Florida Senate - 2007 COMMITTEE AMENDMENT
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CHAMBER ACTION
Senate House
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04/17/2007 11:46 AM .
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11 The Committee on Health and Human Services Appropriations
12 (Peaden) recommended the following amendment:
13
14 Senate Amendment (with title amendment)
15 Delete everything after the enacting clause
16
17 and insert:
18 Section 1. Section 409.811, Florida Statutes, is
19 amended to read:
20 409.811 Definitions relating to Florida Kidcare
21 Act.--As used in ss. 409.810-409.830 ss. 409.810-409.820, the
22 term:
23 (1) "Actuarially equivalent" means that:
24 (a) The aggregate value of the benefits included in
25 health benefits coverage is equal to the value of the benefits
26 in the benchmark benefit plan; and
27 (b) The benefits included in health benefits coverage
28 are substantially similar to the benefits included in the
29 benchmark benefit plan, except that preventive health services
30 must be the same as in the benchmark benefit plan.
31 (2) "Agency" means the Agency for Health Care
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1 Administration.
2 (3) "Applicant" means a parent or guardian of a child
3 or a child whose disability of nonage has been removed under
4 chapter 743, who applies for determination of eligibility for
5 health benefits coverage under ss. 409.810-409.830 ss.
6 409.810-409.820.
7 (4) "Benchmark benefit plan" means the form and level
8 of health benefits coverage established in s. 409.815.
9 (5) "Child" means any person under 19 years of age.
10 (6) "Child with special health care needs" means a
11 child who has a chronic physical, developmental, behavioral,
12 or emotional condition and who also required health care and
13 related services of a type or amount beyond that which is
14 generally required by children. whose serious or chronic
15 physical or developmental condition requires extensive
16 preventive and maintenance care beyond that required by
17 typically healthy children. Health care utilization by such a
18 child exceeds the statistically expected usage of the normal
19 child adjusted for chronological age, and such a child often
20 needs complex care requiring multiple providers,
21 rehabilitation services, and specialized equipment in a number
22 of different settings.
23 (7) "Children's Medical Services Network" or "network"
24 means a statewide managed care service system as defined in s.
25 391.021(1).
26 (8) "Community rate" means a method used to develop
27 premiums for a health insurance plan that spreads financial
28 risk across a large population and allows adjustments only for
29 age, gender, family composition, and geographic area.
30 (9) "Department" means the Department of Health.
31 (10) "Enrollee" means a child who has been determined
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1 eligible for and is receiving coverage under ss.
2 409.810-409.820.
3 (11) "Family" means the group or the individuals whose
4 income is considered in determining eligibility for the
5 Florida Kidcare program. The family includes a child with a
6 custodial parent or caretaker relative who resides in the same
7 house or living unit or, in the case of a child whose
8 disability of nonage has been removed under chapter 743, the
9 child. The family may also include other individuals whose
10 income and resources are considered in whole or in part in
11 determining eligibility of the child.
12 (12) "Family income" means cash received at periodic
13 intervals from any source, such as wages, benefits,
14 contributions, or rental property. Income also may include any
15 money that would have been counted as income under the Aid to
16 Families with Dependent Children (AFDC) state plan in effect
17 prior to August 22, 1996.
18 (13) "Florida Kidcare Plus" means health benefits
19 coverage for children with special health care needs which
20 benefits are delivered through the Children's Medical Services
21 Network established in chapter 391.
22 (14)(13) "Florida Kidcare program," "Kidcare program,"
23 or "program" means the health benefits program for children
24 administered through ss. 409.810-409.830 ss. 409.810-409.820.
25 (15)(14) "Guarantee issue" means that health benefits
26 coverage must be offered to an individual regardless of the
27 individual's health status, preexisting condition, or claims
28 history.
29 (16)(15) "Health benefits coverage" means protection
30 that provides payment of benefits for covered health care
31 services or that otherwise provides, either directly or
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1 through arrangements with other persons, covered health care
2 services on a prepaid per capita basis or on a prepaid
3 aggregate fixed-sum basis.
4 (17)(16) "Health insurance plan" means health benefits
5 coverage under the following:
6 (a) A health plan offered by any certified health
7 maintenance organization or authorized health insurer, except
8 a plan that is limited to the following: a limited benefit,
9 specified disease, or specified accident; hospital indemnity;
10 accident only; limited benefit convalescent care; Medicare
11 supplement; credit disability; dental; vision; long-term care;
12 disability income; coverage issued as a supplement to another
13 health plan; workers' compensation liability or other
14 insurance; or motor vehicle medical payment only; or
15 (b) An employee welfare benefit plan that includes
16 health benefits established under the Employee Retirement
17 Income Security Act of 1974, as amended.
18 (18) "Healthy Kids" means a component of the Florida
19 Kidcare program of medical assistance for children who are 5
20 through 18 years of age and whose family or household incomes
21 are above the Title XIX-income-eligibility threshold.
22 (19)(17) "Medicaid" means the medical assistance
23 program authorized by Title XIX of the Social Security Act,
24 and regulations thereunder, and ss. 409.901-409.920, as
25 administered in this state by the agency.
26 (20)(18) "Medically necessary" means the use of any
27 medical treatment, service, equipment, or supply necessary to
28 palliate the effects of a terminal condition, or to prevent,
29 diagnose, correct, cure, alleviate, or preclude deterioration
30 of a condition that threatens life, causes pain or suffering,
31 or results in illness or infirmity and which is:
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1 (a) Consistent with the symptom, diagnosis, and
2 treatment of the enrollee's condition;
3 (b) Provided in accordance with generally accepted
4 standards of medical practice;
5 (c) Not primarily intended for the convenience of the
6 enrollee, the enrollee's family, or the health care provider;
7 (d) The most appropriate level of supply or service
8 for the diagnosis and treatment of the enrollee's condition;
9 and
10 (e) Approved by the appropriate medical body or health
11 care specialty involved as effective, appropriate, and
12 essential for the care and treatment of the enrollee's
13 condition.
14 (21)(19) "Medikids" means a component of the Florida
15 Kidcare program of medical assistance authorized by Title XXI
16 of the Social Security Act, and regulations thereunder, and s.
17 409.8132, as administered in the state by the agency.
18 (22)(20) "Preexisting condition exclusion" means, with
19 respect to coverage, a limitation or exclusion of benefits
20 relating to a condition based on the fact that the condition
21 was present before the date of enrollment for such coverage,
22 whether or not any medical advice, diagnosis, care, or
23 treatment was recommended or received before such date.
24 (23)(21) "Premium" means the entire cost of a health
25 insurance plan, including the administration fee or the risk
26 assumption charge.
27 (24)(22) "Premium assistance payment" means the
28 monthly consideration paid by the agency per enrollee in the
29 Florida Kidcare program towards health insurance premiums.
30 (25)(23) "Qualified alien" means an alien as defined
31 in s. 431 of the Personal Responsibility and Work Opportunity
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1 Reconciliation Act of 1996, as amended, Pub. L. No. 104-193.
