HOUSE OF REPRESENTATIVES STAFF FINAL BILL ANALYSIS
BILL #: SB 2510 Health
SPONSOR(S): Appropriations
TIED BILLS: IDEN./SIM. BILLS:
FINAL HOUSE FLOOR ACTION: 111 Y’s 0 N’s GOVERNOR’S ACTION: Approved
SUMMARY ANALYSIS
SB 2510 passed the House on May 5, 2023, as amended by the conference committee.
The bill conforms law to the Fiscal Year 2023-2024 General Appropriations Act. The bill:
 Increases the income threshold above which a resident in a State Veterans’ nursing facility would
be required to contribute to his or her account from $130 to $160 per month.
 Clarifies the premiums paid under Florida KidCare's full-pay programs are based on the combined-
risk premium.
 Increases the nursing home prospective payment reimbursement methodology for the Quality
Incentive Program Payment Pool from 6 percent to 10 percent of the September 2016 non-property
related payments of included facilities.
 Creates the Graduate Medical Education Slots for Doctors Program.
 Provides for a portion of the Statewide Medicaid Managed Care achieved savings rebate to be
repaid to the federal government.
 Establishes a Medicaid managed care pilot program to provide home and community-based
services to individuals with developmental disabilities in Hardee, Highlands, Hillsborough, Manatee,
Polk, Miami-Dade and Monroe counties (Medicaid regions D and I).
 Prohibits the Agency for Health Care Administration from requiring a home health agency to meet
the requirements of Medicare certification, if a home health agency does not provide Medicaid-
skilled private duty nursing and attendant care nursing services, beginning October 1, 2021.
The bill was approved by the Governor on June 15, 2023, ch. 2023-243, L.O.F., and will become effective on
July 1, 2023 except as otherwise provided.
This document does not reflect the intent or official position of the bill sponsor or House of Representatives .
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 I. SUBSTANTIVE INFORMATION
A. EFFECT OF CHANGES:
Florida Medicaid
Background
Medicaid is the health care safety net for low-income Floridians. Medicaid is a partnership of the federal
and state governments established to provide coverage for health services for eligible persons. The
program is administered by the Agency for Health Care Administration (AHCA) and financed by federal
and state funds. AHCA delegates certain functions to other state agencies, including the Department of
Children and Families (DCF), the Department of Health, the Agency for Persons with Disabilities, and
the Department of Elderly Affairs (DOEA).
The structure of each state’s Medicaid program varies and what states must pay for is largely
determined by the federal government, as a condition of receiving federal funds. 1 Federal law sets the
amount, scope, and duration of services offered in the program, among other requirements. These
federal requirements create an entitlement that comes with constitutional due process protections. The
entitlement means that two parts of the Medicaid cost equation – people and utilization – are largely
predetermined for the states. The federal government sets the minimum mandatory populations to be
included in every state Medicaid program. The federal government also sets the minimum mandatory
benefits to be covered in every state Medicaid program. These benefits include home health services. 2
States can add benefits, with federal approval.
States have some flexibility in the provision of Medicaid services. Section 1915(b) of the Social Security
Act provides authority for the Secretary of the U.S. Department of Health and Human Services (HHS) to
waive requirements to the extent that he or she “finds it to be cost-effective and efficient and not
inconsistent with the purposes of this title”. Section 1115 of the Social Security Act allows states to
implement demonstrations of innovative service delivery systems that improve care, increase efficiency,
and reduce costs. These laws allow HHS to waive federal requirements to expand populations or
services, or to try new ways of service delivery.
Florida operates under a Section 1115 waiver to use a comprehensive managed care delivery model
for primary and acute care services, the Statewide Medicaid Managed Care (SMMC) Managed Medical
Assistance (MMA) program.3 Florida also has a waiver under Sections 1915(b) and (c) of the Social
Security Act to operate the SMMC Long-Term Care (LTC) program to provide long-term care services,
including nursing facility and home and community-based services, to individuals age 65 and over and
individuals age 18 and over who have a disability.4
State Veterans’ Homes
Background
Once Medicaid eligibility is established for an individual requiring an institutional level of care, some of
his or her income is used to pay for Medicaid services. For individuals residing in an institution to
receive medical care or services, most of their incomes are applied to the cost of that care, with the
exception of a small personal needs allowance used to pay for personal needs that are not covered by
Medicaid.5 A personal needs allowance is the amount of income a resident may retain for personal
expenditures not covered by the nursing home, such as toiletries and haircuts.
1
Title 42 U.S.C. §§ 1396-1396w -5; Title 42 C.F.R. Part 430-456 (§§ 430.0-456.725) (2016).
2
S. 409.905, F.S.
3
S. 409.964, F.S.
4
Id.
