Florida Senate - 2015 COMMITTEE AMENDMENT
Bill No. SPB 7044
Ì6875068Î687506
LEGISLATIVE ACTION
Senate . House
Comm: UNFAV .
03/10/2015 .
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The Committee on Health Policy (Sobel) recommended the
following:
1 Senate Amendment
2
3 Delete lines 92 - 549
4 and insert:
5 (3) “Corporation” means the Florida Healthy Kids
6 Corporation, as established under s. 624.91.
7 (4) “Enrollee” means an individual who has been determined
8 eligible for and is receiving health benefits coverage under
9 this part.
10 (5) “FHIX marketplace” or “marketplace” means the single,
11 centralized market established under s. 408.910 which
12 facilitates health benefits coverage.
13 (6) “Florida Health Insurance Affordability Exchange
14 Program” or “FHIX” means the program created under ss. 409.720
15 409.731.
16 (7) “Florida Healthy Kids Corporation” means the entity
17 created under s. 624.91.
18 (8) “Florida Kidcare program” or “Kidcare program” means
19 the health benefits coverage administered through ss. 409.810
20 409.821.
21 (9) “Health benefits coverage” means the payment of
22 benefits for covered health care services or the availability,
23 directly or through arrangements with other persons, of covered
24 health care services on a prepaid per capita basis or on a
25 prepaid aggregate fixed-sum basis.
26 (10) “Inactive status” means the enrollment status of a
27 participant previously enrolled in health benefits coverage
28 through the FIX marketplace who lost coverage through the
29 marketplace for non-payment, but maintains access to his or her
30 balance in a health savings account or health reimbursement
31 account.
32 (11) “Medicaid” means the medical assistance program
33 authorized by Title XIX of the Social Security Act, and
34 regulations thereunder, and part III and part IV of this
35 chapter, as administered in this state by the agency.
36 (l2) “Modified adjusted gross income” means the
37 individual’s or household’s annual adjusted gross income as
38 defined in s. 36B(d)(2) of the Internal Revenue Code of 1986 and
39 which is used to determine eligibility for FHIX.
40 (13) “Patient Protection and Affordable Care Act” or
41 “Affordable Care Act” means Pub. L. No. 111-148, as further
42 amended by the Health Care and Education Reconciliation Act of
43 2010, Pub. L. No. 111-152, and any amendments to, and
44 regulations or guidance under, those acts.
45 (14) “Premium credit” means the monthly amount paid by the
46 agency per enrollee in the Florida Health Insurance
47 Affordability Exchange Program toward health benefits coverage.
48 (15) “Qualified alien” means an alien as defined in 8
49 U.S.C. s. 1641(b) or (c).
50 (16) “Resident” means a United States citizen or qualified
51 alien who is domiciled in this state.
52 Section 5. Section 409.723, Florida Statutes, is created to
53 read:
54 409.723 Participation.—
55 (1) ELIGIBILITY.—In order to participate in FHIX, an
56 individual must be a resident and must meet the following
57 requirements, as applicable:
58 (a) Qualify as a newly eligible enrollee, who must be an
59 individual as described in s. 1902(a)(10)(A)(i)(VIII) of the
60 Social Security Act or s. 2001 of the Affordable Care Act and as
61 may be further defined by federal regulation.
62 (b) Meet and maintain the responsibilities under subsection
63 (4).
64 (c) Qualify as a participant in the Florida Healthy Kids
65 program under s. 624.91, subject to the implementation of Phase
66 Three under s. 409.727.
67 (2) ENROLLMENT.—To enroll in FHIX, an applicant must submit
68 an application to the department for an eligibility
69 determination.
70 (a) Applications may be submitted by mail, fax, online, or
71 any other method permitted by law or regulation.
72 (b) The department is responsible for any eligibility
73 correspondence and status updates to the participant and other
74 agencies.
75 (c) The department shall review a participant’s eligibility
76 every 12 months.
77 (d) An application or renewal is deemed complete when the
78 participant has met all the requirements under subsection (4).
79 (3) PARTICIPANT RIGHTS.—A participant has all of the
80 following rights:
81 (a) Access to the FHIX marketplace to select the scope,
82 amount, and type of health care coverage and other services to
83 purchase.
84 (b) Continuity and portability of coverage to avoid
85 disruption of coverage and other health care services when the
86 participant’s economic circumstances change.