2 (26)(24) "Resident" means a United States citizen, or
3 qualified alien, who is domiciled in this state.
4 (27)(25) "Rural county" means a county having a
5 population density of fewer less than 100 persons per square
6 mile, or a county defined by the most recent United States
7 Census as rural, in which there is no prepaid health plan
8 participating in the Medicaid program as of July 1, 1998.
9 (28)(26) "Substantially similar" means that, with
10 respect to additional services as defined in s. 2103(c)(2) of
11 Title XXI of the Social Security Act, these services must have
12 an actuarial value equal to at least 75 percent of the
13 actuarial value of the coverage for that service in the
14 benchmark benefit plan and, with respect to the basic services
15 as defined in s. 2103(c)(1) of Title XXI of the Social
16 Security Act, these services must be the same as the services
17 in the benchmark benefit plan.
18 Section 2. Section 409.812, Florida Statutes, is
19 amended to read:
20 409.812 Program created; purpose.--The Florida Kidcare
21 program is created to provide a defined set of health benefits
22 to previously uninsured, low-income children through the
23 establishment of a variety of affordable health benefits
24 coverage options from which families may select coverage and
25 through which families may contribute financially to the
26 health care of their children.
27 Section 3. Section 409.813, Florida Statutes, is
28 amended to read:
29 409.813 Program components; entitlement and
30 nonentitlement.--The Florida Kidcare program includes health
31 benefits coverage provided to children through the following
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1 funding sources, which shall be marketed as the Florida
2 Kidcare program:
3 (1) Title XIX of the Social Security Act Medicaid;
4 (2) Title XXI of the Social Security Act Medikids as
5 created in s. 409.8132;
6 (3) The Title V Program of the Social Security Act, as
7 it relates to children with special health care needs The
8 Florida Healthy Kids Corporation as created in s. 624.91;
9 (4) Employer-sponsored group health insurance plans
10 approved under ss. 409.810-409.830 ss. 409.810-409.820; and
11 (5) Full pay premiums for children with family incomes
12 above the maximum income threshold or children who are not
13 Title XXI-eligible pursuant to s. 409.8141; and The Children's
14 Medical Services network established in chapter 391.
15 (6) General revenue or local contributions.
16
17 Except for Title XIX-funded Florida Kidcare coverage under the
18 Medicaid program, coverage under the Florida Kidcare program
19 is not an entitlement. No cause of action shall arise against
20 the state, the Department of Health, the Department of
21 Children and Family Services, or the Florida Healthy Kids
22 Corporation, or the Agency for Health Care Administration
23 agency for failure to make health services available to any
24 person under ss. 409.810-409.830 ss. 409.810-409.820.
25 Section 4. Section 409.8132, Florida Statutes, is
26 amended to read:
27 409.8132 Medikids program component.--
28 (1) PROGRAM COMPONENT CREATED; PURPOSE.--The Medikids
29 program component is created in the Agency for Health Care
30 Administration to provide health care services under the
31 Florida Kidcare program to eligible children using the
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1 administrative structure and provider network of the Medicaid
2 program.
3 (2) ADMINISTRATION.--The secretary of the agency shall
4 appoint an administrator of the Medikids program component.
5 The Agency for Health Care Administration is designated as the
6 state agency authorized to make payments for medical
7 assistance and related services for the Medikids program
8 component of the Florida Kidcare program. Payments shall be
9 made, subject to any limitations or directions in the General
10 Appropriations Act, only for covered services provided to
11 eligible children by qualified health care providers under the
12 Florida Kidcare program.
13 (3) INSURANCE LICENSURE NOT REQUIRED.--The Medikids
14 program component shall not be subject to the licensing
15 requirements of the Florida Insurance Code or rules adopted
16 thereunder.
17 (4) APPLICABILITY OF LAWS RELATING TO MEDICAID.--The
18 provisions of ss. 409.902, 409.905, 409.906, 409.907, 409.908,
19 409.912, 409.9121, 409.9122, 409.9123, 409.9124, 409.9127,
20 409.9128, 409.913, 409.916, 409.919, 409.920, and 409.9205
21 apply to the administration of the Medikids program component
22 of the Florida Kidcare program, except that s. 409.9122
23 applies to Medikids as modified by the provisions of
24 subsection (7).
25 (5) BENEFITS.--Benefits provided under the Medikids
26 program component shall be the same benefits provided to
27 children as specified in ss. 409.905 and 409.906.
28 (6) ELIGIBILITY.--
29 (a) A child who has attained the age of 1 year but who
30 is under the age of 5 years is eligible to enroll in the
31 Medikids program component of the Florida Kidcare program, if
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1 the child is a member of a family that has a family income
2 which exceeds the Medicaid applicable income level as
3 specified in s. 409.903, but which is equal to or below 200
4 percent of the current federal poverty level. In determining
5 the eligibility of such a child, an assets test is not
6 required. A child who is eligible for Medikids may elect to
7 enroll in Florida Healthy Kids coverage or employer-sponsored
8 group coverage. However, a child who is eligible for Medikids
9 may participate in the Florida Healthy Kids program only if
10 the child has a sibling participating in the Florida Healthy
11 Kids program and the child's county of residence permits such
12 enrollment.
13 (b) The provisions of ss. 409.814, 409.8141, 409.8142,
14 and 409.8149 s. 409.814(3), (4), and (5) shall be applicable
15 to the Medikids program.
16 (7) ENROLLMENT.--Enrollment in the Medikids program
17 component may occur at any time throughout the year. A child
18 may not receive services under the Medikids program until the
19 child is enrolled in a managed care plan or MediPass. Once
20 determined eligible, an applicant may receive choice
21 counseling and select a managed care plan or MediPass. The
22 agency may initiate mandatory assignment for a Medikids
23 applicant who has not chosen a managed care plan or MediPass
24 provider after the applicant's voluntary choice period ends.
25 An applicant may select MediPass under the Medikids program
26 component only in counties that have fewer than two managed
27 care plans available to serve Medicaid recipients and only if
28 the federal Health Care Financing Administration determines
29 that MediPass constitutes "health insurance coverage" as
30 defined in Title XXI of the Social Security Act.
31 (8) PENALTIES FOR VOLUNTARY CANCELLATION.--The agency
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1 shall establish enrollment criteria that must include
2 penalties or waiting periods of not fewer than 60 days for
3 reinstatement of coverage upon voluntary cancellation for
4 nonpayment of premiums.
5 Section 5. Section 409.8134, Florida Statutes, is
6 amended to read:
7 409.8134 Program expenditure ceiling.--
8 (1) Except for the Medicaid program, a ceiling shall
9 be placed on annual federal and state expenditures for the
10 Florida Kidcare program as provided each year in the General
11 Appropriations Act.
12 (2) The Florida Kidcare program may conduct enrollment
13 at any time throughout the year for the purpose of enrolling
14 children eligible for all program components listed in s.
