Florida Senate - 2014                                     SB 710
       
       
        
       By Senator Garcia
       
       
       
       
       
       38-00386-14                                            2014710__
    1                        A bill to be entitled                      
    2         An act relating to health care; providing a directive
    3         to the Division of Law Revision and Information;
    4         amending s. 409.811, F.S.; revising and providing
    5         definitions; transferring, renumbering, and amending
    6         s. 624.91, F.S.; revising the Florida Healthy Kids
    7         Corporation Act to include the Healthy Florida
    8         program; revising participation guidelines for
    9         nonsubsidized enrollees in the Healthy Kids program;
   10         revising the medical loss ratio requirements for
   11         contracts for the Florida Healthy Kids Corporation;
   12         modifying the membership of the corporation’s board of
   13         directors; creating an executive steering committee;
   14         requiring additional corporate compliance
   15         requirements; amending s. 409.813, F.S.; revising the
   16         components of Florida Kidcare; prohibiting a cause of
   17         action from arising against the Florida Healthy Kids
   18         Corporation for failure to make health services
   19         available; amending s. 409.8132, F.S.; revising the
   20         eligibility of the Medikids program component;
   21         revising the enrollment requirements for Medikids;
   22         amending s. 409.8134, F.S., relating to Florida
   23         Kidcare; conforming provisions to changes made by the
   24         act; amending s. 409.814, F.S.; revising eligibility
   25         requirements for Florida Kidcare; amending s. 409.815,
   26         F.S.; revising certain minimum health benefits
   27         coverage under Florida Kidcare; deleting obsolete
   28         provisions; amending s. 409.816, F.S.; conforming
   29         provisions to changes made by the act; repealing s.
   30         409.817, F.S., relating to the approval of health
   31         benefits coverage and financial assistance under the
   32         Kidcare program; repealing s. 409.8175, F.S., relating
   33         to the delivery of services in rural counties;
   34         amending s. 409.8177, F.S.; conforming provisions to
   35         changes made by the act; amending s. 409.818, F.S.;
   36         revising the duties of the Department of Children and
   37         Families and the Agency for Health Care Administration
   38         with regard to the Kidcare program; deleting the
   39         duties of the Department of Health and the Office of
   40         Insurance Regulation with regard to the Kidcare
   41         program; amending s. 409.820, F.S.; requiring the
   42         Department of Health, in consultation with the agency
   43         and the Florida Healthy Kids Corporation, to develop a
   44         minimum set of pediatric and adolescent quality
   45         assurance and access standards for all program
   46         components; creating s. 409.822, F.S.; creating the
   47         Healthy Florida program; providing eligibility and
   48         enrollment requirements; authorizing the corporation
   49         to contract with certain insurers, managed care
   50         organizations, and provider service networks;
   51         encouraging the corporation to contract with insurers
   52         and managed care organizations that participate in
   53         more than one affordable insurance program under
   54         certain circumstances; requiring the corporation to
   55         establish a benefits package and a process for payment
   56         of services; authorizing the corporation to collect
   57         premiums and copayments; requiring the corporation to
   58         oversee the Healthy Florida program and to establish a
   59         grievance process and integrity process; providing for
   60         the applicability of certain state laws for
   61         administering the program; requiring the corporation
   62         to collect certain data and to submit enrollment
   63         reports and interim independent evaluations to the
   64         Legislature; providing for expiration of the program;
   65         authorizing the corporation to comply with federal
   66         requirements upon giving notice to the Legislature;
   67         amending ss. 154.503, 408.910, and 408.915, F.S.;
   68         conforming cross-references; repealing s. 624.915,
   69         F.S., relating to the operating fund of the Florida
   70         Healthy Kids Corporation; amending ss. 627.6474,
   71         636.035, and 641.315, F.S.; prohibiting a contract
   72         between a health insurer, a prepaid health service
   73         organization, or a health maintenance organization and
   74         a dentist from requiring the dentist to provide
   75         services at a set fee under certain circumstances or
   76         to participate in a discount medical plan; amending s.
   77         766.1115, F.S.; revising a definition; requiring a
   78         contract with a governmental contractor for health
   79         care services to include a provision that a health
   80         care provider licensed under ch. 466, F.S., as an
   81         agent of the governmental contractor, may allow a
   82         patient or a parent or guardian of the patient to
   83         voluntarily contribute a fee to cover costs of dental
   84         laboratory work related to the services provided to
   85         the patient without forfeiting the provider’s
   86         sovereign immunity; prohibiting the contribution from
   87         exceeding the actual amount of the dental laboratory
   88         charges; providing that the contribution complies with
   89         the requirements of s. 766.1115, F.S.; providing
   90         applicability; providing appropriations; providing an
   91         effective date.
   92          
   93  Be It Enacted by the Legislature of the State of Florida:
   94  
   95         Section 1. The Division of Law Revision and Information is
   96  directed to rename part II of chapter 409, Florida Statutes, as
   97  the “Florida Kidcare and Healthy Florida Programs.”
   98         Section 2. Section 409.811, Florida Statutes, is reordered
   99  and amended to read:
  100         409.811 Definitions relating to Florida Kidcare Act.—As
  101  used in this part ss. 409.810-409.821, the term:
  102         (1) “Actuarially equivalent” means that:
  103         (a) The aggregate value of the benefits included in health
  104  benefits coverage is equal to the value of the benefits in the
  105  benchmark benefit plan; and
  106         (b) The benefits included in health benefits coverage are
  107  substantially similar to the benefits included in the child
  108  benchmark benefit plan, except that preventive health services
  109  must be the same as in the benchmark benefit plan.
  110         (2) “Agency” means the Agency for Health Care
  111  Administration.
  112         (3) “Applicant” means:
  113         (a) A parent or guardian of a child or a child whose
  114  disability of nonage has been removed under chapter 743, who
  115  applies for a determination of eligibility for health benefits
  116  coverage under Florida Kidcare; or
  117         (b) An individual who applies for a determination of
  118  eligibility under Healthy Florida ss. 409.810-409.821.
  119         (5)(4) “Child benchmark benefit plan” means the form and
  120  level of health benefits coverage established under in s.
  121  409.815.
  122         (4)(5) “Child” means a any person younger than under 19
  123  years of age.
  124         (6) “Child with special health care needs” means a child
  125  whose serious or chronic physical or developmental condition
  126  requires extensive preventive and maintenance care beyond that
  127  required by typically healthy children. Health care utilization
  128  by such a child exceeds the statistically expected usage of the
  129  normal child adjusted for chronological age, and such a child
  130  often needs complex care requiring multiple providers,
  131  rehabilitation services, and specialized equipment in a number
  132  of different settings.
  133         (7) “Children’s Medical Services Network” or “network” has
  134  the same meaning means a statewide managed care service system
  135  as defined in s. 391.021(1).
  136         (8) “CHIP” means the Children’s Health Insurance Program as
  137  authorized under Title XXI of the Social Security Act,
  138  regulations adopted thereunder, and this part, and as
  139  administered in this state by the agency, the department, and
  140  the corporation pursuant to their respective jurisdictions.
  141         (8) “Community rate” means a method used to develop
  142  premiums for a health insurance plan that spreads financial risk
  143  across a large population and allows adjustments only for age,
  144  gender, family composition, and geographic area.
  145         (9) “Corporation” means the Florida Healthy Kids
  146  Corporation established under s. 409.8125.
  147         (10)(9) “Department” means the Department of Health.
  148         (11)(10) “Enrollee” means a child or adult who has been
  149  determined eligible for and is receiving coverage under this
  150  part ss. 409.810-409.821.
  151         (11) “Family” means the group or the individuals whose
  152  income is considered in determining eligibility for the Florida
  153  Kidcare program. The family includes a child with a parent or
  154  caretaker relative who resides in the same house or living unit
  155  or, in the case of a child whose disability of nonage has been
  156  removed under chapter 743, the child. The family may also
  157  include other individuals whose income and resources are
  158  considered in whole or in part in determining eligibility of the
  159  child.
  160         (12) “Family income” means cash received at periodic
  161  intervals from any source, such as wages, benefits,
  162  contributions, or rental property. Income also may include any
  163  money that would have been counted as income under the Aid to
  164  Families with Dependent Children (AFDC) state plan in effect
  165  prior to August 22, 1996.
  166         (12)(13) “Florida Kidcare Program,“Kidcare program,” or
  167  “program” means the health benefits program described in s.
  168  409.813 and administered under this part through ss. 409.810
  169  409.821.
  170         (13)(14) “Guarantee issue” means that health benefits
  171  coverage must be offered to an individual regardless of the
  172  individual’s health status, preexisting condition, or claims
  173  history.
  174         (14)(15) “Health benefits coverage” means protection that
  175  provides payment of benefits for covered health care services or
  176  that otherwise provides, either directly or through arrangements
  177  with other persons, covered health care services on a prepaid
  178  per capita basis or on a prepaid aggregate fixed-sum basis.
  179         (15)(16) “Health insurance plan” means health benefits
  180  coverage under the following:
  181         (a) A health plan offered by a any certified health
  182  maintenance organization or authorized health insurer, except
  183  for a plan that is limited to the following: a limited benefit,
  184  specified disease, or specified accident; hospital indemnity;
  185  accident only; limited benefit convalescent care; Medicare
  186  supplement; credit disability; dental; vision; long-term care;
  187  disability income; coverage issued as a supplement to another
  188  health plan; workers’ compensation liability or other insurance;
  189  or motor vehicle medical payment only; or
  190         (b) An employee welfare benefit plan that includes health
  191  benefits established under the Employee Retirement Income
  192  Security Act of 1974, as amended.
  193         (16) “Healthy Florida” means the program established under
  194  s. 409.822.
  195         (17) “Healthy Kids” means a component of Florida Kidcare
  196  created under s. 409.8125 for children who are 5 through 18
  197  years of age.
  198         (18) “Household income” has the same meaning as in s.
  199  36B(d)(2)(A) of the Internal Revenue Code of 1986 and applies to
  200  the individual or household whose income is being considered in
  201  determining eligibility for Florida Kidcare or Healthy Florida.
  202         (19)(17) “Medicaid” means the medical assistance program
  203  authorized by Title XIX of the Social Security Act, and
  204  regulations thereunder, and ss. 409.901-409.920, as administered
  205  in this state by the agency.
  206         (20)(18) “Medically necessary” means the use of any medical
  207  treatment, service, equipment, or supply necessary to palliate
  208  the effects of a terminal condition, or to prevent, diagnose,
  209  correct, cure, alleviate, or preclude deterioration of a
  210  condition that threatens life, causes pain or suffering, or
  211  results in illness or infirmity and which is:
  212         (a) Consistent with the symptom, diagnosis, and treatment
  213  of the enrollee’s condition;
  214         (b) Provided in accordance with generally accepted
  215  standards of medical practice;
  216         (c) Not primarily intended for the convenience of the
  217  enrollee, the enrollee’s family, or the health care provider;
  218         (d) The most appropriate level of supply or service for the
  219  diagnosis and treatment of the enrollee’s condition; and
  220         (e) Approved by the appropriate medical body or health care
  221  specialty involved as effective, appropriate, and essential for
  222  the care and treatment of the enrollee’s condition.