87 (c) Retention of applicable unspent credits in the
88 participant’s health savings or health reimbursement account
89 following a change in the participant’s eligibility status.
90 Credits are valid for an inactive status participant for up to 5
91 years after the participant first enters an inactive status.
92 (d) Ability to select more than one product or plan on the
93 FHIX marketplace.
94 (e) Choice of at least two health benefits products that
95 meet the requirements of the Affordable Care Act.
96 (4) PARTICIPANT RESPONSIBILITIES.—A participant has all of
97 the following responsibilities:
98 (a) Complete an initial application for health benefits
99 coverage and an annual renewal process, which includes proof of
100 employment, on-the-job training or placement activities, or
101 pursuit of educational opportunities at the following hourly
102 levels:
103 1. For a parent of a child younger than 18 years of age, a
104 minimum of 20 hours weekly.
105 2. For a childless adult, a minimum of 30 hours weekly. A
106 disabled adult or caregiver of a disabled child or adult may
107 submit a request for an exception to these requirements to the
108 corporation. A participant shall annually submit to the
109 department such a request for an exception to the hourly level
110 requirements.
111 (b) Learn and remain informed about the choices available
112 on the FHIX marketplace and the uses of credits in the
113 individual accounts.
114 (c) Execute a contract with the department to acknowledge
115 that:
116 1. FHIX is not an entitlement and state and federal funding
117 may end at any time;
118 2. Failure to pay required premiums or cost sharing will
119 result in a transition to inactive status; and
120 3. Noncompliance with work or educational requirements will
121 result in a transition to inactive status.
122 (d) Select plans and other products in a timely manner.
123 (e) Comply with all program rules and the prohibitions
124 against fraud, as described in s. 414.39.
125 (f) Make monthly premium and any other cost-sharing
126 payments by the deadline.
127 (g) Meet minimum coverage requirements by selecting a high
128 deductible health plan combined with a health savings or health
129 reimbursement account if not selecting a plan with more
130 extensive coverage.
131 (5) COST SHARING.—
132 (a) Enrollees are assessed monthly premiums based on their
133 modified adjusted gross income. The maximum monthly premium
134 payments are set at the following income levels:
135 1. At or below 22 percent of the federal poverty level: $3.
136 2. Greater than 22 percent, but at or below 50 percent, of
137 the federal poverty level: $8.
138 3. Greater than 50 percent, but at or below 75 percent, of
139 the federal poverty level: $15.
140 4. Greater than 75 percent, but at or below 100 percent, of
141 the federal poverty level: $20.
142 5. Greater than 100 percent of the federal poverty level:
143 $25.
144 (b) Depending on the products and services selected by the
145 enrollee, the enrollee may also incur additional cost-sharing
146 copayments, deductibles, or other out-of-pocket costs.
147 (c) An enrollee may be subject to an inappropriate
148 emergency room visit charge of up to $8 for the first visit and
149 up to $25 for any subsequent visit, based on the enrollee’s
150 benefit plan, to discourage inappropriate use of the emergency
151 room.
152 (d) Cumulative annual cost sharing per enrollee may not
153 exceed 5 percent of an enrollee’s annual modified adjusted gross
154 income.
155 (e) If, after a 30-day grace period, a full premium payment
156 has not been received, the enrollee shall be transitioned from
157 coverage to inactive status and may not reenroll for a minimum
158 of 6 months, unless a hardship exception has been granted.
159 Enrollees may seek a hardship exception under the Medicaid Fair
160 Hearing Process.
161 Section 6. Section 409.724, Florida Statutes, is created to
162 read:
163 409.724 Available assistance.—
164 (1) PREMIUM CREDITS.—
165 (a) Standard amount.—The standard monthly premium credit is
166 equivalent to the applicable risk-adjusted capitation rate paid
167 to Medicaid managed care plans under part IV of this chapter.
168 (b) Supplemental funding.—Subject to federal approval,
169 additional resources may be made available to enrollees and
170 incorporated into FHIX.
171 (c) Savings accounts.—In addition to the benefits provided
172 under this section, the corporation must offer each enrollee
173 access to an individual account that qualifies as a health
174 reimbursement account or a health savings account. Eligible
175 unexpended funds from the monthly premium credit must be
176 deposited into each enrollee’s individual account in a timely
177 manner. Enrollees may also be rewarded for healthy behaviors,
178 adherence to wellness programs, and other activities established
179 by the corporation which demonstrate compliance with prevention
180 or disease management guidelines. Funds deposited into these
181 accounts may be used to pay cost-sharing obligations or to
182 purchase other health-related items to the extent permitted
183 under federal law.