15 409.813 except Medicaid. The four Florida Kidcare
16 administrators shall work together to ensure that the
17 year-round enrollment period is announced statewide. Eligible
18 children shall be enrolled on a first-come, first-served basis
19 using the date the enrollment application is received.
20 Enrollment shall immediately cease when the expenditure
21 ceiling is reached. Year-round enrollment shall only be held
22 if the Social Services Estimating Conference determines that
23 sufficient federal and state funds will be available to
24 finance the increased enrollment through federal fiscal year
25 2007. Any individual who is not enrolled must reapply by
26 submitting a new application. The application for the Florida
27 Kidcare program shall be valid for a period of 120 days after
28 the date it was received. At the end of the 120-day period, if
29 the applicant has not been enrolled in the program, the
30 application shall be invalid and the applicant shall be
31 notified of the action. The applicant may resubmit the
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1 application after notification of the action taken by the
2 program. Except for the Medicaid program, whenever the Social
3 Services Estimating Conference determines that there are
4 presently, or will be by the end of the current fiscal year,
5 insufficient funds to finance the current or projected
6 enrollment in the Florida Kidcare program, all additional
7 enrollment must cease and additional enrollment may not resume
8 until sufficient funds are available to finance such
9 enrollment.
10 (3) Upon determination by the Social Services
11 Estimating Conference that there are insufficient funds to
12 finance the current enrollment in the Florida Kidcare program
13 within current appropriations, the program shall initiate
14 disenrollment procedures to remove enrollees, except those
15 children who receive Florida Kidcare Plus benefits enrolled in
16 the Children's Medical Services Network, on a last-in,
17 first-out basis until the expenditure and appropriation levels
18 are balanced.
19 (4) The agencies that administer the Florida Kidcare
20 program components shall collect and analyze the data needed
21 to project program enrollment costs, including price level
22 adjustments, participation and attrition rates, current and
23 projected caseloads, utilization, and current and projected
24 expenditures for the next 3 years. The agencies shall report
25 caseload and expenditure trends to the Social Services
26 Estimating Conference in accordance with chapter 216.
27 Section 6. Section 409.814, Florida Statutes, is
28 amended to read:
29 (Substantial rewording of section. See
30 s. 409.814, F.S., for present text.)
31 409.814 Eligibility.--
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1 (1) ELIGIBILITY FOR THE FLORIDA KIDCARE PROGRAM.--To
2 be eligible for the Florida Kidcare program, a child must be:
3 (a) A resident of the state.
4 (b) Under 19 years of age.
5 (c) Uninsured at the time of application, except for
6 children eligible for Medicaid.
7 (2) ELIGIBILITY FOR FLORIDA KIDCARE PLUS.--To be
8 eligible for the Florida Kidcare Plus benefit delivered by the
9 Children's Medical Services Network in the Florida Kidcare
10 program, a child must meet the requirements of subsection (1)
11 and must be a child with special health care needs as
12 determined through a clinical-eligibility screening instrument
13 administered by the Department of Health pursuant to s.
14 409.818(2).
15 Section 7. Section 409.8141, Florida Statutes, is
16 created to read:
17 409.8141 Premium assistance.--
18 (1) The Florida Kidcare program may provide premium
19 assistance to certain children enrolled in the program. To be
20 eligible for premium assistance, the child must meet the
21 requirements of s. 409.814 and must:
22 (a) Reside in a household where the family income is
23 equal to or less than 200 percent of the federal poverty
24 level;
25 (b) Be a United States citizen or a qualified alien as
26 defined in s. 409.811(24);
27 (c) Not be an inmate of a public institution or a
28 patient in an institution for mental diseases;
29 (d) Not be eligible for coverage under a state health
30 benefit plan on the basis of a family member's employment with
31 a public agency in the state; and
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1 (e) Not be currently eligible for or covered under a
2 family member's group health benefit plan or under other
3 employer health insurance coverage, excluding full-pay Florida
4 Kidcare health benefits coverage, if the cost of the child's
5 participation is not greater than 5 percent of the family's
6 income.
7 (2) A child seeking premium assistance for the Florida
8 Kidcare program is not eligible for premium assistance if the
9 child was covered through an employer-sponsored group coverage
10 6 months prior to the family submitting an application for
11 determination of eligibility under the program, unless the
12 employer-sponsored health coverage was discontinued for
13 good-cause reasons. Good-cause reasons for discontinued
14 employer-sponsored health coverage include:
15 (a) The cost of participation in an employer-sponsored
16 health benefit plan is greater than 5 percent of the family's
17 income;
18 (b) The parent lost a job that provided an
19 employer-sponsored health benefit plan for children;
20 (c) The parent who had health benefits coverage for
21 the child is deceased;
22 (d) The child has a medical condition that, without
23 medical care, would cause serious disability, loss of
24 function, or death;
25 (e) The employer of the parent canceled health
26 benefits coverage for children;
27 (f) The child's health benefits coverage ended because
28 the child reached the maximum lifetime coverage amount;
29 (g) The child has exhausted coverage under a COBRA
30 continuation provision;
31 (h) The health benefits coverage does not cover the
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1 child's health care needs; or
2 (i) Domestic violence led to loss of coverage.
3 (3) Eligibility for premium assistance shall be
4 verified for each applicant and enrollee during the
5 application and reverification processes based on:
6 (a) Family income documented with a copy of the
7 applicant's most recent federal income tax return. In the
8 absence of a federal income tax return, an applicant's wages
9 and earnings statements, W-2 forms, or other appropriate
10 documentation obtained from other government sources,
11 including electronic records, may be considered. An assets
12 test is not required.
13 (b) A statement from the applicant or enrollee that
14 the child is not currently insured by an employer-sponsored or
15 other benefit plan.
16 (4) Enrollees not meeting the eligibility requirements
17 of subsection (1) shall pay the full cost of the premium and
18 are not required to document income. The number of children
19 participating in the non-Title XIX-funded Florida Kidcare
20 program under this subsection whose family income exceeds 200
21 percent of the federal poverty level must not exceed 10
22 percent of total enrollees in the non-title XIX-funded Florida
23 Kidcare program.
24 (5)(a) A Title XIX-funded child enrolled in the
25 Florida Kidcare program is eligible for coverage for 6 months
26 without redetermination or reverification of eligibility.
27 (b) A child found eligible for premium assistance in
28 the Florida Kidcare program shall receive premium assistance
29 for 12 months without reverification of eligibility if the
30 family continues to participate in any applicable cost-sharing
31 pursuant to s. 409.816. The Florida Kidcare program shall
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1 conduct an annual eligibility reverification for each enrollee
2 eligible for premium assistance.
3 (6) If a child loses eligibility for Florida Kidcare
4 health benefits coverage, the child's managed health care
5 provider shall be notified at the same time the family is
6 notified in order to facilitate necessary action to maintain
7 continuous health care coverage.