  223         (21)(19) “Medikids” means a component of the Florida
  224  Kidcare program of medical assistance authorized by Title XXI of
  225  the Social Security Act, and regulations thereunder, and s.
  226  409.8132, as administered in the state by the agency.
  227         (22)“Modified adjusted gross income” has the same meaning
  228  as in s. 36B(d)(2)(B) of the Internal Revenue Code of 1986 and
  229  applies to the individual or household whose income is being
  230  considered in determining eligibility for Florida Kidcare or
  231  Healthy Florida.
  232         (23) “Patient Protection and Affordable Care Act” means the
  233  federal law enacted as Pub. L. No. 111-148, as amended by the
  234  Health Care and Education Reconciliation Act of 2010, Pub. L.
  235  No. 111-152, and any regulations or guidance adopted or issued
  236  pursuant to those acts.
  237         (24)(20) “Preexisting condition exclusion” means, with
  238  respect to coverage, a limitation or exclusion of benefits
  239  relating to a condition based on the fact that the condition was
  240  present before the date of enrollment for such coverage,
  241  regardless of whether or not any medical advice, diagnosis,
  242  care, or treatment was recommended or received before such date.
  243         (25)(21) “Premium” means the entire cost of a health
  244  insurance plan, including the administration fee or the risk
  245  assumption charge.
  246         (26)(22) “Premium assistance payment” means the monthly
  247  consideration paid toward health insurance premiums by the
  248  agency per enrollee in the Florida Kidcare Program towards
  249  health insurance premiums.
  250         (27)(23) “Qualified alien” means an alien as defined in 8
  251  U.S.C. s. 1641 (b) and (c) s. 431 of the Personal Responsibility
  252  and Work Opportunity Reconciliation Act of 1996, as amended,
  253  Pub. L. No. 104-193.
  254         (28)(24) “Resident” means a United States citizen, or
  255  qualified alien, who is domiciled in this state.
  256         (29)(25) “Rural county” means a county having a population
  257  density of less than 100 persons per square mile, or a county
  258  defined by the most recent United States Census as rural, in
  259  which there was is no prepaid health plan participating in the
  260  Medicaid program as of July 1, 1998.
  261         (26) “Substantially similar” means that, with respect to
  262  additional services as defined in s. 2103(c)(2) of Title XXI of
  263  the Social Security Act, these services must have an actuarial
  264  value equal to at least 75 percent of the actuarial value of the
  265  coverage for that service in the benchmark benefit plan and,
  266  with respect to the basic services as defined in s. 2103(c)(1)
  267  of Title XXI of the Social Security Act, these services must be
  268  the same as the services in the benchmark benefit plan.
  269         Section 3. Section 624.91, Florida Statutes, is transferred
  270  and renumbered as section 409.8125, Florida Statutes, and is
  271  reordered and amended to read:
  272         409.8125 624.91 The Florida Healthy Kids Corporation Act.—
  273         (1) SHORT TITLE.—This section may be cited as the “William
  274  G. ‘Doc’ Myers Healthy Kids Corporation Act.”
  275         (2) LEGISLATIVE INTENT.—
  276         (a) The Legislature finds that increased access to health
  277  care services could improve children’s health and reduce the
  278  incidence and costs of childhood illness and disabilities among
  279  children in this state. Many children do not have comprehensive,
  280  affordable health care services available. It is the intent of
  281  the Legislature that the Florida Healthy Kids Corporation
  282  provide comprehensive health insurance coverage to such
  283  children. The corporation is encouraged to cooperate with any
  284  existing health service programs funded by the public or the
  285  private sector.
  286         (b) It is also the intent of the Legislature:
  287         (a) That the Florida Healthy Kids program, established and
  288  administered by the corporation, serve as one of several
  289  providers of services to children eligible for medical
  290  assistance under the federal Children’s Health Insurance Program
  291  (CHIP) Title XXI of the Social Security Act. Although Healthy
  292  Kids the corporation may serve other children, the Legislature
  293  intends that the primary enrollees recipients of services
  294  provided through the corporation be uninsured school-age
  295  children eligible for CHIP with a family income below 200
  296  percent of the federal poverty level, who do not qualify for
  297  Medicaid. It is also the intent of the Legislature that state
  298  and local government Florida Healthy Kids funds be used to
  299  continue coverage, subject to specific appropriations in the
  300  General Appropriations Act, to children not eligible for federal
  301  matching funds under CHIP Title XXI.
  302         (b) That the corporation administer and manage services for
  303  Healthy Florida, a health care program for uninsured adults,
  304  using a unique network of providers and contracts. Enrollees in
  305  Healthy Florida shall receive comprehensive health care services
  306  from private, licensed health insurers that meet standards
  307  established by the corporation. It is further the intent of the
  308  Legislature that these enrollees participate in their own health
  309  care decisionmaking and contribute financially toward their
  310  medical costs. The Legislature intends to provide an alternative
  311  benefit package that includes a full range of services that meet
  312  the needs of the residents of this state. As a new program, the
  313  Legislature intends that a comprehensive analysis be conducted
  314  to measure the overall impact of the program and evaluate
  315  whether the program should be renewed after an initial 3-year
  316  term.
  317         (6)(3) ELIGIBILITY FOR STATE-FUNDED ASSISTANCE.—Only the
  318  following individuals are eligible for state-funded assistance
  319  in paying Florida Healthy Kids or Healthy Florida premiums:
  320         (a) Residents of this state who are eligible for the
  321  Florida Kidcare program pursuant to s. 409.814 or Healthy
  322  Florida pursuant to s. 409.822.
  323         (b) Notwithstanding s. 409.814, legal aliens who are
  324  enrolled in the Florida Healthy Kids program as of January 31,
  325  2004, who do not qualify for CHIP Title XXI federal funds
  326  because they are not qualified aliens as defined in s. 409.811.
  327         (7)(4) NONENTITLEMENT.—Nothing in This section does not
  328  provide shall be construed as providing an individual with an
  329  entitlement to health care services. No cause of action shall
  330  arise against the state, the Florida Healthy Kids corporation,
  331  or a unit of local government for failure to make health
  332  services available under this section.
  333         (3)(5) CORPORATION AUTHORIZATION, DUTIES, POWERS.—
  334         (a) There is created The Florida Healthy Kids Corporation
  335  is hereby established as, a not-for-profit corporation.
  336         (b) The Florida Healthy Kids corporation shall:
  337         1. Arrange for the collection of any family, individual, or
  338  local contributions, or employer payment or premium, in an
  339  amount to be determined by the board of directors, to provide
  340  for payment of premiums for comprehensive insurance coverage and
  341  for the actual or estimated administrative expenses.
  342         2. Arrange for the collection of any voluntary
  343  contributions to provide for the payment of premiums for
  344  enrollees in Florida Kidcare or Healthy Florida program premiums
  345  for children who are not eligible for medical assistance under
  346  Title XIX or Title XXI of the Social Security Act.
  347         3. Subject to the provisions of s. 409.8134, accept
  348  voluntary supplemental local match contributions that comply
  349  with CHIP the requirements of Title XXI of the Social Security
  350  Act for the purpose of providing additional Florida Kidcare
  351  coverage in contributing counties under CHIP Title XXI.
  352         4. Establish the administrative and accounting procedures
  353  for the operation of the corporation.
  354         5. Establish, with consultation from appropriate
  355  professional organizations, standards for preventive health
  356  services and providers and comprehensive insurance benefits
  357  appropriate to children., provided that Such standards for rural
  358  areas may shall not require that limit primary care providers be
  359  to board-certified pediatricians.
  360         6. Determine eligibility for children seeking to
  361  participate in CHIP the Title XXI-funded components of the
  362  Florida Kidcare program consistent with the requirements
  363  specified in s. 409.814, as well as the non-Title-XXI-eligible
  364  children not eligible under CHIP as provided in subsection (6)
  365  (3).
  366         7. Establish procedures under which providers of local
  367  match to, applicants to, and participants in Healthy Kids or
  368  Healthy Families the program may have grievances reviewed by an
  369  impartial body and reported to the board of directors of the
  370  corporation.
  371         8. Establish participation criteria and, if appropriate,
  372  contract with an authorized insurer, health maintenance
  373  organization, or third-party administrator to provide
  374  administrative services to the corporation.
  375         9. Establish enrollment criteria that include penalties or
  376  30-day waiting periods of 30 days for reinstatement of coverage
  377  upon voluntary cancellation for nonpayment of family and
  378  individual premiums under the programs.
  379         10. Contract with authorized insurers or providers any
  380  provider of health care services who meet the, meeting standards
  381  established by the corporation, for the provision of
  382  comprehensive insurance coverage to participants. Such standards
  383  must shall include criteria under which the corporation may
  384  contract with more than one provider of health care services in
  385  program sites.
  386         a. Health plans shall be selected through a competitive bid
  387  process.
  388         b. The Florida Healthy Kids corporation shall purchase
  389  goods and services in the most cost-effective manner consistent
  390  with the delivery of quality medical care. The maximum
  391  administrative cost for a Florida Healthy Kids corporation
  392  contract is shall be 15 percent. For all health care contracts,
  393  the minimum medical loss ratio is for a Florida Healthy Kids
  394  Corporation contract shall be 85 percent. The calculations must
  395  use uniform financial data collected from all plans in a format
  396  established by the corporation and computed for each insurer on
  397  a statewide basis. Funds shall be classified in a manner
  398  consistent with 45 C.F.R. part 158 For dental contracts, the
  399  remaining compensation to be paid to the authorized insurer or
  400  provider under a Florida Healthy Kids Corporation contract shall
  401  be no less than an amount which is 85 percent of premium; to the
  402  extent any contract provision does not provide for this minimum
  403  compensation, this section shall prevail.
  404         c. The health plan selection criteria, and scoring system,
  405  and the scoring results must, shall be available upon request
  406  for inspection after the bids have been awarded.
  407         11. Establish disenrollment criteria if in the event local
  408  matching funds are insufficient to cover enrollments.
  409         12. Develop and implement a plan to publicize the Florida
  410  Kidcare and Healthy Florida program, the eligibility
  411  requirements of the programs program, and the procedures for
  412  enrollment in the programs program and to maintain public
  413  awareness of the corporation and the programs program.
  414         13. Secure staff necessary to properly administer the
  415  corporation. Staff costs shall be funded from state and local
  416  matching funds and such other private or public funds as become
  417  available. The board of directors shall determine the number of
  418  staff members necessary to administer the corporation.
  419         14. In consultation with the partner agencies, provide an
  420  annual a report on the Florida Kidcare program annually to the
  421  Governor, the Chief Financial Officer, the Commissioner of
  422  Education, the President of the Senate, the Speaker of the House
  423  of Representatives, and the Minority Leaders of the Senate and
  424  the House of Representatives.
  425         15. Provide information on a quarterly basis to the
  426  Legislature and the Governor which compares the costs and
  427  utilization of the full-pay enrolled population and the CHIP
  428  subsidized Title XXI-subsidized enrolled population in the
  429  Florida Kidcare program. The information, At a minimum, the
  430  information must include:
  431         a. The monthly enrollment and expenditure for full-pay
  432  enrollees in the Medikids and Florida Healthy Kids programs
  433  compared to the CHIP-subsidized Title XXI-subsidized enrolled
  434  population; and
  435         b. The costs and utilization by service of the full-pay
  436  enrollees in the Medikids and Florida Healthy Kids programs and
  437  the CHIP-subsidized Title XXI-subsidized enrolled population.
