of the Social Security Act.
To appoint health care consultants for the purpose of providing peer review and making recommendations to enhance the delivery and quality of services in the Children’s Medical Services program.
To adopt rules pursuant to ss. 120.536(1) and 120.54 to administer the Children’s Medical Services Act. The rules may include requirements for definitions of terms, program organization, and program description; a process for selecting an area medical director; responsibilities of applicants and clients; requirements for service applications, including required medical and financial information; eligibility requirements for initial treatment and for continued eligibility, including financial and custody issues; methodologies for resource development and allocation, including medical and financial considerations; requirements for reimbursement services rendered to a client; billing and payment requirements for providers; requirements for qualification, appointments, verification, and emergency exceptions for health-professional consultants; general and diagnostic-specific standards for diagnostic and treatment facilities; and standards for the method of service delivery, including consultant services, respect-for-privacy considerations, examination requirements, family support plans, and clinic design.
s. 4, ch. 78-106; s. 96, ch. 98-200; s. 6, ch. 98-288; s. 23, ch. 2000-242; s. 1, ch. 2006-28.
The Children’s Medical Services program shall have a central office and area offices.
The Director of Children’s Medical Services must be a physician licensed under chapter 458 or chapter 459 who has specialized training and experience in the provision of health care to children and who has recognized skills in leadership and the promotion of children’s health programs. The director shall be the deputy secretary and the Deputy State Health Officer for Children’s Medical Services and is appointed by and reports to the State Surgeon General. The director may appoint division directors subject to the approval of the State Surgeon General.
The director shall designate Children’s Medical Services area offices to perform operational activities, including, but not limited to:
Providing case management services for the network.
Providing local oversight of the program.
Determining an individual’s medical and financial eligibility for the program.
Participating in the determination of a level of care and medical complexity for long-term care services.
Authorizing services in the program and developing spending plans.
Participating in the development of treatment plans.
Taking part in the resolution of complaints and grievances from participants and health care providers.
Each Children’s Medical Services area office shall be directed by a physician licensed under chapter 458 or chapter 459 who has specialized training and experience in the provision of health care to children. The director of a Children’s Medical Services area office shall be appointed by the director from the active panel of Children’s Medical Services physician consultants.
s. 9, ch. 78-106; s. 17, ch. 96-403; s. 33, ch. 97-237; s. 7, ch. 98-288; s. 26, ch. 99-397; s. 45, ch. 2008-6.
Subsection (1) former s. 391.051.
The department shall establish the medical criteria to determine if an applicant for the Children’s Medical Services program is an eligible individual.
The following individuals are financially eligible to receive services through the program:
A high-risk pregnant female who is eligible for Medicaid.
Children with special health care needs from birth to 21 years of age who are eligible for Medicaid.
Children with special health care needs from birth to 19 years of age who are eligible for a program under Title XXI of the Social Security Act.
Subject to the availability of funds, the following individuals may receive services through the program:
Children with special health care needs from birth to 21 years of age whose family income is above the requirements for financial eligibility under Title XXI of the Social Security Act and whose projected annual cost of care adjusts the family income to Medicaid financial criteria. In cases where the family income is adjusted based on a projected annual cost of care, the family shall participate financially in the cost of care based on criteria established by the department.
Children with special health care needs from birth to 21 years of age, as provided in Title V of the Social Security Act.
An infant who receives an award of compensation under s. 766.31(1). The Florida Birth-Related Neurological Injury Compensation Association shall reimburse the Children’s Medical Services Network the state’s share of funding, which must thereafter be used to obtain matching federal funds under Title XXI of the Social Security Act.
The department shall determine the financial and medical eligibility of children for the program. The department shall also determine the financial ability of the parents, or persons or other agencies having legal custody over such individuals, to pay the costs of health services under the program. The department may pay reasonable travel expenses related to the determination of eligibility for or the provision of health services.