5
42 U.S.C. s. 1396a (q).
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 The Florida Department of Veterans’ Affairs operates eight skilled nursing facilities and one assisted
living facility.6 Every resident of a state veteran domiciliary or nursing home who receives a pension,
compensation, or gratuity from the United States Government or income from any other source of more
than $130 per month is required to contribute to his or her maintenance and support while residing in a
home, pursuant to a schedule of payment determined by the home administrator and department
director that shall not exceed the actual cost of operating and maintaining the home.7
Effect of the Bill
The bill amends s. 296.37, F.S., to increase the personal needs allowance to $160 per month for
residents of State Veterans’ Homes.
KidCare
Background
The Florida KidCare Program (KidCare or Program) was created by the Florida Legislature in 1998 in
response to the passage of the Children’s Health Insurance Program (CHIP) in 1997. 8 The CHIP
provides federal funding to states to provide subsidized health insurance coverage to uninsured
children in families with incomes that are too high to qualify for Medicaid but who meet other eligibility
requirements. When created, CHIP was initially authorized and allotted funding for 10 years. However,
due the program’s capped funding structure, the federal government has had to repeatedly reauthorize
and extend funding.9 Most recently, the 2023 Consolidated Appropriations Act extended federal funding
for CHIP through fiscal year 2029.10
KidCare encompasses four programs.
1. Medicaid for children
2. The MediKids program
3. The Children’s Medical Services Network (for children with special needs)
4. The Florida Healthy Kids program
Three of the four programs, MediKids, Healthy Kids, and the Children’s Medical Services Network
(CMSN), directly receive federal CHIP funding and constitute Florida’s CHIP program. The CHIP was
designed as a federal and state partnership, similar to Medicaid, with the goal of expanding health
insurance to children whose families earn too much income to be eligible for Medicaid, but not enough
money to purchase private, comprehensive health insurance.
The CHIP is administered by states, according to federal requirements. The program is funded jointly
by states and the federal government. The federal CHIP is authorized and funded through Fiscal Year
2027 via the Bipartisan Budget Act of 2018 (P.L. 115-123).11
CHIP funding is also used to enhance the match rate for some children in Medicaid. More specifically:
 MediKids is a Medicaid “look-alike” program administered by AHCA for children ages 1 through
4 who are at or below 200 percent of the federal poverty level (FPL). 12 Families whose income
6
Florida Department of Veterans’ Affairs, State Veterans’ Homes, available at https://floridavets.org/locations/state-veterans-nursing-homes/ (last visited
May 10, 2023).
7
Section 296.37, F.S
8
CHIP w as created as part of the Balanced Budget Act of 1997 (BBA 97, Pub. L. No. 105.33, s. 4901).
9
The Children’s Health Insurance Program Reauthorization Act of 2009 (CHIPRA, Pub. L. No. 111–3, s.101) reauthorized CHIP through fiscal year (FY)
2013, the Patient Protection and Affordable Care Act of 2010, (ACA, Pub. L. No. 111–148, s. 10203) extended CHIP funding through FY 2015, the
Medicare Access and CHIP Reauthorization Act of 2015 (Pub. L. No. 114–10, s. 301) extended funding through FY 2017, the Healthy Kids Act extended
funding to FY 2023 (Pub. L. No. 115-120, s. 3002), and the Bipartisan Budget Act of 2018, (Pub. L. No. 115-123, s. 50101) extended funding for CHIP
through 2023 .
10
Consolidated Appropriations Act, 2023, Pub. L. No. 117-328, s. 5111.
11
The Medicaid and CHIP Payment and Access Commission, State Children’s Health Insurance Program (CHIP), (February 2018) available at
https://www.macpac.gov/wp-content/uploads/2018/02/State-Children%E2%80%99s-Health-Insurance-Program-CHIP.pdf (last visited May 10, 2023).
12
Section 409.8132(6), F.S.
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 exceeds 200 percent of the FPL can elect to participate in the MediKids full-pay premium
option.13
 Healthy Kids is for children ages 5 through 18 and administered by the Florida Healthy Kids
Corporation (FHKC). Children in families with income between 133 percent and 200 percent of
the FPL ($33,383 and $50,200 for a family of four) are eligible for subsidized coverage through
the Healthy Kids program.14 Families whose income exceeds 200 percent of the FPL can elect
to participate in the Healthy Kids full-pay option.15
 Children’s Medical Services Network (CMSN) is a program for children from birth through age
18 with special health care needs.16 The Department of Health (DOH) operates the program
which is open to all children who meet the clinical eligibility criteria that are Medicaid or Title XXI
eligible.17
 Medicaid eligibility is determined by DCF and provides Title XIX coverage to infants from birth to
age 1 who are at or below 200 percent of the FPL and children ages 1 through 18 who are at or
below 133 percent of the FPL.18
Families who receive Medicaid are not responsible for paying premiums or co-payments. Families with
children that qualify for other KidCare program components are responsible for paying monthly
premiums and co-payments for certain services. The Healthy Kids program 19 and the MediKids
program 20 both utilize a combined-risk premium model of Title XXI-subsidized and full-pay enrollments
for medical insurance payments.