  438  
  439  By February 1, 2010, the Florida Healthy Kids Corporation shall
  440  provide a study to the Legislature and the Governor on premium
  441  impacts to the subsidized portion of the program from the
  442  inclusion of the full-pay program, which shall include
  443  recommendations on how to eliminate or mitigate possible impacts
  444  to the subsidized premiums.
  445         16. Notify all current full-pay enrollees of the
  446  availability of the exchange, as defined in the federal Patient
  447  Protection and Affordable Care Act, and how to access other
  448  affordable insurance options. New applications for full-pay
  449  coverage may not be accepted after September 30, 2014.
  450         17.16. Establish benefit packages that conform to the
  451  provisions of the Florida Kidcare program, as created under this
  452  part in ss. 409.810-409.821.
  453         (c) Coverage under the corporation’s programs program is
  454  secondary to any other available private coverage held by, or
  455  applicable to, the participant child or family member. Insurers
  456  under contract with the corporation are the payors of last
  457  resort and must coordinate benefits with any other third-party
  458  payor that may be liable for the participant’s medical care.
  459         (d) The Florida Healthy Kids corporation shall be a private
  460  corporation not for profit, registered, incorporated, and
  461  organized pursuant to chapter 617, and shall have all powers
  462  necessary to carry out the purposes of this section act,
  463  including, but not limited to, the power to receive and accept
  464  grants, loans, or advances of funds from any public or private
  465  agency and to receive and accept from any source contributions
  466  of money, property, labor, or any other thing of value, to be
  467  held, used, and applied for the purposes of this section act.
  468  The corporation and any committees it forms shall comply with
  469  part III of chapter 112 and chapters 119 and 286.
  470         (4)(6) BOARD OF DIRECTORS AND MANAGEMENT SUPERVISION.—
  471         (a) The Florida Healthy Kids corporation shall operate
  472  subject to the supervision and approval of a board of directors
  473  chaired by an appointee designated by the Governor Chief
  474  Financial Officer or her or his designee, and composed of 15 12
  475  other members. The Senate shall confirm the designated chair and
  476  other board appointees selected for 3-year terms of office as
  477  follows:
  478         1. The Secretary of Health Care Administration, or his or
  479  her designee, as an ex-officio member.
  480         2. The State Surgeon General, or his or her designee, as an
  481  ex-officio member One member appointed by the Commissioner of
  482  Education from the Office of School Health Programs of the
  483  Florida Department of Education.
  484         3. The Secretary of Children and Families, or his or her
  485  designee, as an ex-officio member One member appointed by the
  486  Chief Financial Officer from among three members nominated by
  487  the Florida Pediatric Society.
  488         4. Four members One member, appointed by the Governor, who
  489  represents the Children’s Medical Services Program.
  490         5. Two members One member appointed by the President of the
  491  Senate Chief Financial Officer from among three members
  492  nominated by the Florida Hospital Association.
  493         6. Two members One member, appointed by the Senate Minority
  494  Leader Governor, who is an expert on child health policy.
  495         7. Two members One member, appointed by the Speaker of the
  496  House of Representatives Chief Financial Officer, from among
  497  three members nominated by the Florida Academy of Family
  498  Physicians.
  499         8. Two members One member, appointed by the House Minority
  500  Leader Governor, who represents the state Medicaid program.
  501         9. One member, appointed by the Chief Financial Officer,
  502  from among three members nominated by the Florida Association of
  503  Counties.
  504         10. The State Health Officer or her or his designee.
  505         11. The Secretary of Children and Family Services, or his
  506  or her designee.
  507         12. One member, appointed by the Governor, from among three
  508  members nominated by the Florida Dental Association.
  509         (b) A member of the board of directors may be removed by
  510  the official who made the appointment appointed that member. The
  511  board shall appoint an executive director, who is responsible
  512  for other staff authorized by the board.
  513         (c) Board members are entitled to receive, from funds of
  514  the corporation, reimbursement for per diem and travel expenses
  515  as provided by s. 112.061.
  516         (d) There is shall be no liability on the part of, and no
  517  cause of action shall arise against, any member of the board of
  518  directors, or its employees or agents, for any action they take
  519  in the performance of their powers and duties under this act.
  520         (e) Board members who are serving on or before the
  521  effective date of this act or similar legislation may remain
  522  until July 1, 2015.
  523         (f) An executive steering committee is created to provide
  524  direction and support to management and to make recommendations
  525  to the board on programs. The steering committee consists of the
  526  Secretary of Health Care Administration, the Secretary of
  527  Children and Families, and the State Surgeon General, who may
  528  not delegate their membership or attendance.
  529         (5)(7) LICENSING NOT REQUIRED; FISCAL OPERATION.—
  530         (a) The corporation is shall not be deemed an insurer. The
  531  officers, directors, and employees of the corporation may shall
  532  not be deemed to be agents of an insurer. Neither the
  533  corporation nor any officer, director, or employee of the
  534  corporation is subject to the licensing requirements of the
  535  insurance code or the rules of the Department of Financial
  536  Services or the Office of Insurance Regulation. However, any
  537  marketing representative used utilized and compensated by the
  538  corporation must be appointed as a representative of the
  539  insurers or health services providers with which the corporation
  540  contracts.
  541         (b) The board has complete fiscal control over the
  542  corporation and is responsible for all corporate operations.
  543         (c) The Department of Financial Services shall supervise
  544  any liquidation or dissolution of the corporation and shall
  545  have, with respect to such liquidation or dissolution, shall
  546  have all power granted to it pursuant to the insurance code.
  547         Section 4. Section 409.813, Florida Statutes, is amended to
  548  read:
  549         409.813 Health benefits coverage; program components;
  550  entitlement and nonentitlement.—
  551         (1) The Florida Kidcare program includes health benefits
  552  coverage provided to children through the following program
  553  components, which shall be marketed as the Florida Kidcare
  554  program:
  555         (a) Medicaid;
  556         (b) Medikids as created in s. 409.8132;
  557         (c) The Florida Healthy Kids Corporation as created in s.
  558  409.8125 s. 624.91; and
  559         (d) Employer-sponsored group health insurance plans
  560  approved under ss. 409.810-409.821; and
  561         (d)(e) The Children’s Medical Services network established
  562  in chapter 391.
  563         (2) Except for CHIP-funded Title XIX-funded Florida Kidcare
  564  program coverage under the Medicaid program, coverage under the
  565  Florida Kidcare program is not an entitlement. No cause of
  566  action shall arise against the state, the department, the
  567  Department of Children and Families Family Services, or the
  568  agency, or the corporation for failure to make health services
  569  available to any person under this part ss. 409.810-409.821.
  570         Section 5. Subsections (6) and (7) of section 409.8132,
  571  Florida Statutes, are amended to read:
  572         409.8132 Medikids program component.—
  573         (6) ELIGIBILITY.—
  574         (a) A child who has attained the age of 1 year but who is
  575  under the age of 5 years is eligible to enroll in the Medikids
  576  program component of the Florida Kidcare program, if the child
  577  is a member of a family that has a household family income
  578  greater than which exceeds the Medicaid applicable income level
  579  as specified in s. 409.903, but which is equal to or below 200
  580  percent of the current federal poverty level. In determining the
  581  eligibility of such a child, an assets test is not required. A
  582  child who is eligible for Medikids may elect to enroll in
  583  Florida Healthy Kids coverage or employer-sponsored group
  584  coverage. However, a child who is eligible for Medikids may
  585  participate in the Florida Healthy Kids Program only if the
  586  child has a sibling participating in the Florida Healthy Kids
  587  Program and the child’s county of residence permits such
  588  enrollment.
  589         (b) The provisions of s. 409.814 apply to the Medikids
  590  program.
  591         (7) ENROLLMENT.—Enrollment in the Medikids program
  592  component may occur at any time throughout the year. A child may
  593  not receive services under the Medikids program until the child
  594  is enrolled in a managed care plan or MediPass. Once determined
  595  eligible, an applicant may receive choice counseling and select
  596  a managed care plan or MediPass. The agency may initiate
  597  mandatory assignment for a Medikids applicant who has not chosen
  598  a managed care plan or MediPass provider after the applicant’s
  599  voluntary choice period ends. An applicant may select MediPass
  600  under the Medikids program component only in counties that have
  601  fewer than two managed care plans available to serve Medicaid
  602  recipients and only if the federal Health Care Financing
  603  Administration determines that MediPass constitutes “health
  604  insurance coverage” as defined in Title XXI of the Social
  605  Security Act.
  606         Section 6. Subsection (2) of section 409.8134, Florida
  607  Statutes, is amended to read:
  608         409.8134 Program expenditure ceiling; enrollment.—
  609         (2) The Florida Kidcare program may conduct enrollment
  610  continuously throughout the year.
  611         (a) Children eligible for coverage under the CHIP-funded
  612  Title XXI-funded Florida Kidcare program shall be enrolled on a
  613  first-come, first-served basis using the date the enrollment
  614  application is received. Enrollment shall immediately cease when
  615  the expenditure ceiling is reached. Year-round enrollment shall
  616  only be held only if the Social Services Estimating Conference
  617  determines that sufficient federal and state funds will be
  618  available to finance the increased enrollment.
  619         (b)An The application for the Florida Kidcare program is
  620  valid for a period of 120 days after the date it was received.
  621  At the end of the 120-day period, If the applicant has not been
  622  enrolled in the program by the end of the 120-day period, the
  623  application is invalid and the applicant shall be notified of
  624  the action. The applicant may reactivate the application after
  625  notification of the action taken by the program.
  626         (c) Except for the Medicaid program, if whenever the Social
  627  Services Estimating Conference determines that there are
  628  presently, or will be by the end of the current fiscal year will
  629  be, insufficient funds to finance the current or projected
  630  enrollment in the Florida Kidcare program, all additional
  631  enrollment must cease and additional enrollment may not resume
  632  until sufficient funds are available to finance such enrollment.
  633         Section 7. Section 409.814, Florida Statutes, is amended to
  634  read:
  635         409.814 Eligibility.—A child who has not reached 19 years
  636  of age whose household family income is equal to or below 200
  637  percent of the federal poverty level is eligible for the Florida
  638  Kidcare program as provided in this section. If an enrolled
  639  individual is determined to be ineligible for coverage, he or
  640  she must be immediately disenrolled from the respective Florida
  641  Kidcare program component and referred to another affordable
  642  insurance program.
  643         (1) A child who is eligible for Medicaid coverage under s.
  644  409.903 or s. 409.904 must be offered an opportunity to enroll
  645  enrolled in Medicaid and is not eligible to receive health
  646  benefits under any other health benefits coverage authorized
  647  under the Florida Kidcare program. A child who is eligible for
  648  Medicaid and opts to enroll in CHIP may disenroll from CHIP at
  649  any time and transition to Medicaid. Such transition must occur
  650  without a break in coverage.
