Fla. Stat. § 409.9855 — Florida Code / Title XXX / Chapter 409 / Part IV / Section 409.9855
409.9855 Pilot program for individuals with developmental disabilities.
Status: in_force

(1) PILOT PROGRAM IMPLEMENTATION. — (a) The agency shall implement a pilot program for individuals with developmental disabilities to provide coverage of comprehensive services using a managed care model. The agency may seek federal approval through a state plan amendment or Medicaid waiver as necessary to implement the pilot program. (b) The agency shall administer the pilot program pursuant to s. 409.963 and as a component of the Statewide Medicaid Managed Care model established by this part. Unless otherwise specified, ss. 409.961-409.969 apply to the pilot program. For purposes of the pilot program, compliance with s. 409.966 is deemed satisfied by the competitive procurement procedures conducted for contracts effective on February 1, 2025. (c) The agency shall make capitated payments to managed care organizations for comprehensive coverage, including managed medical assistance benefits and long-term care under this part and community-based services described in s. 393.066(3).

(2) ELIGIBILITY; VOLUNTARY ENROLLMENT; DISENROLLMENT. — (a) Participation in the pilot program is voluntary and limited to the maximum number of enrollees specified in the General Appropriations Act. An individual must make an affirmative choice before any enrollment action by the agency. The agency may not automatically enroll eligible individuals. (b) To be eligible for enrollment in the pilot program, an individual must: 1. Be Medicaid eligible. 2. Be 18 years of age or older. 3. Have a developmental disability as defined in s. 393.063. 4. Be placed in any preenrollment category for individual budget waiver services under chapter 393 and reside in Statewide Medicaid Managed Care Regions D or I; effective October 1, 2025, be placed in any preenrollment category for individual budget waiver services under chapter 393 regardless of region; or, effective July 1, 2026, be enrolled in the individual budget waiver services program under chapter 393 or in the long-term care managed care program under this part regardless of region. (c) The agency shall enroll individuals in the pilot program based on verification that the individual has met the criteria in paragraph (b). 1. The Agency for Persons with Disabilities shall transmit to the agency weekly data files of clients enrolled in the Medicaid home and community-based services waiver program under chapter 393 and clients in preenrollment categories pursuant to s. 393.065. The agency shall maintain a record of individuals with developmental disabilities who may be eligible for the pilot program using this data, Medicaid enrollment data transmitted by the Department of Children and Families, and any available collateral data. 2. The agency shall determine and administer the process for enrollment. A needs assessment conducted by the Agency for Persons with Disabilities is not required for enrollment. The agency shall notify individuals with developmental disabilities of the opportunity to voluntarily enroll in the pilot program and explain the benefits available through the pilot program, the process for enrollment, and the procedures for disenrollment, including the requirement for continued coverage after disenrollment pursuant to paragraph (d). 3. The agency shall provide a call center staffed by agents trained to assist individuals with developmental disabilities and their families in learning about and enrolling in the pilot program. 4. The agency shall coordinate with the Department of Children and Families and the Agency for Persons with Disabilities to develop partnerships with community-based organizations to disseminate information about the pilot program to providers of covered services and potential enrollees. (d) Notwithstanding any provisions of s. 393.065 to the contrary, an enrollee must be afforded an opportunity to enroll in any appropriate existing Medicaid waiver program if any of the following conditions occur: 1. At any point during the operation of the pilot program, an enrollee declares an intent to voluntarily disenroll, provided that he or she has been covered for the entire previous plan year by the pilot program. 2. The agency determines the enrollee has a good cause reason to disenroll. 3. The pilot program ceases to operate. Such enrollees must receive an individualized transition plan to assist him or her in accessing sufficient services and supports for the enrollee’s safety, well-being, and continuity of care.

(3) PILOT PROGRAM BENEFITS. — (a) Plans participating in the pilot program must, at a minimum, cover the following: 1. All benefits included in s. 409.973. 2. All benefits included in s. 409.98. 3. All benefits included in s. 393.066(3). 4. Any additional benefits negotiated by the agency pursuant to paragraph (4)(b). (b) All providers of the benefits listed under paragraph (a) must meet the provider qualifications established by the agency for the Medicaid long-term care managed care program under this section. If no such qualifications apply to a specific benefit or provider type, the provider must meet the provider qualifications established by the Agency for Persons with Disabilities for the individual budget waiver services program under chapter 393. (c) Support coordination services must maximize the use of natural supports and community partnerships. (d) The plans participating in the pilot program must provide all categories of benefits through a single, integrated model of care. (e) Participating plans must provide benefits to enrollees in accordance with an individualized care plan which is evaluated and updated at least quarterly and as warranted by changes in an enrollee’s circumstances. Participating plans must conduct an individualized assessment of each enrollee within 5 days after enrollment to determine the enrollee’s functional, behavioral, and physical needs. The assessment method or instrument must be approved by the agency. (f) Participating plans must offer a consumer-directed services option in accordance with s. 409.221.