184 (d) Enrollee contributions.—The enrollee may make deposits
185 to his or her account at any time to supplement the premium
186 credit, to purchase additional FHIX products, or to offset other
187 cost-sharing obligations.
188 (e) Third parties.—Third parties, including, but not
189 limited to, an employer or relative, may also make deposits on
190 behalf of the enrollee into the enrollee’s FHIX marketplace
191 account. The enrollee may not withdraw any funds as a refund,
192 except those funds the enrollee has deposited into his or her
193 account.
194 (2) CHOICE COUNSELING.—The agency and the corporation shall
195 work together to develop a choice counseling program for FHIX.
196 The choice counseling program must ensure that participants have
197 information about the FHIX marketplace program, products, and
198 services and that participants know where and whom to call for
199 questions or to make their plan selections. The choice
200 counseling program must provide culturally sensitive materials
201 and must take into consideration the demographics of the
202 projected population.
203 (3) EDUCATION CAMPAIGN.—The agency, the corporation, and
204 the Florida Healthy Kids Corporation must coordinate an ongoing
205 enrollee education campaign beginning in Phase One, as provided
206 in s. 409.27, informing participants, at a minimum:
207 (a) How the transition process to the FHIX marketplace will
208 occur and the timeline for the enrollee’s specific transition.
209 (b) What plans are available and how to research
210 information about available plans.
211 (c) Information about other available insurance
212 affordability programs for the individual and his or her family.
213 (d) Information about health benefits coverage, provider
214 networks, and cost sharing for available plans in each region.
215 (e) Information on how to complete the required annual
216 renewal process, including renewal dates and deadlines.
217 (f) Information on how to update eligibility if the
218 participant’s data have changed since his or her last renewal or
219 application date.
220 (4) CUSTOMER SUPPORT.—Beginning in Phase Two, the Florida
221 Healthy Kids Corporation shall provide customer support for
222 FHIX, shall address general program information, financial
223 information, and customer service issues, and shall provide
224 status updates on bill payments. Customer support must also
225 provide a toll-free number and maintain a website that is
226 available in multiple languages and that meets the needs of the
227 enrollee population.
228 (5) INACTIVE PARTICIPANTS.—The corporation must inform the
229 inactive participant about other insurance affordability
230 programs and electronically refer the participant to the federal
231 exchange or other insurance affordability programs, as
232 appropriate.
233 Section 7. Section 409.725, Florida Statutes, is created to
234 read:
235 409.725 Available products and services.—The FHIX
236 marketplace shall offer the following products and services:
237 (1) Authorized products and services pursuant to s.
238 408.910.
239 (2) Medicaid managed care plans under part IV of this
240 chapter.
241 (3) Authorized products under the Florida Healthy Kids
242 Corporation pursuant to s. 624.91.
243 (4) Employer-sponsored plans.
244 Section 8. Section 409.726, Florida Statutes, is created to
245 read:
246 409.726 Program accountability.—
247 (1) All managed care plans that participate in FHIX must
248 collect and maintain encounter level data in accordance with the
249 encounter data requirements under s. 409.967(2)(d) and are
250 subject to the accompanying penalties under s. 409.967(2)(h)2.
251 The agency is responsible for the collection and maintenance of
252 the encounter level data.
253 (2) The corporation, in consultation with the agency, shall
254 establish access and network standards for contracts on the FHIX
255 marketplace and shall ensure that contracted plans have
256 sufficient providers to meet enrollee needs. The corporation, in
257 consultation with the agency, shall develop quality of coverage
258 and provider standards specific to the adult population.
259 (3) The department shall develop accountability measures
260 and performance standards to be applied to applications and
261 renewal applications for FHIX which are submitted online, by
262 mail, by fax, or through referrals from a third party. The
263 minimum performance standards are:
264 (a) Application processing speed.—Ninety percent of all
265 applications, from all sources, must be processed within 45
266 days.
267 (b) Applications processing speed from online sources.
268 Ninety-five percent of all applications received from online
269 sources must be processed within 45 days.
270 (c) Renewal application processing speed.—Ninety percent of
271 all renewals, from all sources, must be processed within 45
272 days.
273 (d) Renewal application processing speed from online
274 sources.—Ninety-five percent of all applications received from
275 online sources must be processed within 45 days.