Any child who has been provided with surgical or medical care or treatment under this act prior to being adopted shall continue to be eligible to be provided with such care or treatment after his or her adoption, regardless of the financial ability of the persons adopting the child.
s. 6, ch. 13620, 1929; CGL 1936 Supp. 3640(6); s. 1, ch. 57-21; ss. 19, 35, ch. 69-106; s. 1, ch. 73-114; s. 178, ch. 77-147; s. 1, ch. 77-159; ss. 8, 13, 14, ch. 78-106; s. 1, ch. 78-332; s. 696, ch. 95-148; s. 8, ch. 98-288; s. 73, ch. 2003-416; s. 39, ch. 2004-5; s. 17, ch. 2004-350.
Subsection (3) former s. 391.046; subsection (4) former s. 391.07.
Benefits provided under the program for children with special health care needs shall be the same benefits provided to children as specified in ss. 409.905 and 409.906. The department may offer additional benefits 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. No child or person determined eligible for the program who is eligible under Title XIX or Title XXI of the Social Security Act shall receive any service other than an initial health care screening or treatment of an emergency medical condition as defined in s. 395.002, until such child or person is enrolled in Medicaid or a Title XXI program.
s. 9, ch. 98-288; s. 27, ch. 99-397.
The department shall establish the criteria to designate health care providers to participate in the Children’s Medical Services network. The department shall follow, whenever available, national guidelines for selecting health care providers to serve children with special health care needs.
The department shall require that all health care providers under contract with the program be duly licensed in the state, if such licensure is available, and meet such criteria as may be established by the department.
The department may initiate agreements with other state or local governmental programs or institutions for the coordination of health care to eligible individuals receiving services from such programs or institutions.
Notwithstanding any other law, the department may contract with health care providers licensed in another state to provide health services to participants in the Children’s Medical Services program when necessary due to an emergency or in order to provide specialty services or greater convenience to the participants for receiving timely and effective health care services. The department may adopt rules to administer this subsection.
ss. 6, 7, ch. 78-106; s. 10, ch. 98-288; s. 18, ch. 2004-350.
Subsection (2) former s. 391.036; subsection (3) former s. 391.041.
Physicians; private sector services.—
It is not a violation of s. 112.313(7) for a physician licensed under chapter 458 or chapter 459 who is providing private sector services to clients of the department or who is employed by or has a contractual relationship with any business entity or agency that is a contract provider for the department to also be employed by the department to provide services under this chapter or chapter 39 if:
The physician does not enter into contracts with the department on behalf of any business entity or agency with whom the physician is employed or has an employment or contractual relationship.
The physician’s private sector employment or contractual relationship does not create a conflict between the physician’s private sector interests and public duties or impede the full and faithful discharge of the physician’s public duties as an employee of the department.
The physician’s employment with the department does not compromise the ability of department clients to make a voluntary choice among department-referred physicians and private providers for their medical services.
s. 16, ch. 2001-53.
The department shall reimburse health care providers for services rendered through the Children’s Medical Services network using cost-effective methods, including, but not limited to, capitation, discounted fee-for-service, unit costs, and cost reimbursement. Medicaid reimbursement rates shall be utilized to the maximum extent possible, where applicable.
Reimbursement to the Children’s Medical Services program for services provided to children with special health care needs who participate in the Florida Kidcare program and who are not Medicaid recipients shall be on a capitated basis.
s. 11, ch. 98-288.
The Children’s Medical Services program shall comply with s. 402.24, concerning third-party liabilities and recovery of third-party payments for health services.
s. 12, ch. 98-288.
Service delivery systems.—
The program shall apply managed care methods to ensure the efficient operation of the Children’s Medical Services network. Such methods include, but are not limited to, capitation payments, utilization management and review, prior authorization, and case management.
The components of the network are:
Qualified primary care physicians who shall serve as the gatekeepers and who shall be responsible for the provision or authorization of health services to an eligible individual who is enrolled in the Children’s Medical Services network.
Comprehensive specialty care arrangements that meet the requirements of s. 391.035 to provide acute care, specialty care, long-term care, and chronic disease management for eligible individuals.
Case management services.