(4) ELIGIBLE PLANS; PLAN SELECTION. — (a) To be eligible to participate in the pilot program, a plan must have been awarded a contract to provide long-term care services pursuant to s. 409.981 as a result of an invitation to negotiate. (b) The agency shall select, as provided in s. 287.057(1), one plan to participate in the pilot program for each of the two regions. The director of the Agency for Persons with Disabilities or his or her designee must be a member of the negotiating team. 1. The invitation to negotiate must specify the criteria and the relative weight assigned to each criterion that will be used for determining the acceptability of submitted responses and guiding the selection of the plans with which the agency and the Agency for Persons with Disabilities negotiate. In addition to any other criteria established by the agency, in consultation with the Agency for Persons with Disabilities, the agency shall consider the following factors in the selection of eligible plans: a. Experience serving similar populations, including the plan’s record in achieving specific quality standards with similar populations. b. Establishment of community partnerships with providers which create opportunities for reinvestment in community-based services. c. Provision of additional benefits, particularly behavioral health services, the coordination of dental care, and other initiatives that improve overall well-being. d. Provision of and capacity to provide mental health therapies and analysis designed to meet the needs of individuals with developmental disabilities. e. Evidence that an eligible plan has written agreements or signed contracts or has made substantial progress in establishing relationships with providers before submitting its response. f. Experience in the provision of person-centered planning as described in 42 C.F.R. s. 441.301(c)(1). g. Experience in robust provider development programs that result in increased availability of Medicaid providers to serve the developmental disabilities community. 2. After negotiations are conducted, the agency shall select the eligible plans that are determined to be responsive and provide the best value to the state. Preference must be given to plans that: a. Have signed contracts in sufficient numbers to meet the specific standards established under s. 409.967(2)(c), including contracts for personal supports, skilled nursing, residential habilitation, adult day training, mental health services, respite care, companion services, and supported employment, as those services are defined in the Florida Medicaid Developmental Disabilities Individual Budgeting Waiver Services Coverage and Limitations Handbook as adopted by reference in rule 59G-13.070, Florida Administrative Code. b. Have well-defined programs for recognizing patient-centered medical homes and providing increased compensation to recognized medical homes, as defined by the plan. c. Have well-defined programs related to person-centered planning as described in 42 C.F.R. s. 441.301(c)(1). d. Have robust and innovative programs for provider development and collaboration with the Agency for Persons with Disabilities. (c) A plan selected by the agency pursuant to this subsection is responsible for implementing the pilot program in its initial stage and through any subsequent expansion until it is reprocured in accordance with s. 409.967(1).

(5) PAYMENT. — (a) The selected plans must receive a per-member, per-month payment based on a rate developed specifically for the unique needs of the developmentally disabled population. (b) The agency must ensure that the rate for the integrated system is actuarially sound. (c) The revenues and expenditures of the selected plan which are associated with the implementation of the pilot program must be included in the reporting and regulatory requirements established in s. 409.967(3).

(6) PROGRAM IMPLEMENTATION AND EVALUATION. — (a) The agency shall conduct monitoring and evaluations and require corrective actions or payment of penalties as may be necessary to secure compliance with contractual requirements, consistent with its obligations under this section, including, but not limited to, compliance with provider network standards, financial accountability, performance standards, health care quality improvement systems, and program integrity. (b) The agency shall submit progress reports to the Governor, the President of the Senate, and the Speaker of the House of Representatives upon the federal approval, implementation, and operation of the pilot program, as follows: 1. By August 30, 2025, a status report on progress made toward federal approval of the waiver or waiver amendment needed to implement the pilot program. 2. By December 31, 2025, a status report on implementation of the pilot program. 3. By December 31, 2025, and annually thereafter, a status report on the operation of the pilot program, including, but not limited to, all of the following: a. Program enrollment, including the number and demographics of enrollees. b. Any complaints received. c. Access to approved services. (c) The agency shall establish specific measures of access, quality, and costs of the pilot program. The agency may contract with an independent evaluator to conduct such evaluation. The evaluation must include assessments of cost savings; consumer education, choice, and access to services; plans for future capacity and the enrollment of new Medicaid providers; coordination of care; person-centered planning and person-centered well-being outcomes; health and quality-of-life outcomes; and quality of care by each eligibility category and managed care plan in each pilot program site. The evaluation must describe any administrative or legal barriers to the implementation and operation of the pilot program in each region. 1. The agency shall conduct quality assurance monitoring of the pilot program to include client satisfaction with services, client health and safety outcomes, client well-being outcomes, and service delivery in accordance with the client’s care plan. 2. The agency shall submit the results of the evaluation to the Governor, the President of the Senate, and the Speaker of the House of Representatives by October 1, 2029.

(7) MANAGED CARE PLAN ACCOUNTABILITY. — Plans participating in the pilot program must consult with the Agency for Persons with Disabilities for the express purpose of ensuring adequate provider capacity before placing an enrollee of the pilot program in a group home licensed by the Agency for Persons with Disabilities.

History: s. 6, ch. 2023-243; s. 5, ch. 2025-130.