  651         (2) A child who is not eligible for Medicaid, but who is
  652  eligible for another component of the Florida Kidcare program,
  653  may obtain health benefits coverage under any of the other
  654  components listed in s. 409.813 if such coverage is approved and
  655  available in the county in which the child resides.
  656         (3) A CHIP-funded Title XXI-funded child who is eligible
  657  for the Florida Kidcare program who is a child with special
  658  health care needs, as determined through a medical or behavioral
  659  screening instrument, is eligible for health benefits coverage
  660  from, and shall be assigned to, and may opt out of the
  661  Children’s Medical Services Network.
  662         (4) The following children are not eligible to receive
  663  CHIP-funded Title XXI-funded premium assistance for health
  664  benefits coverage under the Florida Kidcare program, except
  665  under Medicaid if the child would have been eligible for
  666  Medicaid under s. 409.903 or s. 409.904 as of June 1, 1997:
  667         (a) A child who is covered under a family member’s group
  668  health benefit plan or under other private or employer health
  669  insurance coverage, if the cost of the child’s participation is
  670  not greater than 5 percent of the household family’s income. If
  671  a child is otherwise eligible for a subsidy under the Florida
  672  Kidcare program and the cost of the child’s participation in the
  673  family member’s health insurance benefit plan is greater than 5
  674  percent of the household family’s income, the child may enroll
  675  in the appropriate subsidized Florida Kidcare program component.
  676         (b) A child who is seeking premium assistance for the
  677  Florida Kidcare program through employer-sponsored group
  678  coverage, if the child has been covered by the same employer’s
  679  group coverage during the 60 days before the family submitted an
  680  application for determination of eligibility under the program.
  681         (b)(c) A child who is an alien, but who does not meet the
  682  definition of qualified alien, in the United States.
  683         (c)(d) A child who is an inmate of a public institution or
  684  a patient in an institution for mental diseases.
  685         (d)(e) A child who is otherwise eligible for premium
  686  assistance for the Florida Kidcare program and has had his or
  687  her coverage in an employer-sponsored or private health benefit
  688  plan voluntarily canceled in the last 60 days, except those
  689  children whose coverage was voluntarily canceled for good cause,
  690  including, but not limited to, the following circumstances:
  691         1. The cost of participation in an employer-sponsored
  692  health benefit plan is greater than 5 percent of the household’s
  693  modified adjusted gross family’s income;
  694         2. The parent lost a job that provided an employer
  695  sponsored health benefit plan for children;
  696         3. The parent who had health benefits coverage for the
  697  child is deceased;
  698         4. The child has a medical condition that, without medical
  699  care, would cause serious disability, loss of function, or
  700  death;
  701         5. The employer of the parent canceled health benefits
  702  coverage for children;
  703         6. The child’s health benefits coverage ended because the
  704  child reached the maximum lifetime coverage amount;
  705         7. The child has exhausted coverage under a COBRA
  706  continuation provision;
  707         8. The health benefits coverage does not cover the child’s
  708  health care needs; or
  709         9. Domestic violence led to loss of coverage.
  710         (5) A child who is otherwise eligible for the Florida
  711  Kidcare program and who has a preexisting condition that
  712  prevents coverage under another insurance plan as described in
  713  paragraph (4)(a) which would have disqualified the child for the
  714  Florida Kidcare program if the child were able to enroll in the
  715  plan is eligible for Florida Kidcare coverage when enrollment is
  716  possible.
  717         (5)(6) A child whose household’s modified adjusted gross
  718  family income is above 200 percent of the federal poverty level
  719  or a child who is excluded under the provisions of subsection
  720  (4) may participate in the Florida Kidcare program as provided
  721  in s. 409.8132 or, if the child is ineligible for Medikids by
  722  reason of age, in the Florida Healthy Kids program, subject to
  723  the following:
  724         (a) The family is not eligible for premium assistance
  725  payments and must pay the full cost of the premium, including
  726  any administrative costs.
  727         (b) The board of directors of the Florida Healthy Kids
  728  Corporation may offer a reduced benefit package to these
  729  children in order to limit program costs for such families.
  730         (c) The corporation shall notify all current full-pay
  731  enrollees of the availability of the exchange and how to access
  732  other affordable insurance options.
  733         (6)(7) Once a child is enrolled in the Florida Kidcare
  734  program, the child is eligible for coverage for 12 months
  735  without a redetermination or reverification of eligibility, if
  736  the family continues to pay the applicable premium. Eligibility
  737  for program components funded through CHIP Title XXI of the
  738  Social Security Act terminates when a child attains the age of
  739  19. A child who has not attained the age of 5 and who has been
  740  determined eligible for the Medicaid program is eligible for
  741  coverage for 12 months without a redetermination or
  742  reverification of eligibility.
  743         (7)(8) When determining or reviewing a child’s eligibility
  744  under the Florida Kidcare Program, the applicant shall be
  745  provided with reasonable notice of changes in eligibility which
  746  may affect enrollment in one or more of the program components.
  747  If a transition from one program component to another is
  748  authorized, there must shall be cooperation between the program
  749  components and the affected family which promotes continuity of
  750  health care coverage. Any authorized transfers must be managed
  751  within the program’s overall appropriated or authorized levels
  752  of funding. Each component of the program shall establish a
  753  reserve to ensure that transfers between components are will be
  754  accomplished within current year appropriations. These reserves
  755  shall be reviewed by each convening of the Social Services
  756  Estimating Conference to determine their the adequacy of such
  757  reserves to meet actual experience.
  758         (8)(9) In determining the eligibility of a child, an assets
  759  test is not required. Each applicant shall provide documentation
  760  during the application process and the redetermination process,
  761  including, but not limited to, the following:
  762         (a) Proof of household family income, which must be
  763  verified electronically to determine financial eligibility for
  764  the Florida Kidcare program. Written documentation, which may
  765  include wages and earnings statements or pay stubs, W-2 forms,
  766  or a copy of the applicant’s most recent federal income tax
  767  return, is required only if the electronic verification is not
  768  available or does not substantiate the applicant’s income.
  769         (b)  A statement from all applicable, employed household
  770  family members that:
  771         1. Their employers do not sponsor health benefit plans for
  772  employees;
  773         2. The potential enrollee is not covered by an employer
  774  sponsored health benefit plan; or
  775         3. The potential enrollee is covered by an employer
  776  sponsored health benefit plan and the cost of the employer
  777  sponsored health benefit plan is more than 5 percent of the
  778  household’s modified adjusted gross family’s income.
  779         (c) To enroll in the Children’s Medical Services Network, a
  780  completed application, including a clinical screening.
  781         (d) Eligibility shall be determined through electronic
  782  matching using the federally managed data services hub and other
  783  resources. Written documentation from the applicant may be
  784  accepted if the electronic verification does not substantiate
  785  the applicant’s income or if there has been a change in
  786  circumstances.
  787         (9)(10) Subject to paragraph (4)(a), the Florida Kidcare
  788  program shall withhold benefits from an enrollee if the program
  789  obtains evidence that the enrollee is no longer eligible,
  790  submitted incorrect or fraudulent information in order to
  791  establish eligibility, or failed to provide verification of
  792  eligibility. The applicant or enrollee shall be notified that
  793  because of such evidence, program benefits will be withheld
  794  unless the applicant or enrollee contacts a designated
  795  representative of the program by a specified date, which must be
  796  within 10 working days after the date of notice, to discuss and
  797  resolve the matter. The program shall make every effort to
  798  resolve the matter within a timeframe that does will not cause
  799  benefits to be withheld from an eligible enrollee.
  800         (10)(11) The following individuals may be subject to
  801  prosecution in accordance with s. 414.39:
  802         (a) An applicant obtaining or attempting to obtain benefits
  803  for a potential enrollee under the Florida Kidcare if program
  804  when the applicant knows or should have known the potential
  805  enrollee does not qualify for the Florida Kidcare program.
  806         (b) An individual who assists an applicant in obtaining or
  807  attempting to obtain benefits for a potential enrollee under the
  808  Florida Kidcare if program when the individual knows or should
  809  have known the potential enrollee does not qualify for the
  810  Florida Kidcare program.
  811         Section 8. Subsection (2) of section 409.815, Florida
  812  Statutes, is amended to read:
  813         409.815 Health benefits coverage; limitations.—
  814         (2) BENCHMARK BENEFITS.—In order for health benefits
  815  coverage to qualify for premium assistance payments for an
  816  eligible child under this part ss. 409.810-409.821, the health
  817  benefits coverage, except for coverage under Medicaid and
  818  Medikids, must include the following minimum benefits, as
  819  medically necessary.
  820         (a) Preventive health services.—Covered services include:
  821         1. Well-child care, including services recommended in the
  822  Guidelines for Health Supervision of Children and Youth as
  823  developed by the American Academy of Pediatrics;
  824         2. Immunizations and injections;
  825         3. Health education counseling and clinical services;
  826         4. Vision screening; and
  827         5. Hearing screening.
  828         (b) Inpatient hospital services.—All covered services
  829  provided for the medical care and treatment of an enrollee who
  830  is admitted as an inpatient to a hospital licensed under part I
  831  of chapter 395, with the following exceptions:
  832         1. All admissions must be authorized by the enrollee’s
  833  health benefits coverage provider.
  834         2. The length of the patient stay shall be determined based
  835  on the medical condition of the enrollee in relation to the
  836  necessary and appropriate level of care.
  837         3. Room and board may be limited to semiprivate
  838  accommodations, unless a private room is considered medically
  839  necessary or semiprivate accommodations are not available.
  840         4. Admissions for rehabilitation and physical therapy are
  841  limited to 15 days per contract year.
  842         (c) Emergency services.—Covered services include visits to
  843  an emergency room or other licensed facility if needed
  844  immediately due to an injury or illness and delay means risk of
  845  permanent damage to the enrollee’s health. Health maintenance
  846  organizations must shall comply with the provisions of s.
  847  641.513.
  848         (d) Maternity services.—Covered services include maternity
  849  and newborn care, including prenatal and postnatal care, with
  850  the following limitations:
  851         1. Coverage may be limited to the fee for vaginal
  852  deliveries; and
  853         2. Initial inpatient care for newborn infants of enrolled
  854  adolescents is shall be covered, including normal newborn care,
  855  nursery charges, and the initial pediatric or neonatal
  856  examination, and the infant may be covered for up to 3 days
  857  following birth.
  858         (e) Organ transplantation services.—Covered services
  859  include pretransplant, transplant, and postdischarge services
  860  and treatment of complications after transplantation if for
  861  transplants deemed necessary and appropriate within the
  862  guidelines set by the Organ Transplant Advisory Council under s.
  863  765.53 or the Bone Marrow Transplant Advisory Panel under s.
  864  627.4236.
  865         (f)  Outpatient services.—Covered services include
  866  preventive, diagnostic, therapeutic, palliative care, and other
  867  services provided to an enrollee in the outpatient portion of a
  868  health facility licensed under chapter 395, except for the
  869  following limitations:
  870         1. Services must be authorized by the enrollee’s health
  871  benefits coverage provider; and
  872         2. Treatment for temporomandibular joint disease (TMJ) is
  873  specifically excluded.