The Children’s Medical Services network may contract with school districts participating in the certified school match program pursuant to ss. 409.908(21) and 1011.70 for the provision of school-based services, as provided for in s. 409.9071, for Medicaid-eligible children who are enrolled in the Children’s Medical Services network.
If a newborn has an abnormal screening result for metabolic or other hereditary and congenital disorders which is identified through the newborn screening program pursuant to s. 383.14, the newborn shall be referred to the Children’s Medical Services program for additional testing, medical management, early intervention services, or medical referral.
s. 13, ch. 98-288; s. 978, ch. 2002-387; s. 19, ch. 2004-350.
Health care provider agreements.—
The department is authorized to establish health care provider agreements for participation in the Children’s Medical Services program.
s. 14, ch. 98-288.
Quality of care requirements.—
The Children’s Medical Services program shall develop quality of care and service integration standards and reporting requirements for health care providers that participate in the Children’s Medical Services program. The program shall ensure that these standards are not duplicative of other standards and requirements for health care providers.
s. 15, ch. 98-288.
Grievance reporting and resolution requirements.—
The department shall adopt and implement a system to provide assistance to eligible individuals and health care providers to resolve complaints and grievances. To the greatest extent possible, the department shall use existing grievance reporting and resolution processes. The department shall ensure that the system developed for the Children’s Medical Services program does not duplicate existing grievance reporting and resolution processes.
s. 16, ch. 98-288.
The department shall operate a system to oversee the activities of Children’s Medical Services program participants, and health care providers and their representatives, to prevent fraudulent and abusive behavior, overutilization and duplicative utilization, and neglect of participants and to recover overpayments as appropriate. For the purposes of this section, the terms “abuse” and “fraud” have the meanings provided in s. 409.913. The department shall refer incidents of suspected fraud and abuse, and overutilization and duplicative utilization, to the appropriate regulatory agency.
s. 17, ch. 98-288.
Research and evaluation.—
The department may initiate, fund, and conduct research and evaluation projects to improve the delivery of children’s medical services. The department may cooperate with public and private agencies engaged in work of a similar nature.
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.
s. 10, ch. 78-106; s. 18, ch. 98-288.
Former s. 391.061.
CHILDREN’S MEDICAL SERVICES
COUNCILS AND PANELS
Statewide Children’s Medical Services Network Advisory Council.—
The State Surgeon General may appoint a Statewide Children’s Medical Services Network Advisory Council for the purpose of acting as an advisory body to the department. Specifically, the duties of the council shall include, but not be limited to:
Recommending standards and credentialing requirements for health care providers rendering health services to Children’s Medical Services network participants.
Making recommendations to the director of Children’s Medical Services concerning the selection of health care providers for the Children’s Medical Services network.
Reviewing and making recommendations concerning network health care provider or participant disputes that are brought to the attention of the advisory council.
Providing input to the Children’s Medical Services program on the policies governing the Children’s Medical Services network.
Reviewing the financial reports and financial status of the network and making recommendations concerning the methods of payment and cost controls for the network.
Reviewing and recommending the scope of benefits for the network.
Reviewing network performance measures and outcomes and making recommendations for improvements to the network and its maintenance and collection of data and information.
The council shall be composed of 12 members representing the private health care provider sector, families with children who have special health care needs, the Agency for Health Care Administration, the Chief Financial Officer, the Florida Chapter of the American Academy of Pediatrics, an academic health center pediatric program, and the health insurance industry. Members shall be appointed for 4-year, staggered terms. In no case shall an employee of the Department of Health serve as a member or as an ex officio member of the advisory council. A vacancy shall be filled for the remainder of the unexpired term in the same manner as the original appointment. A member may not be appointed to more than two consecutive terms. However, a member may be reappointed after being off the council for at least 2 years.
Members shall receive no compensation, but shall be reimbursed for per diem and travel expenses in accordance with the provisions of s. 112.061.
s. 23, ch. 98-288; s. 44, ch. 99-397; s. 410, ch. 2003-261; s. 46, ch. 2008-6.