8 Section 8. Section 409.8142, Florida Statutes, is
9 created to read:
10 409.8142 Penalties.--
11 (1) Subject to s. 624.91(4), the Florida Kidcare
12 program shall withhold benefits from an enrollee if the
13 program obtains evidence that the enrollee is no longer
14 eligible, submitted incorrect or fraudulent information in
15 order to establish eligibility, or failed to provide
16 verification of eligibility. The applicant or enrollee shall
17 be notified that, because of such evidence, program benefits
18 will be withheld unless the applicant or enrollee contacts a
19 designated representative of the program by a specified date,
20 which must be within 10 business days after the date of
21 notice, to discuss and resolve the matter. The program shall
22 make every effort to resolve the matter within a timeframe
23 that will not cause benefits to be withheld from an eligible
24 enrollee.
25 (2) If, subsequent to any eligibility determination,
26 an individual is determined to be ineligible for coverage, he
27 or she must immediately be disenrolled from the Florida
28 Kidcare program.
29 (3) Waiting periods of not less than 60 days for
30 reinstatement of coverage upon voluntary cancellation for
31 nonpayment of premiums when applicable shall be established by
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1 the agency.
2 Section 9. Section 409.8149, Florida Statutes, is
3 created to read:
4 409.8149 Enrollment; plan choice.--
5 (1) ENROLLMENT.--The Florida Kidcare program may
6 conduct enrollment at any time throughout the year for the
7 purpose of enrolling children eligible for all coverage funded
8 pursuant to s. 409.813, except Medicaid. Eligible children
9 shall be enrolled on a first-come, first-served basis, based
10 upon the date the enrollment application is received. The
11 application for the Florida Kidcare program is valid for a
12 period of 120 days after the date the application is received.
13 At the end of the 120-day period, if the applicant has not
14 been enrolled in the program, the application is invalid and
15 the applicant shall be notified of the action. The applicant
16 may resubmit the application after notification of the action
17 taken by the program.
18 (2) PLAN CHOICE.--
19 (a) Enrollees who do not voluntarily choose a benefit
20 plan shall be assigned to a managed care plan by the Florida
21 Kidcare program. The program shall assign enrollees eligible
22 for Medicaid to a Medicaid managed care plan or to the
23 Medicaid fee-for-service program if a Medicaid managed care
24 plan does not exist in the geographical area in which the
25 enrollee resides. The program shall assign all other enrollees
26 to plans selected pursuant to s. 624.91 in the geographical
27 area in which each enrollee resides.
28 (b) Upon selection or assignment, an enrollee shall
29 have 90 days during which to voluntarily disenroll from a
30 benefit plan and select another.
31 (c) Upon the anniversary of enrollment, each enrollee
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1 may voluntarily select another benefit plan. The Florida
2 Kidcare program shall notify enrollees of their options with
3 respect to the annual open enrollment 60 days prior to the
4 anniversary of initial enrollment.
5 Section 10. Section 409.815, Florida Statutes, is
6 amended to read:
7 409.815 Health benefits coverage; limitations.--
8 (1) MEDICAID BENEFITS.--For purposes of the Florida
9 Kidcare program, benefits available under Medicaid and
10 Medikids include those goods and services provided under the
11 medical assistance program authorized by Title XIX of the
12 Social Security Act, and regulations thereunder, as
13 administered in this state by the agency. This includes those
14 mandatory Medicaid services authorized under s. 409.905, and
15 optional Medicaid services authorized under s. 409.906, and
16 emergency services provided under s. 409.9128. Effective July
17 1, 2008, health benefits available under the Florida Kidcare
18 program shall include the same mandatory and optional Medicaid
19 services as specified in s. 409.830(2)., rendered on behalf of
20 eligible individuals by qualified providers, in accordance
21 with federal requirements for Title XIX, subject to any
22 limitations or directions provided for in the General
23 Appropriations Act or chapter 216, and according to
24 methodologies and limitations set forth in agency rules and
25 policy manuals and handbooks incorporated by reference
26 thereto.
27 (2) BENCHMARK BENEFITS.--In order for health benefits
28 coverage to qualify for premium assistance payments for an
29 eligible child under ss. 409.810-409.830 ss. 409.810-409.820,
30 the health benefits coverage, except for coverage under
31 Medicaid and Medikids, must include the following minimum
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1 benefits, as medically necessary.
2 (a) Preventive health services.--Covered services
3 include:
4 1. Well-child care, including services recommended in
5 the Guidelines for Health Supervision of Children and Youth as
6 developed by the American Academy of Pediatrics;
7 2. Immunizations and injections;
8 3. Health education counseling and clinical services;
9 4. Vision screening; and
10 5. Hearing screening.
11 (b) Inpatient hospital services.--All covered services
12 provided for the medical care and treatment of an enrollee who
13 is admitted as an inpatient to a hospital licensed under part
14 I of chapter 395, with the following exceptions:
15 1. All admissions must be authorized by the enrollee's
16 health benefits coverage provider.
17 2. The length of the patient stay shall be determined
18 based on the medical condition of the enrollee in relation to
19 the necessary and appropriate level of care.
20 3. Room and board may be limited to semiprivate
21 accommodations, unless a private room is considered medically
22 necessary or semiprivate accommodations are not available.
23 4. Admissions for rehabilitation and physical therapy
24 are limited to 15 days per contract year.
25 (c) Emergency services.--Covered services include
26 visits to an emergency room or other licensed facility if
27 needed immediately due to an injury or illness and delay means
28 risk of permanent damage to the enrollee's health. Health
29 maintenance organizations shall comply with the provisions of
30 s. 641.513.
31 (d) Maternity services.--Covered services include
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1 maternity and newborn care, including prenatal and postnatal
2 care, with the following limitations:
3 1. Coverage may be limited to the fee for vaginal
4 deliveries; and
5 2. Initial inpatient care for newborn infants of
6 enrolled adolescents shall be covered, including normal
7 newborn care, nursery charges, and the initial pediatric or
8 neonatal examination, and the infant may be covered for up to
9 3 days following birth.
10 (e) Organ transplantation services.--Covered services
11 include pretransplant, transplant, and postdischarge services
12 and treatment of complications after transplantation for
13 transplants deemed necessary and appropriate within the
14 guidelines set by the Organ Transplant Advisory Council under
15 s. 765.53 or the Bone Marrow Transplant Advisory Panel under
16 s. 627.4236.
17 (f) Outpatient services.--Covered services include
18 preventive, diagnostic, therapeutic, palliative care, and
19 other services provided to an enrollee in the outpatient
20 portion of a health facility licensed under chapter 395,
21 except for the following limitations:
22 1. Services must be authorized by the enrollee's
23 health benefits coverage provider; and
24 2. Treatment for temporomandibular joint disease (TMJ)
25 is specifically excluded.
26 (g) Behavioral health services.--
27 1. Mental health benefits include:
28 a. Inpatient services, limited to not more than 30
29 inpatient days per contract year for psychiatric admissions,
30 or residential services in facilities licensed under s.