  874         (g) Behavioral health services.—
  875         1. Mental health benefits include:
  876         a. Inpatient services, limited to 30 inpatient days per
  877  contract year for psychiatric admissions, or residential
  878  services in facilities licensed under s. 394.875(6) or s.
  879  395.003 in lieu of inpatient psychiatric admissions; however, a
  880  minimum of 10 of the 30 days shall be available only for
  881  inpatient psychiatric services if authorized by a physician; and
  882         b. Outpatient services, including outpatient visits for
  883  psychological or psychiatric evaluation, diagnosis, and
  884  treatment by a licensed mental health professional, limited to
  885  40 outpatient visits each contract year.
  886         2. Substance abuse services include:
  887         a. Inpatient services, limited to 7 inpatient days per
  888  contract year for medical detoxification only and 30 days of
  889  residential services; and
  890         b. Outpatient services, including evaluation, diagnosis,
  891  and treatment by a licensed practitioner, limited to 40
  892  outpatient visits per contract year.
  893  
  894  Effective October 1, 2009, Covered services include inpatient
  895  and outpatient services for mental and nervous disorders as
  896  defined in the most recent edition of the Diagnostic and
  897  Statistical Manual of Mental Disorders published by the American
  898  Psychiatric Association. Such benefits include psychological or
  899  psychiatric evaluation, diagnosis, and treatment by a licensed
  900  mental health professional and inpatient, outpatient, and
  901  residential treatment of substance abuse disorders. Any benefit
  902  limitations, including duration of services, number of visits,
  903  or number of days for hospitalization or residential services,
  904  may shall not be any less favorable than those for physical
  905  illnesses generally. The program may also implement appropriate
  906  financial incentives, peer review, utilization requirements, and
  907  other methods used for the management of benefits provided for
  908  other medical conditions in order to reduce service costs and
  909  utilization without compromising quality of care.
  910         (h) Durable medical equipment.—Covered services include
  911  equipment and devices that are medically indicated to assist in
  912  the treatment of a medical condition and specifically prescribed
  913  as medically necessary, with the following limitations:
  914         1. Low-vision and telescopic aids aides are not included.
  915         2. Corrective lenses and frames may be limited to one pair
  916  every 2 years, unless the prescription or head size of the
  917  enrollee changes.
  918         3. Hearing aids are shall be covered only if when medically
  919  indicated to assist in the treatment of a medical condition.
  920         4. Covered prosthetic devices include artificial eyes and
  921  limbs, braces, and other artificial aids.
  922         (i) Health practitioner services.—Covered services include
  923  services and procedures rendered to an enrollee if when
  924  performed to diagnose and treat diseases, injuries, or other
  925  conditions, including care rendered by health practitioners
  926  acting within the scope of their practice, with the following
  927  exceptions:
  928         1. Chiropractic services shall be provided in the same
  929  manner as under in the Florida Medicaid program.
  930         2. Podiatric services may be limited to one visit per day
  931  totaling two visits per month for specific foot disorders.
  932         (j) Home health services.—Covered services include
  933  prescribed home visits by both registered and licensed practical
  934  nurses to provide skilled nursing services on a part-time
  935  intermittent basis, subject to the following limitations:
  936         1. Coverage may be limited to include skilled nursing
  937  services only;
  938         2. Meals, housekeeping, and personal comfort items may be
  939  excluded; and
  940         3. Private duty nursing is limited to circumstances where
  941  such care is medically necessary.
  942         (k) Hospice services.—Covered services include reasonable
  943  and necessary services for palliation or management of an
  944  enrollee’s terminal illness, with the following exceptions:
  945         1. Once a family elects to receive hospice care for an
  946  enrollee, other services that treat the terminal condition will
  947  not be covered; and
  948         2. Services required for conditions totally unrelated to
  949  the terminal condition are covered to the extent that the
  950  services are included in this section.
  951         (l) Laboratory and X-ray services.—Covered services include
  952  diagnostic testing, including clinical radiologic, laboratory,
  953  and other diagnostic tests.
  954         (m)  Nursing facility services.—Covered services include
  955  regular nursing services, rehabilitation services, drugs and
  956  biologicals, medical supplies, and the use of appliances and
  957  equipment furnished by the facility, with the following
  958  limitations:
  959         1. All admissions must be authorized by the health benefits
  960  coverage provider.
  961         2. The length of the patient stay shall be determined based
  962  on the medical condition of the enrollee in relation to the
  963  necessary and appropriate level of care, but is limited to not
  964  more than 100 days per contract year.
  965         3. Room and board may be limited to semiprivate
  966  accommodations, unless a private room is considered medically
  967  necessary or semiprivate accommodations are not available.
  968         4. Specialized treatment centers and independent kidney
  969  disease treatment centers are excluded.
  970         5. Private duty nurses, television, and custodial care are
  971  excluded.
  972         6. Admissions for rehabilitation and physical therapy are
  973  limited to 15 days per contract year.
  974         (n) Prescribed drugs.—
  975         1. Coverage includes shall include drugs prescribed for the
  976  treatment of illness or injury if when prescribed by a licensed
  977  health practitioner acting within the scope of his or her
  978  practice.
  979         2. Prescribed drugs may be limited to generics if available
  980  and brand name products if a generic substitution is not
  981  available, unless the prescribing licensed health practitioner
  982  indicates that a brand name is medically necessary.
  983         3. Prescribed drugs covered under this section shall
  984  include all prescribed drugs covered under the Florida Medicaid
  985  program.
  986         (o) Therapy services.—Covered services include
  987  rehabilitative services, including occupational, physical,
  988  respiratory, and speech therapies, with the following
  989  limitations:
  990         1. Services must be for short-term rehabilitation where
  991  significant improvement in the enrollee’s condition will result;
  992  and
  993         2. Services are shall be limited to not more than 24
  994  treatment sessions within a 60-day period per episode or injury,
  995  with the 60-day period beginning with the first treatment.
  996         (p) Transportation services.—Covered services include
  997  emergency transportation required in response to an emergency
  998  situation.
  999         (q) Dental services.Effective October 1, 2009, Dental
 1000  services are shall be covered as required under federal law and
 1001  may also include those dental benefits provided to children by
 1002  the Florida Medicaid program under s. 409.906(6).
 1003         (r) Lifetime maximum.—Health benefits coverage obtained
 1004  under this part ss. 409.810-409.820 shall pay an enrollee’s
 1005  covered expenses at a lifetime maximum of $1 million per covered
 1006  child.
 1007         (s) Cost sharing.—Cost-sharing provisions must comply with
 1008  s. 409.816.
 1009         (t) Exclusions.—
 1010         1. Experimental or investigational procedures that have not
 1011  been clinically proven by reliable evidence are excluded;
 1012         2. Services performed for cosmetic purposes only or for the
 1013  convenience of the enrollee are excluded; and
 1014         3. Abortion may be covered only if necessary to save the
 1015  life of the mother or if the pregnancy is the result of an act
 1016  of rape or incest.
 1017         (u) Enhancements to minimum requirements.—
 1018         1. This section sets the minimum benefits that must be
 1019  included in any health benefits coverage, other than Medicaid or
 1020  Medikids coverage, offered under this part ss. 409.810-409.821.
 1021  Health benefits coverage may include additional benefits not
 1022  included under this subsection, but may not include benefits
 1023  excluded under paragraph (s).
 1024         2. Health benefits coverage may extend any limitations
 1025  beyond the minimum benefits described in this section.
 1026  
 1027  Except for the Children’s Medical Services Network, the agency
 1028  may not increase the premium assistance payment for either
 1029  additional benefits provided beyond the minimum benefits
 1030  described in this section or the imposition of less restrictive
 1031  service limitations.
 1032         (v) Applicability of other state laws.—Health insurers,
 1033  health maintenance organizations, and their agents are subject
 1034  to the provisions of the Florida Insurance Code, except for any
 1035  such provisions waived under in this section.
 1036         1. Except as expressly provided in this section, a law
 1037  requiring coverage for a specific health care service or
 1038  benefit, or a law requiring reimbursement, utilization, or
 1039  consideration of a specific category of licensed health care
 1040  practitioner, does not apply to a health insurance plan policy
 1041  or contract offered or delivered under this part ss. 409.810
 1042  409.821 unless that law is made expressly applicable to such
 1043  policies or contracts.
 1044         2. Notwithstanding chapter 641, a health maintenance
 1045  organization may issue contracts providing benefits equal to,
 1046  exceeding, or actuarially equivalent to the benchmark benefit
 1047  plan authorized by this section and may pay providers located in
 1048  a rural county negotiated fees or Medicaid reimbursement rates
 1049  for services provided to enrollees who are residents of the
 1050  rural county.
 1051         (w) Reimbursement of federally qualified health centers and
 1052  rural health clinics.Effective October 1, 2009, Payments for
 1053  services provided to enrollees by federally qualified health
 1054  centers and rural health clinics under this section shall be
 1055  reimbursed using the Medicaid Prospective Payment System as
 1056  provided for under s. 2107(e)(1)(D) of the Social Security Act.
 1057  If such services are paid for by health insurers or health care
 1058  providers under contract with the Florida Healthy Kids
 1059  corporation, such entities are responsible for this payment. The
 1060  agency may seek any available federal grants to assist with this
 1061  transition.
 1062         Section 9. Section 409.816, Florida Statutes, is amended to
 1063  read:
 1064         409.816 Limitations on premiums and cost sharing.—The
 1065  following limitations on premiums and cost sharing are
 1066  established for the program.
 1067         (1) Enrollees who receive coverage under the Medicaid
 1068  program may not be required to pay:
 1069         (a) Enrollment fees, premiums, or similar charges; or
 1070         (b) Copayments, deductibles, coinsurance, or similar
 1071  charges.
 1072         (2) Enrollees in households that have families with a
 1073  modified adjusted gross family income equal to or below 150
 1074  percent of the federal poverty level, who are not receiving
 1075  coverage under the Medicaid program, are may not be required to
 1076  pay:
 1077         (a) Enrollment fees, premiums, or similar charges that
 1078  exceed the maximum monthly charge permitted under s. 1916(b)(1)
 1079  of the Social Security Act; or
 1080         (b) Copayments, deductibles, coinsurance, or similar
 1081  charges that exceed a nominal amount, as determined consistent
 1082  with regulations referred to in s. 1916(a)(3) of the Social
 1083  Security Act. However, such charges may not be imposed for
 1084  preventive services, including well-baby and well-child care,
 1085  age-appropriate immunizations, and routine hearing and vision
 1086  screenings.
 1087         (3) Enrollees in households that have families with a
 1088  modified adjusted gross family income above 150 percent of the
 1089  federal poverty level who are not receiving coverage under the
 1090  Medicaid program or who are not eligible under s. 409.814(5) s.
 1091  409.814(6) may be required to pay enrollment fees, premiums,
 1092  copayments, deductibles, coinsurance, or similar charges on a
 1093  sliding scale related to income, except that the total annual
 1094  aggregate cost sharing with respect to all children in a
 1095  household family may not exceed 5 percent of the household’s
 1096  modified adjusted family’s income. However, copayments,
 1097  deductibles, coinsurance, or similar charges may not be imposed
 1098  for preventive services, including well-baby and well-child
 1099  care, age-appropriate immunizations, and routine hearing and
 1100  vision screenings.