276 (4) The agency, the department, and the Florida Healthy
277 Kids Corporation must meet the following standards for their
278 respective roles in the program:
279 (a) Eighty-five percent of calls must be answered in 20
280 seconds or less.
281 (b) One hundred percent of all contacts, which include, but
282 are not limited to, telephone calls, faxed documents and
283 requests, and e-mails, must be handled within 2 business days.
284 (c) Any self-service tools available to participants, such
285 as interactive voice response systems, must be operational 7
286 days a week, 24 hours a day, at least 98 percent of each month.
287 (5) The agency, the department, and the Florida Healthy
288 Kids Corporation must conduct an annual satisfaction survey to
289 address all measures that require participant input specific to
290 the FHIX marketplace program. The parties may elect to
291 incorporate these elements into the annual report required under
292 subsection (7).
293 (6) The agency and the corporation shall post online
294 monthly enrollment reports for FHIX.
295 (7) An annual report is due no later than July 1 to the
296 Governor, the President of the Senate, and the Speaker of the
297 House of Representatives. The annual report must be coordinated
298 by the agency and the corporation and must include, but is not
299 limited to:
300 (a) Enrollment and application trends and issues.
301 (b) Utilization and cost data.
302 (c) Customer satisfaction.
303 (d) Funding sources in health savings accounts or health
304 reimbursement accounts.
305 (e) Enrollee use of funds in health savings accounts or
306 health reimbursement accounts.
307 (f) Types of products and plans purchased.
308 (g) Movement of enrollees across different insurance
309 affordability programs.
310 (h) Recommendations for program improvement.
311 Section 9. Section 409.727, Florida Statutes, is created to
312 read:
313 409.727 Implementation schedule.—The agency, the
314 corporation, the department, and the Florida Healthy Kids
315 Corporation shall begin implementation of FHIX by the effective
316 date of this act, with statewide implementation in all regions,
317 as described in s. 409.966(2), by January 1, 2016.
318 (1) READINESS REVIEW.—Before implementation of any phase
319 under this section, the agency shall conduct a readiness review
320 in consultation with the FHIX Workgroup described in s. 409.729.
321 The agency must determine that the region has satisfied, at a
322 minimum, the following readiness milestones:
323 (a) Functional readiness of the service delivery platform
324 for the phase.
325 (b) Plan availability and presence of plan choice.
326 (c) Provider network capacity and adequacy of the available
327 plans in the region.
328 (d) Availability of customer support.
329 (e) Other factors critical to the success of FHIX.
330 (2) PHASE ONE.—
331 (a) Phase One begins on July 1, 2015. The agency, the
332 corporation, and the Florida Healthy Kids Corporation shall
333 coordinate activities to ensure that enrollment begins by July
334 1, 2015.
335 (b) To be eligible during this phase, a participant must
336 meet the requirements under s. 409.723(1)(a).
337 (c) An enrollee is entitled to receive health benefits
338 coverage in the same manner as provided under and through the
339 selected managed care plans in the Medicaid managed care program
340 in part IV of this chapter.
341 (d) An enrollee shall have a choice of at least two managed
342 care plans in each region.
343 (e) Choice counseling and customer service must be provided
344 in accordance with s. 409.724(2).
345 (3) PHASE TWO.—
346 (a) Beginning no later than January 1, 2016, and contingent
347 upon federal approval, participants may enroll or transition to
348 health benefits coverage under the FHIX marketplace.
349 (b) To be eligible during this phase, a participant must
350 meet the requirements under s. 409.723(1)(a) and (b).
351 (c) An enrollee may select any benefit, service, or product
352 available.
353 (d) The corporation shall notify an enrollee of his or her
354 premium credit amount and how to access the FHIX marketplace
355 selection process.
356 (e) A Phase One enrollee must be transitioned to the FHIX
357 marketplace by April 1, 2016. An enrollee who does not select a
358 plan or service on the FHIX marketplace by that deadline shall
359 be moved to inactive status.
360 (f) An enrollee shall have a choice of at least two managed
361 care plans in each region which meet or exceed the Affordable
362 Care Act’s requirements and which qualify for a premium credit
363 on the FHIX marketplace.
364 (g) Choice counseling and customer service must be provided
365 in accordance with s. 409.724(2) and (4).
366 (4) PHASE THREE.—
367 (a) No later than July 1, 2016, the corporation and the
368 Florida Healthy Kids Corporation must begin the transition of
369 enrollees under s. 624.91 to the FHIX marketplace.