31 394.875(8) or s. 395.003 in lieu of inpatient psychiatric
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1 admissions; however, a minimum of 10 of the 30 days shall be
2 available only for inpatient psychiatric services when
3 authorized by a physician; and
4 b. Outpatient services, including outpatient visits
5 for psychological or psychiatric evaluation, diagnosis, and
6 treatment by a licensed mental health professional, limited to
7 a maximum of 40 outpatient visits each contract year.
8 2. Substance abuse services include:
9 a. Inpatient services, limited to not more than 7
10 inpatient days per contract year for medical detoxification
11 only and 30 days of residential services; and
12 b. Outpatient services, including evaluation,
13 diagnosis, and treatment by a licensed practitioner, limited
14 to a maximum of 40 outpatient visits per contract year.
15 (h) Durable medical equipment.--Covered services
16 include equipment and devices that are medically indicated to
17 assist in the treatment of a medical condition and
18 specifically prescribed as medically necessary, with the
19 following limitations:
20 1. Low-vision and telescopic aides are not included.
21 2. Corrective lenses and frames may be limited to one
22 pair every 2 years, unless the prescription or head size of
23 the enrollee changes.
24 3. Hearing aids shall be covered only when medically
25 indicated to assist in the treatment of a medical condition.
26 4. Covered prosthetic devices include artificial eyes
27 and limbs, braces, and other artificial aids.
28 (i) Health practitioner services.--Covered services
29 include services and procedures rendered to an enrollee when
30 performed to diagnose and treat diseases, injuries, or other
31 conditions, including care rendered by health practitioners
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1 acting within the scope of their practice, with the following
2 exceptions:
3 1. Chiropractic services shall be provided in the same
4 manner as in the Florida Medicaid program.
5 2. Podiatric services may be limited to one visit per
6 day totaling two visits per month for specific foot disorders.
7 (j) Home health services.--Covered services include
8 prescribed home visits by both registered and licensed
9 practical nurses to provide skilled nursing services on a
10 part-time intermittent basis, subject to the following
11 limitations:
12 1. Coverage may be limited to include skilled nursing
13 services only;
14 2. Meals, housekeeping, and personal comfort items may
15 be excluded; and
16 3. Private duty nursing is limited to circumstances
17 where such care is medically necessary.
18 (k) Hospice services.--Covered services include
19 reasonable and necessary services for palliation or management
20 of an enrollee's terminal illness, with the following
21 exceptions:
22 1. Once a family elects to receive hospice care for an
23 enrollee, other services that treat the terminal condition
24 will not be covered; and
25 2. Services required for conditions totally unrelated
26 to the terminal condition are covered to the extent that the
27 services are included in this section.
28 (l) Laboratory and X-ray services.--Covered services
29 include diagnostic testing, including clinical radiologic,
30 laboratory, and other diagnostic tests.
31 (m) Nursing facility services.--Covered services
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1 include regular nursing services, rehabilitation services,
2 drugs and biologicals, medical supplies, and the use of
3 appliances and equipment furnished by the facility, with the
4 following limitations:
5 1. All admissions must be authorized by the health
6 benefits coverage provider.
7 2. The length of the patient stay shall be determined
8 based on the medical condition of the enrollee in relation to
9 the necessary and appropriate level of care, but is limited to
10 not more than 100 days per contract year.
11 3. Room and board may be limited to semiprivate
12 accommodations, unless a private room is considered medically
13 necessary or semiprivate accommodations are not available.
14 4. Specialized treatment centers and independent
15 kidney disease treatment centers are excluded.
16 5. Private duty nurses, television, and custodial care
17 are excluded.
18 6. Admissions for rehabilitation and physical therapy
19 are limited to 15 days per contract year.
20 (n) Prescribed drugs.--
21 1. Coverage shall include drugs prescribed for the
22 treatment of illness or injury when prescribed by a licensed
23 health practitioner acting within the scope of his or her
24 practice.
25 2. Prescribed drugs may be limited to generics if
26 available and brand name products if a generic substitution is
27 not available, unless the prescribing licensed health
28 practitioner indicates that a brand name is medically
29 necessary.
30 3. Prescribed drugs covered under this section shall
31 include all prescribed drugs covered under the Florida
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1 Medicaid program.
2 (o) Therapy services.--Covered services include
3 rehabilitative services, including occupational, physical,
4 respiratory, and speech therapies, with the following
5 limitations:
6 1. Services must be for short-term rehabilitation
7 where significant improvement in the enrollee's condition will
8 result; and
9 2. Services shall be limited to not more than 24
10 treatment sessions within a 60-day period per episode or
11 injury, with the 60-day period beginning with the first
12 treatment.
13 (p) Transportation services.--Covered services include
14 emergency transportation required in response to an emergency
15 situation.
16 (q) Dental services.--Dental services shall be covered
17 and may include those dental benefits provided to children by
18 the Florida Medicaid program under s. 409.906(6).
19 (r) Lifetime maximum.--Health benefits coverage
20 obtained under ss. 409.810-409.820 shall pay an enrollee's
21 covered expenses at a lifetime maximum of $1 million per
22 covered child.
23 (s) Cost-sharing.--Cost-sharing provisions must comply
24 with s. 409.816.
25 (t) Exclusions.--
26 1. Experimental or investigational procedures that
27 have not been clinically proven by reliable evidence are
28 excluded;
29 2. Services performed for cosmetic purposes only or
30 for the convenience of the enrollee are excluded; and
31 3. Abortion may be covered only if necessary to save
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1 the life of the mother or if the pregnancy is the result of an
2 act of rape or incest.
3 (u) Enhancements to minimum requirements.--
4 1. This section sets the minimum benefits that must be
5 included in any health benefits coverage, other than Medicaid
6 or Medikids coverage, offered under ss. 409.810-409.820.
7 Health benefits coverage may include additional benefits not
8 included under this subsection, but may not include benefits
9 excluded under paragraph (s).
10 2. Health benefits coverage may extend any limitations
11 beyond the minimum benefits described in this section.
12
13 Except for the Children's Medical Services Network, the agency
14 may not increase the premium assistance payment for either
15 additional benefits provided beyond the minimum benefits
16 described in this section or the imposition of less
17 restrictive service limitations.
18 (v) Applicability of other state laws.--Health
19 insurers, health maintenance organizations, and their agents
20 are subject to the provisions of the Florida Insurance Code,
21 except for any such provisions waived in this section.
22 1. Except as expressly provided in this section, a law
23 requiring coverage for a specific health care service or
24 benefit, or a law requiring reimbursement, utilization, or
25 consideration of a specific category of licensed health care
26 practitioner, does not apply to a health insurance plan policy
27 or contract offered or delivered under ss. 409.810-409.820
28 unless that law is made expressly applicable to such policies
29 or contracts.
30 2. Notwithstanding chapter 641, a health maintenance
31 organization may issue contracts providing benefits equal to,
24
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1 exceeding, or actuarially equivalent to the benchmark benefit
2 plan authorized by this section and may pay providers located
3 in a rural county negotiated fees or Medicaid reimbursement
4 rates for services provided to enrollees who are residents of
5 the rural county.