Technical advisory panels.—
The State Surgeon General may establish technical advisory panels to assist in developing specific policies and procedures for the Children’s Medical Services program.
s. 25, ch. 98-288; s. 46, ch. 99-397; s. 47, ch. 2008-6.
AND INTERVENTION PROGRAMS
Developmental evaluation and intervention programs; legislative findings and intent.—
The Legislature finds that the high-risk and disabled newborn infants in this state need in-hospital and outpatient developmental evaluation and intervention and that their families need training and support services. The Legislature further finds that there is an identifiable and increasing number of infants who need developmental evaluation and intervention and family support due to the fact that increased numbers of low-birthweight and sick full-term newborn infants are now surviving because of the advances in neonatal intensive care medicine; increased numbers of medically involved infants are remaining inappropriately in hospitals because their parents lack the confidence or skills to care for these infants without support; and increased numbers of infants are at risk due to parent risk factors, such as substance abuse, teenage pregnancy, and other high-risk conditions.
It is the intent of the Legislature to establish developmental evaluation and intervention services at all hospitals providing Level II or Level III neonatal intensive care services, in order that families with high-risk or disabled infants may gain the services and skills they need to support their infants.
It is the intent of the Legislature that a methodology be developed to integrate information on infants with potentially disabling conditions with other early intervention programs, including Part C of Pub. L. No. 105-17 and the Healthy Start program.
s. 12, ch. 89-379; s. 25, ch. 91-282; s. 7, ch. 94-140; s. 26, ch. 98-288; s. 51, ch. 2004-350.
Former s. 383.215(1), (2).
As used in ss. 391.301-391.307, the term:
“Developmental intervention” means individualized therapies and services needed to enhance both the infant’s or toddler’s growth and development and family functioning.
“Infant or toddler” means a child from birth until the child’s third birthday.
“In-hospital intervention services” means the provision of assessments; the provision of individualized services; monitoring and modifying the delivery of medical interventions; and enhancing the environment for the high-risk, developmentally disabled, or medically involved infant or toddler in order to achieve optimum growth and development.
“Parent support and training” means a range of services to families of high-risk, developmentally disabled, or medically involved infants or toddlers, including family counseling; financial planning; agency referral; development of parent-to-parent support groups; education concerning growth, development, and developmental intervention and objective measurable skills, including abuse avoidance skills; training of parents to advocate for their child; and bereavement counseling.
s. 12, ch. 89-379; s. 7, ch. 94-140; s. 1039, ch. 95-148; s. 20, ch. 2004-350.
Former s. 383.215(3).
Developmental evaluation and intervention services shall be established at each hospital that provides Level II or Level III neonatal intensive care services. Program services shall be made available to an infant or toddler identified as being at risk for developmental disabilities, or identified as medically involved, who, along with his or her family, would benefit from program services. Program services shall be made available to infants or toddlers in a Level II or Level III neonatal intensive care unit or in a pediatric intensive care unit, or infants who have a metabolic or genetic disorder or a condition identified through the newborn screening program. The developmental evaluation and intervention programs are subject to the availability of moneys and the limitations established by the General Appropriations Act or chapter 216. Evaluation and referral services and initial developmental assessments services shall be provided to each infant or toddler. Other program services may be provided to an infant or toddler, and the family of the infant or toddler, who do not meet the financial eligibility criteria for the Children’s Medical Services program based on the availability of funding, including insurance and fees.
Each developmental evaluation and intervention program shall have a program director, a medical director, and necessary staff to carry out the program. The program director shall establish and coordinate the developmental evaluation and intervention program. The program shall include, but is not limited to:
In-hospital evaluation and intervention services, parent support and training, and family support planning and case management.
Regularly held multidisciplinary team meetings to develop and update the family support plan. In addition to the family, a multidisciplinary team may include a physician, physician assistant, psychologist, psychotherapist, educator, social worker, nurse, physical or occupational therapist, speech pathologist, developmental evaluation and intervention program director, case manager, others who are involved with the in-hospital and posthospital discharge care plan, and anyone the family wishes to include as a member of the team. The family support plan is a written plan that describes the infant or toddler, the services the infant or toddler and his or her family need, and the intended outcomes of the services.