 1101         Section 10. Section 409.817, Florida Statutes, is repealed.
 1102         Section 11. Section 409.8175, Florida Statutes, is
 1103  repealed.
 1104         Section 12. Subsection (1) of section 409.8177, Florida
 1105  Statutes, is amended to read:
 1106         409.8177 Program evaluation.—
 1107         (1) The agency, in consultation with the Department of
 1108  Health, the Department of Children and Families Family Services,
 1109  and the Florida Healthy Kids corporation, shall contract for an
 1110  evaluation of the Florida Kidcare program and shall by January 1
 1111  of each year submit to the Governor, the President of the
 1112  Senate, and the Speaker of the House of Representatives a report
 1113  of the program. In addition to the items specified under s. 2108
 1114  of Title XXI of the Social Security Act, the report shall
 1115  include an assessment of crowd-out and access to health care, as
 1116  well as the following:
 1117         (a) An assessment of the operation of the program,
 1118  including the progress made in reducing the number of uncovered
 1119  low-income children.
 1120         (b) An assessment of the effectiveness in increasing the
 1121  number of children with creditable health coverage, including an
 1122  assessment of the impact of outreach.
 1123         (c) The characteristics of the children and families
 1124  assisted under the program, including ages of the children,
 1125  household family income, and access to or coverage by other
 1126  health insurance before enrolling in prior to the program and
 1127  after disenrollment from the program.
 1128         (d) The quality of health coverage provided, including the
 1129  types of benefits provided.
 1130         (e) The amount and level, including payment of part or all
 1131  of any premium, of assistance provided.
 1132         (f) The average length of coverage of a child under the
 1133  program.
 1134         (g) The program’s choice of health benefits coverage and
 1135  other methods used for providing child health assistance.
 1136         (h) The sources of nonfederal funding used in the program.
 1137         (i) An assessment of the effectiveness of the Florida
 1138  Kidcare program, including Medicaid, the Florida Healthy Kids
 1139  program, Medikids, and the Children’s Medical Services Network,
 1140  and other public and private programs in the state in increasing
 1141  the availability of affordable quality health insurance and
 1142  health care for children.
 1143         (j) A review and assessment of state activities to
 1144  coordinate the program with other public and private programs.
 1145         (k) An analysis of changes and trends in the state that
 1146  affect the provision of health insurance and health care to
 1147  children.
 1148         (l) A description of any plans the state has for improving
 1149  the availability of health insurance and health care for
 1150  children.
 1151         (m) Recommendations for improving the program.
 1152         (n) Other studies as necessary.
 1153         Section 13. Section 409.818, Florida Statutes, is amended
 1154  to read:
 1155         409.818 Administration.—In order to administer this part
 1156  implement ss. 409.810-409.821, the following agencies shall have
 1157  the following duties:
 1158         (1) The Department of Children and Families Family Services
 1159  shall:
 1160         (a) Maintain Develop a simplified eligibility determination
 1161  and renewal process application mail-in form to be used for
 1162  determining the eligibility of children for coverage under the
 1163  Florida Kidcare program, in consultation with the agency, the
 1164  Department of Health, and the Florida Healthy Kids corporation.
 1165  The simplified eligibility process application form must include
 1166  an item that provides an opportunity for the applicant to
 1167  indicate whether coverage is being sought for a child with
 1168  special health care needs. Families applying for children’s
 1169  Medicaid coverage must also be able to use the simplified
 1170  application process form without having to pay a premium.
 1171         (b) Establish and maintain the eligibility determination
 1172  process under the program except as specified in subsection (3),
 1173  which includes the following: (5).
 1174         1. The department shall directly, or through the services
 1175  of a contracted third-party administrator, establish and
 1176  maintain a process to be for determining eligibility of children
 1177  for coverage under the program. The eligibility determination
 1178  process must be used solely for determining the eligibility of
 1179  applicants for health benefits coverage under the program. The
 1180  eligibility determination process must include an initial
 1181  determination of eligibility for any coverage offered under the
 1182  program, as well as a redetermination or reverification of
 1183  eligibility each subsequent 6 months. Effective January 1, 1999,
 1184  A child who has not attained the age of 5 years of age and who
 1185  has been determined eligible for the Medicaid program is
 1186  eligible for coverage for 12 months without a redetermination or
 1187  reverification of eligibility. In conducting an eligibility
 1188  determination, the department shall determine if the child has
 1189  special health care needs.
 1190         2. The department, in consultation with the agency for
 1191  Health Care Administration and the Florida Healthy Kids
 1192  corporation, shall develop procedures for redetermining
 1193  eligibility which enable applicants and enrollees a family to
 1194  easily update any change in circumstances which could affect
 1195  eligibility.
 1196         3. The department may accept changes in a family’s status
 1197  as reported to the department by the Florida Healthy Kids
 1198  corporation or the exchange as defined under the Patient
 1199  Protection and Affordable Care Act without requiring a new
 1200  application from the family. Redetermination of a child’s
 1201  eligibility for Medicaid may not be linked to a child’s
 1202  eligibility determination for other programs.
 1203         4. The department, in consultation with the agency and the
 1204  corporation, shall develop a combined eligibility notice to
 1205  inform applicants or enrollees of their application or renewal
 1206  status, as appropriate. By January 1, 2015, the content of the
 1207  notice must be coordinated to meet all federal and state law and
 1208  regulatory requirements under the federal Patient Protection and
 1209  Affordable Care Act. The notice shall be issued by the last
 1210  agency or department to make an eligibility, renewal, or denial
 1211  determination.
 1212         (c) Inform program applicants about eligibility
 1213  determinations and provide information about eligibility of
 1214  applicants to the Florida Kidcare program and to insurers and
 1215  their agents, through a centralized coordinating office.
 1216         (d) Adopt rules necessary for conducting program
 1217  eligibility functions.
 1218         (2) The Department of Health shall:
 1219         (a) Design an eligibility intake process for the program,
 1220  in coordination with the Department of Children and Family
 1221  Services, the agency, and the Florida Healthy Kids Corporation.
 1222  The eligibility intake process may include local intake points
 1223  that are determined by the Department of Health in coordination
 1224  with the Department of Children and Family Services.
 1225         (b) Chair a state-level Florida Kidcare coordinating
 1226  council to review and make recommendations concerning the
 1227  implementation and operation of the program. The coordinating
 1228  council shall include representatives from the department, the
 1229  Department of Children and Family Services, the agency, the
 1230  Florida Healthy Kids Corporation, the Office of Insurance
 1231  Regulation of the Financial Services Commission, local
 1232  government, health insurers, health maintenance organizations,
 1233  health care providers, families participating in the program,
 1234  and organizations representing low-income families.
 1235         (c) In consultation with the Florida Healthy Kids
 1236  Corporation and the Department of Children and Family Services,
 1237  establish a toll-free telephone line to assist families with
 1238  questions about the program.
 1239         (d) Adopt rules necessary to implement outreach activities.
 1240         (2)(3)Pursuant to The agency for Health Care
 1241  Administration, under the authority granted in s. 409.914(1),
 1242  the agency shall:
 1243         (a) Calculate the premium assistance payment necessary to
 1244  comply with the premium and cost-sharing limitations specified
 1245  in s. 409.816 and the Patient Protection and Affordable Care
 1246  Act. The premium assistance payment for each enrollee in a
 1247  health insurance plan participating in the Florida Healthy Kids
 1248  corporation must shall equal the premium approved by the Florida
 1249  Healthy Kids corporation and the Office of Insurance Regulation
 1250  of the Financial Services Commission pursuant to ss. 627.410 and
 1251  641.31, less any enrollee’s share of the premium established
 1252  within the limitations specified in s. 409.816. The premium
 1253  assistance payment for each enrollee in an employer-sponsored
 1254  health insurance plan approved under ss. 409.810-409.821 shall
 1255  equal the premium for the plan adjusted for any benchmark
 1256  benefit plan actuarial equivalent benefit rider approved by the
 1257  Office of Insurance Regulation pursuant to ss. 627.410 and
 1258  641.31, less any enrollee’s share of the premium established
 1259  within the limitations specified in s. 409.816. In calculating
 1260  the premium assistance payment levels for children with family
 1261  coverage, the agency shall set the premium assistance payment
 1262  levels for each child proportionately to the total cost of
 1263  family coverage.
 1264         (b) Make premium assistance payments to health insurance
 1265  plans on a periodic basis. The agency may use its Medicaid
 1266  fiscal agent or a contracted third-party administrator in making
 1267  these payments. The agency may require health insurance plans
 1268  that participate in the Medikids program or employer-sponsored
 1269  group health insurance to collect premium payments from an
 1270  enrollee’s family. Participating health insurance plans shall
 1271  report premium payments collected on behalf of enrollees in the
 1272  program to the agency in accordance with a schedule established
 1273  by the agency.
 1274         (c) Monitor compliance with quality assurance and access
 1275  standards developed under s. 409.820 and in accordance with s.
 1276  2103(f) of the Social Security Act, 42 U.S.C. s. 1397cc(f).
 1277         (d) Establish a mechanism for investigating and resolving
 1278  complaints and grievances from program applicants, enrollees,
 1279  and health benefits coverage providers, and maintain a record of
 1280  complaints and confirmed problems. In the case of a child who is
 1281  enrolled in a managed care health maintenance organization, the
 1282  agency must use the provisions of s. 641.511 to address
 1283  grievance reporting and resolution requirements.
 1284         (e) Approve health benefits coverage for participation in
 1285  the program, following certification by the Office of Insurance
 1286  Regulation under subsection (4).
 1287         (e)(f) Adopt rules necessary for calculating premium
 1288  assistance payment levels, making premium assistance payments,
 1289  monitoring access and quality assurance standards and,
 1290  investigating and resolving complaints and grievances,
 1291  administering the Medikids program, and approving health
 1292  benefits coverage.
 1293         (f) Contract with the corporation for the administration of
 1294  Florida Kidcare and Healthy Florida and to facilitate the
 1295  release of any federal and state funds.
 1296  
 1297  The agency is designated the lead state agency for CHIP Title
 1298  XXI of the Social Security Act for purposes of receipt of
 1299  federal funds, for reporting purposes, and for ensuring
 1300  compliance with federal and state regulations and rules.
 1301         (4) The Office of Insurance Regulation shall certify that
 1302  health benefits coverage plans that seek to provide services
 1303  under the Florida Kidcare program, except those offered through
 1304  the Florida Healthy Kids Corporation or the Children’s Medical
 1305  Services Network, meet, exceed, or are actuarially equivalent to
 1306  the benchmark benefit plan and that health insurance plans will
 1307  be offered at an approved rate. In determining actuarial
 1308  equivalence of benefits coverage, the Office of Insurance
 1309  Regulation and health insurance plans must comply with the
 1310  requirements of s. 2103 of Title XXI of the Social Security Act.
 1311  The department shall adopt rules necessary for certifying health
 1312  benefits coverage plans.