6 Section 11. Section 409.816, Florida Statutes, is
7 amended to read:
8 409.816 Limitations on premiums and cost-sharing;
9 penalties for nonpayment of premiums.--The following
10 limitations on premiums and cost-sharing are established for
11 the program.
12 (1) Enrollees who receive coverage under Title XIX of
13 the Social Security Act the Medicaid program may not be
14 required to pay:
15 (a) Enrollment fees, premiums, or similar charges; or
16 (b) Copayments, deductibles, coinsurance, or similar
17 charges.
18 (2) Enrollees in families with a family income equal
19 to or below 150 percent of the federal poverty level, who are
20 not receiving coverage under the Medicaid program, may not be
21 required to pay:
22 (a) Enrollment fees, premiums, or similar charges that
23 exceed the maximum monthly charge permitted under s.
24 1916(b)(1) of the Social Security Act; or
25 (b) Copayments, deductibles, coinsurance, or similar
26 charges that exceed a nominal amount, as determined consistent
27 with regulations referred to in s. 1916(a)(3) of the Social
28 Security Act. However, such charges may not be imposed for
29 preventive services, including well-baby and well-child care,
30 age-appropriate immunizations, and routine hearing and vision
31 screenings.
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1 (3) Enrollees in families with a family income above
2 150 percent of the federal poverty level, who are not
3 receiving coverage under Title XIX of the Social Security Act
4 the Medicaid program or who are not eligible under s. 409.814
5 s. 409.814(5), may be required to pay enrollment fees,
6 premiums, copayments, deductibles, coinsurance, or similar
7 charges on a sliding scale related to income, except that the
8 total annual aggregate cost-sharing with respect to all
9 children in a family may not exceed 5 percent of the family's
10 income. However, copayments, deductibles, coinsurance, or
11 similar charges may not be imposed for preventive services,
12 including well-baby and well-child care, age-appropriate
13 immunizations, and routine hearing and vision screenings.
14 Section 12. Section 409.817, Florida Statutes, is
15 amended to read:
16 409.817 Approval of health benefits coverage;
17 financial assistance.--In order for health insurance coverage
18 to qualify for premium assistance payments for an eligible
19 child under ss. 409.810-409.830 ss. 409.810-409.820, the
20 health benefits coverage must:
21 (1) Be certified by the Office of Insurance Regulation
22 of the Financial Services Commission under s. 409.818 as
23 meeting, exceeding, or being actuarially equivalent to the
24 benchmark benefit plan;
25 (1)(2) Be guarantee issued;
26 (2)(3) Be community rated;
27 (3)(4) Not impose any preexisting condition exclusion
28 for covered benefits; however, group health insurance plans
29 may permit the imposition of a preexisting condition
30 exclusion, but only insofar as it is permitted under s.
31 627.6561;
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1 (4)(5) Comply with the applicable limitations on
2 premiums and cost-sharing in s. 409.816;
3 (5)(6) Comply with the quality assurance and access
4 standards developed under s. 409.818 s. 409.820; and
5 (6)(7) Establish periodic open enrollment periods,
6 which may not occur more frequently than quarterly.
7 Section 13. Section 409.818, Florida Statutes, is
8 amended to read:
9 409.818 Administration.--In order to implement ss.
10 409.810-409.830 ss. 409.810-409.820, the following agencies
11 shall have the following duties:
12 (1) The Department of Children and Family Services
13 shall:
14 (a) Develop a standardized intake process for all
15 Community Access Network partners which informs applicants
16 about coverage and services available through the Florida
17 Kidcare program and collects all information necessary to
18 assess eligibility for any premium assistance.
19 (b)(a) Develop a standardized simplified eligibility
20 application process mail-in form to be used for determining
21 the eligibility of children for coverage for all funding
22 sources through under the Florida Kidcare program, in
23 consultation with the agency, the Department of Health, and
24 the Florida Healthy Kids Corporation. The department shall
25 collect all information necessary to determine eligibility for
26 premium assistance and provide simplified eligibility
27 application form must include an item that provides an
28 opportunity for the applicant to indicate whether coverage is
29 being sought for a child with special health care needs.
30 Families applying for children's Medicaid coverage must also
31 be able to use the standardized simplified application process
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1 form without having to pay a premium.
2 (c)(b) Establish and maintain the eligibility
3 determination process under the program except as specified in
4 subsection (5). No later than July 1, 2008, the department
5 shall directly, or through the services of a contracted
6 third-party administrator, establish and maintain a process
7 for determining eligibility of children for coverage under the
8 entire Florida Kidcare program. The eligibility determination
9 process must be used solely for determining eligibility of
10 applicants for health benefits coverage under the program. The
11 eligibility determination process must include an initial
12 determination of eligibility for any coverage offered under
13 the program, as well as a redetermination or reverification of
14 eligibility each subsequent 6 months. Effective January 1,
15 1999, A child who has not attained the age of 5 and who has
16 been determined eligible for the Medicaid program is eligible
17 for coverage for 12 months without a redetermination or
18 reverification of eligibility. In conducting an eligibility
19 determination, the department shall determine if the child has
20 special health care needs. The department, in consultation
21 with the Agency for Health Care Administration and the Florida
22 Healthy Kids Corporation, shall develop procedures for
23 redetermining eligibility which enable a family to easily
24 update any change in circumstances which could affect
25 eligibility. The department may accept changes in a family's
26 status as reported to the department by the Florida Healthy
27 Kids Corporation without requiring a new application from the
28 family. Redetermination of a child's eligibility for Medicaid
29 may not be linked to a child's eligibility determination for
30 other programs.
31 (d)(c) Inform program applicants about eligibility
28
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1 determinations and ensure appropriate followup procedures for
2 plan enrollment provide information about eligibility of
3 applicants to Medicaid, Medikids, the Children's Medical
4 Services Network, and the Florida Healthy Kids Corporation,
5 and to insurers and their agents, through a centralized
6 coordinating office.
7 (e) No later than, July 1, 2008, in consultation with
8 the Agency for Health Care Administration, establish a single
9 toll-free telephone line to assist families that have
10 questions about the Florida Kidcare program. The single
11 toll-free line shall also connect the applicant or enrollee
12 with customer service for account information established
13 under s. 409.830(1)(b).
14 (f)(d) Adopt such rules as may be necessary for
15 conducting program eligibility functions.
16 (2) The Department of Health shall:
17 (a) In consultation with the agency, develop a minimum
18 set of pediatric quality assurance and access standards,
19 including reporting requirements, for the Florida Kidcare
20 program. The standards must include a process for granting
21 exceptions to specific requirements for quality assurance and
22 access. Compliance with the standards shall be a condition of
23 program participation by health benefits coverage providers.