Discharge planning by the multidisciplinary team, including referral and followup to primary medical care and modification of the family support plan.
Education and training for neonatal and pediatric intensive care services staff, volunteers, and others, as needed, in order to expand the services provided to high-risk, developmentally disabled, or medically involved infants and toddlers and their families.
Followup intervention services after hospital discharge, to aid the family and the high-risk, developmentally disabled, or medically involved infant’s or toddler’s transition into the community. Support services shall be coordinated at the request of the family and within the context of the family support plan.
Referral to and coordination of services with community providers.
Educational materials about infant care, infant growth and development, community resources, medical conditions and treatments, and family advocacy.
Involvement of the parents and guardians of each identified high-risk, developmentally disabled, or medically involved infant or toddler.
s. 12, ch. 89-379; s. 25, ch. 91-282; s. 7, ch. 94-140; s. 1040, ch. 95-148; s. 27, ch. 98-288; s. 21, ch. 2004-350.
Former s. 383.215(4).
The Department of Health shall:
Develop a plan for statewide implementation of the developmental evaluation and intervention program.
Develop rules, procedures, and contracts to implement the developmental evaluation and intervention program.
The Department of Education, in cooperation with the Department of Health, shall:
Develop an educational management program for hearing-impaired infants.
Develop an involvement program for parents or guardians of hearing-impaired infants.
s. 12, ch. 89-379; s. 7, ch. 94-140; s. 90, ch. 97-101; s. 28, ch. 98-288; s. 16, ch. 2000-337; s. 27, ch. 2001-170.
Former s. 383.215(5).
Program standards; rules.—
The Department of Health shall adopt rules for the administration of the developmental evaluation and intervention program. The rules shall specify standards for the development and operation of the program, including, but not limited to:
Standards governing the eligibility for program services and the requirements of the population to be served.
Criteria for determining an infant’s or a toddler’s need for developmental evaluation and intervention program services.
Minimum developmental evaluation and intervention and support services.
Program staff requirements and personnel qualifications.
Reporting and program evaluation procedures.
s. 8, ch. 94-140; s. 91, ch. 97-101; s. 29, ch. 98-288; s. 51, ch. 2004-350.
Program funding; contracts.—
Developmental evaluation and intervention programs shall be provided under a contract between the Department of Health and the provider and are subject to funding and other limitations established in the General Appropriations Act or chapter 216. The contract shall make the services of the provider contingent upon funding. Failure to comply with the standards established in s. 391.305 is grounds for termination of a contract.
s. 9, ch. 94-140; s. 92, ch. 97-101.
At least annually during the contract period, the Department of Health shall evaluate each developmental evaluation and intervention program. The department shall develop criteria to evaluate child and family outcomes, program participation, service coordination, and program effectiveness.
The department shall develop, in conjunction with the directors of the developmental evaluation and intervention programs, a system to assess the population served and the impact of the screening and the evaluation and intervention components of the programs, to monitor the impact of the programs on families and infants served, and to evaluate the cost-effectiveness of the components of the programs.
s. 10, ch. 94-140; s. 93, ch. 97-101; s. 30, ch. 98-288.
Infants and Toddlers Early Intervention Program.—
The Department of Health may implement and administer part C of the federal Individuals with Disabilities Education Act (IDEA), which shall be known as the “Florida Infants and Toddlers Early Intervention Program.”
The department, jointly with the Department of Education, shall annually prepare a grant application to the United States Department of Education for funding early intervention services for infants and toddlers with disabilities, from birth through 36 months of age, and their families pursuant to part C of the federal Individuals with Disabilities Education Act.
The department, jointly with the Department of Education, shall include a reading initiative as an early intervention service for infants and toddlers.
s. 5, ch. 2004-245; s. 22, ch. 2004-350.