 1313         (3)(5) The Florida Healthy Kids corporation shall retain
 1314  its functions as authorized under s. 409.8125 in s. 624.91,
 1315  including eligibility determination for participation in the
 1316  Healthy Kids program.
 1317         (4)(6) The agency, the Department of Health, the Department
 1318  of Children and Families Family Services, and the Florida
 1319  Healthy Kids corporation, and the Office of Insurance
 1320  Regulation, after consultation with and approval of the Speaker
 1321  of the House of Representatives and the President of the Senate,
 1322  may are authorized to make program modifications that are
 1323  necessary to overcome any objections of the United States
 1324  Department of Health and Human Services to obtain approval of
 1325  the state’s CHIP child health insurance plan under Title XXI of
 1326  the Social Security Act.
 1327         Section 14. Section 409.820, Florida Statutes, is amended
 1328  to read:
 1329         409.820 Quality assurance and access standards.—Except for
 1330  Medicaid, the Department of Health, in consultation with the
 1331  agency and the Florida Healthy Kids corporation, shall develop a
 1332  minimum set of pediatric and adolescent quality assurance and
 1333  access standards for all program components. The standards must
 1334  include a process for granting exceptions to specific
 1335  requirements for quality assurance and access. Compliance with
 1336  the standards shall be a condition of program participation by
 1337  health benefits coverage providers. These standards must shall
 1338  comply with the provisions of this chapter, and chapter 641, and
 1339  Title XXI of the Social Security Act.
 1340         Section 15. Section 409.822, Florida Statutes, is created
 1341  to read:
 1342         409.822Healthy Florida.—
 1343         (1) PROGRAM CREATION.—Healthy Florida, a health care
 1344  program for lower income, uninsured adults who meet the
 1345  eligibility guidelines established under s. 409.8125, is
 1346  created. The corporation shall administer the program under its
 1347  existing corporate governance and structure.
 1348         (2) ELIGIBILITY.—To be eligible and to remain eligible for
 1349  Healthy Florida, an individual must be a resident of this state
 1350  and meet the following additional criteria:
 1351         (a) Be identified as newly eligible, as defined in s.
 1352  1902(a)(10)(A)(i)(VIII) of the Social Security Act or s. 2001 of
 1353  the federal Patient Protection and Affordable Care Act, and as
 1354  may be further defined by federal regulation.
 1355         (b) Maintain eligibility with the corporation and meet all
 1356  renewal requirements as established by the corporation.
 1357         (c) Renew eligibility on at least an annual basis.
 1358         (3) ENROLLMENT.—The corporation may begin the enrollment of
 1359  applicants in Healthy Florida on October 1, 2014. Enrollment may
 1360  occur directly, through the services of a third-party
 1361  administrator, referrals from the Department of Children and
 1362  Families, and the exchange as defined by the federal Patient
 1363  Protection and Affordable Care Act. When an enrollee disenrolls,
 1364  the corporation must provide him or her with information about
 1365  other affordable insurance programs and electronically refer the
 1366  enrollee to the exchange or other programs, as appropriate. The
 1367  earliest coverage effective date under the program shall be
 1368  January 1, 2015.
 1369         (4) DELIVERY OF SERVICES.—The corporation shall contract
 1370  with authorized insurers licensed under chapter 627; managed
 1371  care organizations authorized under chapter 641; and provider
 1372  service networks authorized under ss. 409.912(4)(d) and
 1373  409.962(13) which are prepaid plans. These insurers, managed
 1374  care organizations, and provider service networks must meet
 1375  standards established by the corporation to provide
 1376  comprehensive health care services to enrollees who qualify for
 1377  services under this section. The corporation may contract for
 1378  such services on a statewide or regional basis. To encourage
 1379  continuity of care among enrollees who transition across
 1380  multiple affordable insurance programs, the corporation is
 1381  encouraged to contract with those insurers and managed care
 1382  organizations that participate in more than one such program.
 1383         (a) The corporation shall establish access and network
 1384  standards for such contracts and ensure that contracted
 1385  providers have sufficient providers to meet enrollee needs.
 1386  Quality standards shall be developed by the corporation,
 1387  specific to the adult population, which take into consideration
 1388  recommendations from the National Committee on Quality
 1389  Assurance, stakeholders, and other existing performance
 1390  indicators from both public and commercial populations. The
 1391  corporation and its contracted health plans shall develop
 1392  policies that minimize the disruption of enrollee medical homes
 1393  when enrollees transition between affordable insurance plans.
 1394         (b) The corporation shall provide an enrollee a choice of
 1395  plans. The corporation may select a plan if no selection has
 1396  been received before the coverage start date. Once enrolled, an
 1397  enrollee has an initial 90-day, free-look period before a lock
 1398  in period of up to 12 months is applied. Exceptions to the lock
 1399  in period must be offered to an enrollee for reasons based on
 1400  good cause or qualifying events.
 1401         (c) The corporation may consider contracts that provide
 1402  family plans that would allow members from multiple state and
 1403  federally funded programs to remain together under the same
 1404  plan.
 1405         (d) All contracts must meet the medical loss ratio
 1406  requirements under this part.
 1407         (5) BENEFITS.—The corporation shall establish a benefits
 1408  package that is actuarially equivalent to the benchmark benefit
 1409  plan offered under s. 409.815(2), excluding dental, and meets
 1410  the alternative benefits package requirements under s. 1937 of
 1411  the Social Security Act. Benefits must be offered as an
 1412  integrated, single package.
 1413         (a) In addition to benchmark benefits, health reimbursement
 1414  accounts or a comparable health savings account for each
 1415  enrollee must be established through the corporation or the
 1416  contracts managed by the corporation. Enrollees must be rewarded
 1417  for healthy behaviors, wellness program adherence, and other
 1418  activities established by the corporation which demonstrate
 1419  compliance with preventive care or disease management
 1420  guidelines. Funds deposited into these accounts may be used to
 1421  pay cost-sharing obligations or to purchase over-the-counter
 1422  health items to the extent allowed under federal law or
 1423  regulation.
 1424         (b) Enhanced services may be offered if the cost of such
 1425  additional services provides savings to the overall plan.
 1426         (c) The corporation shall establish a process for the
 1427  payment of wrap-around services not covered by the benchmark
 1428  benefit plan through a separate subcapitation process to its
 1429  contracted providers if it is determined that such services are
 1430  required by federal law. Such services would be covered if
 1431  deemed medically necessary on an individual basis. The
 1432  subcapitation pool is subject to a separate reconciliation
 1433  process under the medical loss ratio provisions in this part.
 1434         (d) A prior authorization process and other utilization
 1435  controls may be established by the plan for any benefit if
 1436  approved by the corporation.
 1437         (6) COST SHARING.—The corporation may collect premiums and
 1438  copayments from enrollees in accordance with federal law.
 1439  Amounts to be collected for Healthy Florida must be established
 1440  annually in the General Appropriations Act.
 1441         (a) Payment of a monthly premium may be required before the
 1442  establishment of an enrollee’s coverage start date and to retain
 1443  monthly coverage.
 1444         (b) An enrollee who has a family income above the federal
 1445  poverty level may be required to make nominal copayments, in
 1446  accordance with federal rule, as a condition of receiving a
 1447  health care service.
 1448         (c) A provider is responsible for the collection of point
 1449  of-service cost-sharing obligations. The enrollee’s cost-sharing
 1450  contribution is considered part of the provider’s total
 1451  reimbursement. Failure to collect an enrollee’s cost sharing
 1452  reduces the provider’s share of the reimbursement.
 1453         (7) PROGRAM MANAGEMENT.—The corporation is responsible for
 1454  the oversight of Healthy Florida. The agency shall seek a state
 1455  plan amendment or other appropriate federal approval to
 1456  implement Healthy Florida. The agency shall consult with the
 1457  corporation in the amendment’s development and, by June 14,
 1458  2014, submit the state plan amendment to the federal Department
 1459  of Health and Human Services. The agency shall contract with the
 1460  corporation for the administration of Healthy Florida and for
 1461  the timely release of federal and state funds. The agency
 1462  retains its authority as provided in ss. 409.902 and 409.963.
 1463         (a) The corporation shall establish a grievance resolution
 1464  process in which Healthy Florida enrollees are informed of their
 1465  rights under the Medicaid fair hearing process, as appropriate,
 1466  or any alternative resolution process adopted by the
 1467  corporation.
 1468         (b) The corporation shall establish a program integrity
 1469  process to ensure compliance with program guidelines. At a
 1470  minimum, the corporation shall withhold benefits from an
 1471  applicant or enrollee if the corporation obtains evidence that
 1472  the applicant or enrollee is no longer eligible, submitted
 1473  incorrect or fraudulent information in order to establish
 1474  eligibility, or failed to provide verification of eligibility.
 1475  The corporation shall notify the applicant or enrollee that,
 1476  because of such evidence, program benefits must be withheld
 1477  unless the applicant or enrollee contacts a designated
 1478  representative of the corporation by a specified date, which
 1479  must be within 10 working days after the date of notice, to
 1480  discuss and resolve the matter. The corporation shall make every
 1481  effort to resolve the matter within a timeframe that does not
 1482  cause benefits to be withheld from an eligible enrollee. The
 1483  following individuals may be subject to specific prosecution in
 1484  accordance with s. 414.39:
 1485         1. An applicant who obtains or attempts to obtain benefits
 1486  for a potential enrollee under Healthy Florida when the
 1487  applicant knows or should have known that the potential enrollee
 1488  does not qualify for Healthy Florida.
 1489         2. An individual who assists an applicant in obtaining or
 1490  attempting to obtain benefits for a potential enrollee under
 1491  Healthy Florida when the individual knows or should have known
 1492  that the potential enrollee does not qualify for Healthy
 1493  Florida.
 1494         (8) APPLICABILITY OF LAWS RELATING TO MEDICAID.—Sections
 1495  409.902, 409.9128, and 409.920 apply to the administration of
 1496  Healthy Florida.
 1497         (9) PROGRAM EVALUATION.—The corporation shall collect both
 1498  eligibility and enrollment data from program applicants and
 1499  enrollees as well as encounter and utilization data from all
 1500  contracted entities during the program term. The corporation
 1501  shall submit monthly enrollment reports to the President of the
 1502  Senate, the Speaker of the House of Representatives, and the
 1503  Minority Leaders of the Senate and the House of Representatives.
 1504  The corporation shall submit an interim independent evaluation
 1505  of Healthy Florida to the presiding officers by July 1, 2016,
 1506  with annual evaluations due July 1 thereafter. The evaluations
 1507  must address, at a minimum, application and enrollment trends
 1508  and issues, utilization and cost data, and customer
 1509  satisfaction.
 1510         (10) PROGRAM EXPIRATION.—The Healthy Florida program
 1511  expires at the end of the state fiscal year in which any of
 1512  these conditions occur:
 1513         (a) The federal match contribution falls below 90 percent.
 1514         (b) The federal match contribution falls below the
 1515  increased federal medical assistance percentages for medical
 1516  assistance for newly eligible mandatory individuals as specified
 1517  in the Patient Protection and Affordable Care Act.
 1518         (c) The federal match for the Healthy Florida program and
 1519  the Medicaid program are blended under federal law or regulation
 1520  in a way that causes the overall federal contribution to
 1521  diminish when compared to separate, nonblended federal
 1522  contributions.