24 These standards shall comply with the provisions of this
25 chapter and chapter 641 and Title XXI of the Social Security
26 Act.
27 (b) Determine clinical eligibility for and administer
28 the Florida Kidcare Plus health benefits coverage. Design an
29 eligibility intake process for the program, in coordination
30 with the Department of Children and Family Services, the
31 agency, and the Florida Healthy Kids Corporation. The
29
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1 eligibility intake process may include local intake points
2 that are determined by the Department of Health in
3 coordination with the Department of Children and Family
4 Services.
5 (b) Chair a state-level coordinating council to review
6 and make recommendations concerning the implementation and
7 operation of the program. The coordinating council shall
8 include representatives from the department, the Department of
9 Children and Family Services, the agency, the Florida Healthy
10 Kids Corporation, the Office of Insurance Regulation of the
11 Financial Services Commission, local government, health
12 insurers, health maintenance organizations, health care
13 providers, families participating in the program, and
14 organizations representing low-income families.
15 (c) In consultation with the Florida Healthy Kids
16 Corporation and the Department of Children and Family
17 Services, establish a toll-free telephone line to assist
18 families with questions about the program.
19 (c)(d) Adopt such rules as may be necessary to
20 implement this subsection outreach activities.
21 (3) The Agency for Health Care Administration, under
22 the authority granted in s. 409.914(1), shall:
23 (a) Calculate the premium assistance payment necessary
24 to comply with the premium and cost-sharing limitations
25 specified in s. 409.816. The premium assistance payment for
26 each enrollee in a health insurance plan participating in the
27 Florida Healthy Kids Corporation shall equal the premium
28 approved by the Florida Healthy Kids Corporation and the
29 Office of Insurance Regulation of the Financial Services
30 Commission pursuant to ss. 627.410 and 641.31, less any
31 enrollee's share of the premium established within the
30
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1 limitations specified in s. 409.816. The premium assistance
2 payment for each enrollee in an employer-sponsored health
3 insurance plan approved under ss. 409.810-409.820 shall equal
4 the premium for the plan adjusted for any benchmark benefit
5 plan actuarial equivalent benefit rider approved by the Office
6 of Insurance Regulation pursuant to ss. 627.410 and 641.31,
7 less any enrollee's share of the premium established within
8 the limitations specified in s. 409.816. In calculating the
9 premium assistance payment levels for children with family
10 coverage, the agency shall set the premium assistance payment
11 levels for each child proportionately to the total cost of
12 family coverage.
13 (b) Provide fiscal management for Title XIX and Title
14 XXI funding for the Florida Kidcare program, distributing
15 funds among Florida Healthy Kids, the Department of Children
16 and Family Services, and the Department of Health based on
17 costs and the participation of children in the plans and
18 programs available to Florida Kidcare program participants.
19 (c)(b) Make premium assistance payments to health
20 insurance plans on a periodic basis. The agency may use its
21 Medicaid fiscal agent or a contracted third-party
22 administrator in making these payments. The agency may
23 require health insurance plans that participate in the
24 Medikids program or employer-sponsored group health insurance
25 to collect premium payments from an enrollee's family.
26 Participating health insurance plans shall report premium
27 payments collected on behalf of enrollees in the program to
28 the agency in accordance with a schedule established by the
29 agency.
30 (d)(c) Monitor compliance with quality assurance and
31 access standards developed under paragraph (2)(a) s. 409.820.
31
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1 (e)(d) Establish a mechanism for investigating and
2 resolving complaints and grievances from program applicants,
3 enrollees, and health benefits coverage providers, and
4 maintain a record of complaints and confirmed problems. In the
5 case of a child who is enrolled in a health maintenance
6 organization, the agency must use the provisions of s. 641.511
7 to address grievance reporting and resolution requirements.
8 (e) Approve health benefits coverage for participation
9 in the program, following certification by the Office of
10 Insurance Regulation under subsection (4).
11 (f) Adopt rules necessary for calculating premium
12 assistance payment levels, making premium assistance payments,
13 monitoring access and quality assurance standards,
14 investigating and resolving complaints and grievances,
15 administering the Medikids program, and approving health
16 benefits coverage. The agency is designated the lead state
17 agency for Title XXI of the Social Security Act for purposes
18 of receipt of federal funds, for reporting purposes, and for
19 ensuring compliance with federal and state regulations and
20 rules.
21 (g) Develop and implement an outreach and marketing
22 program that educates the public about the Florida Kidcare
23 program, explains procedures for enrolling in Florida Kidcare,
24 and maintains public awareness of the program.
25 (h) Seek and implement federal waivers or state plan
26 amendments necessary to implement this section and ss.
27 409.810-409.830.
28 (4) The Office of Insurance Regulation shall certify
29 that health benefits coverage plans that seek to provide
30 services under the Florida Kidcare program, except those
31 offered through the Florida Healthy Kids Corporation or the
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1 Children's Medical Services Network, meet, exceed, or are
2 actuarially equivalent to the benchmark benefit plan and that
3 health insurance plans will be offered at an approved rate. In
4 determining actuarial equivalence of benefits coverage, the
5 Office of Insurance Regulation and health insurance plans must
6 comply with the requirements of s. 2103 of Title XXI of the
7 Social Security Act. The department shall adopt rules
8 necessary for certifying health benefits coverage plans.
9 (5) The Florida Healthy Kids Corporation shall retain
10 its functions as authorized in s. 624.91, including
11 eligibility determination for participation in the Healthy
12 Kids program.
13 (4)(6) The agency, in consultation with the Department
14 of Health, the Department of Children and Family Services, the
15 Florida Healthy Kids Corporation, and the Office of Insurance
16 Regulation, after consultation with and approval of the
17 Speaker of the House of Representatives and the President of
18 the Senate, is are authorized to make program modifications
19 that are necessary to overcome any objections of the United
20 States Department of Health and Human Services to obtain
21 approval of the state's child health insurance plan under
22 Title XXI of the Social Security Act.
23 Section 14. Section 409.820, Florida Statutes, is
24 repealed.
25 Section 15. Section 409.821, Florida Statutes, is
26 amended to read:
27 409.821 Florida Kidcare program public records
28 exemption.--Notwithstanding any other law to the contrary, Any
29 information identifying a Florida Kidcare program applicant or
30 enrollee, as defined in s. 409.811, held by the Agency for
31 Health Care Administration, the Department of Children and
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1 Family Services, the Department of Health, or the Florida
2 Healthy Kids Corporation is confidential and exempt from s.
3 119.07(1) and s. 24(a), Art. I of the State Constitution. Such
4 information may be disclosed to another governmental entity
5 only if disclosure is necessary for the entity to perform its
6 duties and responsibilities under the Florida Kidcare program
7 and shall be disclosed to the Department of Revenue for
8 purposes of administering the state Title IV-D program. The
9 receiving governmental entity must maintain the confidential
10 and exempt status of such information. Furthermore, such
11 information may not be released to any person without the
12 written consent of the program enrollee or the parent or
13 guardian of the enrollee applicant. This exemption applies to
14 any information identifying a Florida Kidcare program
15 applicant or enrollee held by the Agency for Health Care
16 Administration, the Department of Children and Family
17 Services, the Department of Health, or the Florida Healthy
18 Kids Corporation before, on, or after the effective date of
19 this exemption. A violation of this section is a misdemeanor
20 of the second degree, punishable as provided in s. 775.082 or
21 s. 775.083. This section does not prohibit an enrollee's
22 parent or legal guardian from obtaining confirmation of
23 coverage, dates of coverage, name of the enrollee's health
24 plan, and amount of premium being paid.