The total monthly family payment for CHIP enrollees is $15 or $20 for families with incomes between
133 percent and 200 percent of the FPL.21 The per-child monthly premium rate is $210.18 for full-pay
MediKids coverage and $259.50 for full-pay Healthy Kids coverage, including dental coverage. 22
As of March 2023, 4,883 children are enrolled in subsidized MediKids; 3,280 children are enrolled in
MediKids under the full-pay option; 76,340 children are enrolled in subsidized Healthy Kids; 21,650
children are enrolled in Healthy Kids under the full-pay option; 6,575 children are enrolled in the CMSN;
and 2,466,597 children are enrolled in the Medicaid program. 23
Effect of Bill
The bill amends s. 409.814, F.S., to clarify the premiums paid under Florida KidCare’s full-pay
programs are based on the combined-risk premium.
Nursing Prospective Payment System
Background
On October 1, 2018, Florida Medicaid nursing homes transitioned from facility-specific cost based rates
to the prospective rate reimbursement methodology, which determines rates in advance of payment.
13
Agency for Health Care Administration, Florida KidCare, Welcome to MediKids,
https://ahca.myflorida.com/content/download/11063/file/FLORIDA_MEDIKIDS_INFORMATION_12-1-2021.pdf (last visited May 10, 2023).
14
Florida Healthy Kids Corporation, Subsidized Premiums/Copays, https://www.healthykids.org/cost/subsidized/ (last visited May 10, 2023).
15
Id.
16
See ch. 391, F.S.
17
Id.
18
Florida Healthy Kids, Florida KidCare Health and Dental Insurance Program Eligibility Overview,
https://www.floridakidcare.org/_docs/Florida_KidCare_Income_Guidelines.pdf (last visited May 10, 2023).
19
Chapter 2019-115, Law s of Fla., Specific Appropriation 178.
20
Chapter 2020-111, Law s of Fla., Specific Appropriation 185.
21
Supra, note 18.
22
Id.
23
Agency for Health Care Administration, Florida KidCare, Florida KidCare Enrollment Report, March 2023 (on file w ith the Senate Appropriations
Committee on Health and Human Services).
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 Section 409.908, F.S., provides the methodology24 and parameters for rate setting including
reimbursement rates for direct care, indirect care, and operating costs.
The methodology includes a parameter for a Quality Incentive Payment, in which a provider is awarded
points for process, outcome, structural and credentialing measures using most recently reported data
on May 31 of the rate period year.25
The Quality Incentive Payment calculation26 is as follows:
Facility Annualized Quality Points with
Medicaid Days Lower Limit Total Quality Budget
X X
Average Annualized Sum of Total Points Facility Annualized
Medicaid Days Awarded to All Facilities Medicaid Days
Payment amounts are limited to 6 percent of the September 2016 non-property related payments of
included facilities.27
Effect of the Bill
The bill amends s. 409.908, F.S., modifying the parameters governing the nursing home prospective
payment methodology for Medicaid provider reimbursement to increase the quality incentive payment
pool from 6 percent to 10 percent of the September 2016 non-property related payments of included
facilities.
Graduate Medical Education
Background
Graduate medical education (GME) refers to the training residents complete after medical school
graduation to develop clinical and professional skills required to practice medicine. During this
education, residents train in a specialty (e.g., general surgery, pediatrics, or internal medicine). 28 All
medical school graduates must complete a period of GME, or residency training, to be licensed to
practice medicine in the United States. GME comprises the second phase, after medical school, of the
formal education that prepares doctors for medical practice. During residency, doctors learn skills and
techniques specific to their chosen specialty under the supervision of attending physicians and serve as
part of a care team.29
GME programs include residencies and fellowships. First year GME students fill categorical or
preliminary resident positions. Categorical residents begin a multi-year program with a sponsoring
institution during their first year of GME training. During their first year, preliminary residents receive
prerequisite training. After receiving prerequisite training, preliminary residents transfer to categorical
resident programs. After completing a residency program, physicians may also pursue advanced GME
training by completing a fellowship in a subspecialty program, such as cardiology or vascular surgery. 30
24
Nursing Home Prospective Payment System Calculation: (Operating Price + Direct Care Price - Floor Reduction + Indirect Care Price - Floor
Reduction + FRVS Rate + Pass Through Payments) * Budget Neutrality Factor + Quality Incentive Payment + Medicaid Share of NFQA + Ventilator
Supplemental Payment + High Medicaid Utilization and High Direct Patient Care Add-On)) + Unit Cost Rate Increase
25
R. 59G-6.010(2)(y), F.A.C.
26
Id.
27
S. 409.908(2)(e), F.S. (2022).
28
Office of Program Policy Analysis and Government Accountability, Florida’s Graduate Medical Education System (Report No. 14