370 (b) Eligibility during this phase is based on meeting the
371 requirements of Phase II and s. 409.723(1)(c).
372 (c) An enrollee may select any benefit, service, or product
373 available under s. 409.725.
374 (d) A Florida Healthy Kids enrollee who selects a FHIX
375 marketplace plan must be provided a premium credit equivalent to
376 the average capitation rate paid in his or her county of
377 residence under Florida Healthy Kids as of June 30, 2016. The
378 enrollee is responsible for any difference in costs and may use
379 any remaining funds for supplemental benefits on the FHIX
380 marketplace.
381 (e) The corporation shall notify an enrollee of his or her
382 premium credit amount and how to access the FHIX marketplace
383 selection process.
384 (f) Choice counseling and customer service must be provided
385 in accordance with s. 409.724(2) and (4).
386 (g) Enrollees under s. 624.91 must transition to the FHIX
387 marketplace by September 30, 2016.
388 Section 10. Section 409.728, Florida Statutes, is created
389 to read:
390 409.728 Program operation and management.—In order to
391 implement ss. 409.720-409.731:
392 (1) The Agency for Health Care Administration shall do all
393 of the following:
394 (a) Contract with the corporation for the development,
395 implementation, and administration of the Florida Health
396 Insurance Affordability Exchange Program and for the release of
397 any federal, state, or other funds appropriated to the
398 corporation.
399 (b) Administer Phase One of FHIX.
400 (c) Provide administrative support to the FHIX Workgroup
401 under s. 409.729.
402 (d) Transition the FHIX enrollees to the FHIX marketplace
403 beginning January 1, 2016, in accordance with the transition
404 workplan. Stakeholders that serve low-income individuals and
405 families must be consulted during the implementation and
406 transition process through a public input process. All regions
407 must complete the transition no later than April 1, 2016.
408 (e) Timely transmit enrollee information to the
409 corporation.
410 (f) Beginning with Phase Two, determine annually the risk
411 adjusted rate to be paid per month based on historical
412 utilization and spending data for the medical and behavioral
413 health of this population, projected forward, and adjusted to
414 reflect the eligibility category, medical and dental trends,
415 geographic areas, and the clinical risk profile of the
416 enrollees.
417 (g) Transfer to the corporation such funds as approved in
418 the General Appropriations Act for the premium credits.
419 (h) Encourage Medicaid managed care plans to apply as
420 vendors to the marketplace to facilitate continuity of care and
421 family care coordination.
422 (2) The Department of Children and Families shall, in
423 coordination with the corporation, the agency, and the Florida
424 Healthy Kids Corporation, determine eligibility of applications
425 and application renewals for FHIX in accordance with s. 409.902
426 and shall transmit eligibility determination information on a
427 timely basis to the agency and corporation.
428 (3) The Florida Healthy Kids Corporation shall do all of
429 the following:
430 (a) Retain its duties and responsibilities under s. 624.91
431 for Phase One and Phase Two of the program.
432 (b) Provide customer service for the FHIX marketplace, in
433 coordination with the agency and the corporation.
434 (c) Transfer funds and provide financial support to the
435 FHIX marketplace, including the collection of monthly cost
436 sharing.
437 (d) Conduct financial reporting related to such activities,
438 in coordination with the corporation and the agency.
439 (e) Coordinate activities for the program with the agency,
440 the department, and the corporation.
441 (f) Begin the development of FHIX during Phase One.
442 (g) Implement and administer Phase Two and Phase Three of
443 the FHIX marketplace and the ongoing operations of the program.
444 (h) Offer health benefits coverage packages on the FHIX
445 marketplace, including plans compliant with the Affordable Care
446 Act.
447 (i) Offer FHIX enrollees a choice of at least two plans per
448 county at each benefit level which meet the requirements under
449 the Affordable Care Act.
450 (j) Provide an opportunity for participation in Medicaid
451 managed care plans if those plans meet the requirements of the
452 FHIX marketplace.
453 (k) Offer enhanced or customized benefits to FHIX
454 marketplace enrollees.
455 (l) Provide sufficient staff and resources to meet the
456 program needs of enrollees.
457 (m) Provide an opportunity for plans contracted with or
458 previously contracted with the Florida Healthy Kids Corporation
459 under s. 624.91 to participate with FHIX if those plans meet the
460 requirements of the program.