 1523         Section 16. The Florida Healthy Kids Corporation may make
 1524  such changes as are necessary to comply with the objections of
 1525  the federal Department of Health and Human Services in order to
 1526  gain approval of the Healthy Florida program in compliance with
 1527  the federal Patient Protection and Affordable Care Act, Pub. L.
 1528  No. 111-148, as amended by the federal Health Care and Education
 1529  Reconciliation Act of 2010, Pub. L. No. 111-152, upon giving
 1530  notice to the Senate and the House of Representatives of the
 1531  proposed changes. If there is a conflict between this section
 1532  and the federal Patient Protection and Affordable Care Act, the
 1533  provision must be interpreted and applied so as to comply with
 1534  federal law.
 1535         Section 17. Paragraph (e) of subsection (2) of section
 1536  154.503, Florida Statutes, is amended to read:
 1537         154.503 Primary Care for Children and Families Challenge
 1538  Grant Program; creation; administration.—
 1539         (2) The department shall:
 1540         (e) Coordinate with the primary care program developed
 1541  pursuant to s. 154.011, the Florida Healthy Kids Corporation
 1542  program created in s. 409.8125 s. 624.91, the school health
 1543  services program created in ss. 381.0056 and 381.0057, and the
 1544  volunteer health care provider program developed pursuant to s.
 1545  766.1115.
 1546         Section 18. Paragraph (d) of subsection (14) of section
 1547  408.910, Florida Statutes, is amended to read:
 1548         408.910 Florida Health Choices Program.—
 1549         (14) EXEMPTION FROM PUBLIC RECORDS REQUIREMENTS.—
 1550         (d) Authorized release.—
 1551         1. Upon request, information made confidential and exempt
 1552  pursuant to this subsection shall be disclosed to:
 1553         a. Another governmental entity in the performance of its
 1554  official duties and responsibilities.
 1555         b. Any person who has the written consent of the program
 1556  applicant.
 1557         c. The Florida Kidcare program for the purpose of
 1558  administering the program authorized under part II of chapter
 1559  409 in ss. 409.810-409.821.
 1560         2. Paragraph (b) does not prohibit a participant’s legal
 1561  guardian from obtaining confirmation of coverage, dates of
 1562  coverage, the name of the participant’s health plan, and the
 1563  amount of premium being paid.
 1564         Section 19. Paragraph (c) of subsection (4) of section
 1565  408.915, Florida Statutes, is amended to read:
 1566         408.915 Eligibility pilot project.—The Agency for Health
 1567  Care Administration, in consultation with the steering committee
 1568  established in s. 408.916, shall develop and implement a pilot
 1569  project to integrate the determination of eligibility for health
 1570  care services with information and referral services.
 1571         (4) The pilot project shall include eligibility
 1572  determinations for the following programs:
 1573         (c) Florida Healthy Kids as described in s. 409.8125 s.
 1574  624.91 and within eligibility guidelines provided in s. 409.814.
 1575         Section 20. Section 624.915, Florida Statutes, is repealed.
 1576         Section 21. Section 627.6474, Florida Statutes, is amended
 1577  to read:
 1578         627.6474 Provider contracts.—
 1579         (1) A health insurer may shall not require a contracted
 1580  health care practitioner as defined in s. 456.001(4) to accept
 1581  the terms of other health care practitioner contracts with the
 1582  insurer or any other insurer, or health maintenance
 1583  organization, under common management and control with the
 1584  insurer, including Medicare and Medicaid practitioner contracts
 1585  and those authorized by s. 627.6471, s. 627.6472, s. 636.035, or
 1586  s. 641.315, except for a practitioner in a group practice as
 1587  defined in s. 456.053 who must accept the terms of a contract
 1588  negotiated for the practitioner by the group, as a condition of
 1589  continuation or renewal of the contract. A Any contract
 1590  provision that violates this section is void. A violation of
 1591  this subsection section is not subject to the criminal penalty
 1592  specified in s. 624.15.
 1593         (2)A contract between a health insurer and a dentist
 1594  licensed under chapter 466 for the provision of services to an
 1595  insured may not:
 1596         (a) Contain a provision that requires the dentist to
 1597  provide services to the insured under such contract at a fee set
 1598  by the health insurer unless such services are covered services
 1599  under the applicable contract. Covered services are those
 1600  services that are listed as a benefit that the insured is
 1601  entitled to receive under the contract. An insurer may not
 1602  provide merely de minimis reimbursement or coverage in order to
 1603  avoid the requirements of this subsection. Fees for covered
 1604  services shall be set in good faith and may not be nominal.
 1605         (b) Require as a condition of the contract that the dentist
 1606  participate in a discount medical plan under part II of chapter
 1607  636.
 1608         Section 22. Subsection (13) is added to section 636.035,
 1609  Florida Statutes, to read:
 1610         636.035 Provider arrangements.—
 1611         (13)A contract between a prepaid limited health service
 1612  organization and a dentist licensed under chapter 466 for the
 1613  provision of services to a subscriber of the prepaid limited
 1614  health service organization may not:
 1615         (a) Contain a provision that requires the dentist to
 1616  provide services to the subscriber of the prepaid limited health
 1617  service organization at a fee set by the prepaid limited health
 1618  service organization unless such services are covered services
 1619  under the applicable contract. Covered services are those
 1620  services that are listed as a benefit that the subscriber is
 1621  entitled to receive under the contract. A prepaid limited health
 1622  service organization may not provide merely de minimis
 1623  reimbursement or coverage in order to avoid the requirements of
 1624  this subsection. Fees for covered services shall be set in good
 1625  faith and may not be nominal.
 1626         (b) Require as a condition of the contract that the dentist
 1627  participate in a discount medical plan under part II of this
 1628  chapter.
 1629         Section 23. Subsection (11) is added to section 641.315,
 1630  Florida Statutes, to read:
 1631         641.315 Provider contracts.—
 1632         (11)A contract between a health maintenance organization
 1633  and a dentist licensed under chapter 466 for the provision of
 1634  services to a subscriber of the health maintenance organization
 1635  may not:
 1636         (a) Contain a provision that requires the dentist to
 1637  provide services to the subscriber of the health maintenance
 1638  organization at a fee set by the health maintenance organization
 1639  unless such services are covered services under the applicable
 1640  contract. Covered services are those services that are listed as
 1641  a benefit that the subscriber is entitled to receive under the
 1642  contract. A health maintenance organization may not provide
 1643  merely de minimis reimbursement or coverage in order to avoid
 1644  the requirements of this subsection. Fees for covered services
 1645  shall be set in good faith and may not be nominal.
 1646         (b) Require as a condition of the contract that the dentist
 1647  participate in a discount medical plan under part II of chapter
 1648  636.
 1649         Section 24. Paragraph (a) of subsection (3) of section
 1650  766.1115, Florida Statutes, is amended, and paragraph (h) is
 1651  added to subsection (4) of that section, to read:
 1652         766.1115 Health care providers; creation of agency
 1653  relationship with governmental contractors.—
 1654         (3) DEFINITIONS.—As used in this section, the term:
 1655         (a) “Contract” means an agreement executed in compliance
 1656  with this section between a health care provider and a
 1657  governmental contractor which allows. This contract shall allow
 1658  the health care provider to deliver health care services to low
 1659  income recipients as an agent of the governmental contractor.
 1660  The contract must be for volunteer, uncompensated services. For
 1661  services to qualify as volunteer, uncompensated services under
 1662  this section, the health care provider may not must receive no
 1663  compensation from the governmental contractor for any services
 1664  provided under the contract and may must not bill or accept
 1665  compensation from the recipient, or a any public or private
 1666  third-party payor, for the specific services provided to the
 1667  low-income recipients covered by the contract.
 1668         (4) CONTRACT REQUIREMENTS.—A health care provider that
 1669  executes a contract with a governmental contractor to deliver
 1670  health care services on or after April 17, 1992, as an agent of
 1671  the governmental contractor is an agent for purposes of s.
 1672  768.28(9), while acting within the scope of duties under the
 1673  contract, if the contract complies with the requirements of this
 1674  section and regardless of whether the individual treated is
 1675  later found to be ineligible. A health care provider under
 1676  contract with the state may not be named as a defendant in any
 1677  action arising out of medical care or treatment provided on or
 1678  after April 17, 1992, under contracts entered into under this
 1679  section. The contract must provide that:
 1680         (h) As an agent of the governmental contractor for purposes
 1681  of s. 768.28(9), while acting within the scope of duties under
 1682  the contract, a health care provider licensed under chapter 466
 1683  may allow a patient or a parent or guardian of the patient to
 1684  voluntarily contribute a fee to cover costs of dental laboratory
 1685  work related to the services provided to the patient. This
 1686  contribution may not exceed the actual cost of the dental
 1687  laboratory charges and is deemed in compliance with this
 1688  section.
 1689  
 1690  A governmental contractor that is also a health care provider is
 1691  not required to enter into a contract under this section with
 1692  respect to the health care services delivered by its employees.
 1693         Section 25. The amendments to ss. 627.6474, 636.035, and
 1694  641.315, Florida Statutes, apply to contracts entered into or
 1695  renewed on or after July 1, 2014.
 1696         Section 26. (1) The sum of $1,258,054,808 from the Medical
 1697  Care Trust Fund is appropriated to the Agency for Health Care
 1698  Administration beginning in the 2014-2015 fiscal year to provide
 1699  coverage for individuals who enroll in the Healthy Florida
 1700  program.
 1701         (2) The sum of $254,151 from the General Revenue Fund and
 1702  $18,235,833 from the Medical Care Trust Fund is appropriated to
 1703  the Agency for Health Care Administration beginning in the 2014
 1704  2015 fiscal year to comply with federal regulations to
 1705  compensate insurers and managed care organizations that contract
 1706  with the Healthy Florida program for the imposition of the
 1707  annual fee on health insurance providers under s. 9010 of the
 1708  federal Patient Protection and Affordable Care Act, Pub. L. No.
 1709  111-148, as amended by the federal Health Care and Education
 1710  Reconciliation Act of 2010, Pub. L. No. 111-152.
 1711         (3) The sum of $10,676,377 from the General Revenue Fund
 1712  and $10,676,377 from the Medical Care Trust Fund is appropriated
 1713  beginning in the 2014-2015 fiscal year to the Agency for Health
 1714  Care Administration to contract with the Florida Healthy Kids
 1715  Corporation under s. 409.818(2)(f), Florida Statutes, to fund
 1716  the administrative costs of implementing and operating the
 1717  Healthy Florida program.
 1718         (4) The Agency for Health Care Administration may submit
 1719  budget amendments to the Legislative Budget Commission pursuant
 1720  to chapter 216, Florida Statutes, during the 2014-2015 fiscal
 1721  year to fund the Healthy Florida program for the coverage of
 1722  children who transfer from the Florida Kidcare program to the
 1723  Healthy Florida program, or to provide additional spending
 1724  authority from the Medical Care Trust Fund under subsection (1)
 1725  for the coverage of individuals who enroll in the Healthy
 1726  Florida program.
 1727         Section 27. This act shall take effect upon becoming a law.