25 Section 16. Section 409.830, Florida Statutes, is
26 created to read:
27 409.830 Florida Kidcare Program Consolidation
28 Initiative.--The Florida Kidcare Program Consolidation
29 Initiative is created to provide a seamless delivery system of
30 health benefits to uninsured, low-income children. The
31 initiative shall consolidate the administration of the Florida
34
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1 Kidcare program under the fewest entities necessary for the
2 purpose of conducting marketing and outreach, eligibility
3 determination, premium collection, contract management of
4 health plans and fiscal agents, quality assurance and
5 grievance resolution, and fiscal management of all the
6 components of the Florida Kidcare program. The initiative
7 shall consolidate the Florida Kidcare program's administrative
8 structure and align polices by no later than July 1, 2009. The
9 Agency for Health Care Administration shall manage the
10 consolidation of the Florida Kidcare program. A deputy
11 secretary of Florida Kidcare is created within the agency to
12 represent the interest of children in obtaining necessary
13 health care services and health care coverage. The deputy
14 secretary of Florida Kidcare shall develop policies and
15 strategies for issues related to children's lack of access to
16 high-quality and affordable health care services and coverage.
17 The deputy secretary shall identify and provide
18 recommendations for ways to improve the delivery of services
19 for children through the Florida Kidcare program.
20 (1) ADMINISTRATION.--
21 (a) The Agency for Health Care Administration is
22 designated as the single state agency authorized to make
23 payments for medical assistance and related services; to
24 conduct contract management of health plans, providers, and
25 fiscal agents; to collect premiums; to develop and implement
26 quality assurance and grievance-resolution processes; to
27 conduct marketing and outreach programs; and to conduct other
28 fiscal-management activities relating to all the components of
29 the Florida Kidcare program no later than July 1, 2008.
30 1. The agency, in consultation with the Department of
31 Children and Family Services, shall adopt a standardized
35
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1 application form for the purpose of collecting all information
2 necessary to determine eligibility for all components of the
3 Florida Kidcare program. All eligibility information shall be
4 electronically verified to the extent possible. Each applicant
5 shall supply written documentation of any eligibility
6 information that cannot be electronically verified.
7 2. The agency may contract with capitated managed care
8 plans and other providers to deliver health benefits as
9 necessary under this section and to begin providing services
10 by July 1, 2008.
11 3. No later than July 1, 2008, the agency is
12 responsible for developing and distributing marketing and
13 outreach materials that educate families about the Florida
14 Kidcare program as a whole, including eligibility
15 requirements, application procedures, benefit design, and
16 other information considered necessary to assist families in
17 applying for and remaining in the Florida Kidcare program.
18 Marketing and outreach materials shall present the Florida
19 Kidcare program as a single program and explain that the
20 family's information is collected in order to determine if the
21 family is eligible for a premium discount or for no premium
22 requirement.
23 4. The agency may adopt rules as necessary to
24 administer the Florida Kidcare program, except as specified in
25 s. 409.818.
26 (b) The Department of Children and Family Services is
27 responsible for conducting eligibility determination for all
28 components of the Florida Kidcare program no later than July
29 1, 2008.
30 1. No later than July 1, 2008, the Department of
31 Children and Family Services, in coordination with the agency,
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1 shall be responsible for eligibility determination, including
2 receiving and processing applications for all program
3 components, determining eligibility for all program
4 components, receiving electronic verification, and
5 transmitting and receiving all correspondence related to the
6 eligibility-determination process. All correspondence shall be
7 identified solely with the Florida Kidcare program as a whole.
8 2. No later than July 1, 2008, the Department of
9 Children and family Services is responsible to provide a
10 single toll-free line for a customer service call center to
11 access account information and provide general information
12 concerning the Florida Kidcare program.
13 (c) The Florida Healthy Kids Corporation's remaining
14 roles and responsibilities as defined in s. 624.91 shall be
15 transferred to the agency no later than July 1, 2009.
16 (2) BENEFITS.--No later than July 1, 2008, health
17 benefits, as specified in paragraphs (a) and (b), shall be
18 provided to eligible children under the Florida Kidcare
19 program, except those children with special health care needs
20 who shall be provided benefits under the Florida Kidcare Plus
21 Plan.
22 (a) No later than July 1, 2008, the Florida Kidcare
23 program shall contain the same benefits as specified in ss.
24 409.905 and 409.906 and emergency services provided under s.
25 409.9128.
26 (b) The Florida Kidcare Plus Plan as defined in s.
27 409.811(13) shall contain the same benefits as specified in
28 ss. 409.905 and 409.906 and emergency services provided under
29 s. 409.9128.
30 (3) SERVICE DELIVERY SYSTEMS.--No later than July 1,
31 2008, health care services under the Florida Kidcare program
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1 shall be delivered through managed care plans, primary care
2 case management providers, and fee-for-service providers under
3 contract or other arrangement with the agency. Title XXI
4 enrollees, excluding those enrolled in the Florida Kidcare
5 Plus Plan, shall enroll in a managed care plan if two or more
6 plans are available. Florida Healthy Kids Corporation shall
7 extend health plan contracts through June 30, 2009, for
8 children enrolled in the Florida Healthy Kids program as of
9 July 1, 2008.
10 (4) ELIGIBILITY.--Effective July 1, 2008, children
11 eligible to participate in the Florida Kidcare program are
12 those qualified under the eligibility standards specified in
13 ss. 409.8132, 409.814, 409.8141, 409.903, and 409.904.
14 (5) ENROLLMENT.--Effective July 1, 2008, the parents,
15 guardians or persons applying on behalf of children determined
16 eligible after June 30, 2008, shall choose a Florida Kidcare
17 Plan providing the benefits as described in s. 409.830(2)(a)
18 and (b). Children enrolled in Florida Healthy Kids plans on
19 June 30, 2008, shall transfer to a Florida Kidcare Plan
20 providing the benefits as described in s. 409.830(2)(a) and
21 (b) no later than June 30, 2009.
22 (6) CAPITATION RATES.--No later than July 1, 2008, any
23 managed care plan that participates in the Florida Kidcare
24 program shall be compensated in accordance with s. 409.9124,
25 except in counties compensated in accordance with s.
26 409.91211.
27 (7) WAIVER AUTHORITY.--The agency shall seek federal
28 waiver approval or amendments to the Medicaid state plan and
29 Title XXI state plan which are necessary to implement the
30 initiative as specified in this section.
31 Section 17. Section 624.91, Florida Statutes, is
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1 amended to read:
2 624.91 The Florida Healthy Kids Corporation Act.--
3 (1) SHORT TITLE.--This section may be cited as the
4 "William G. 'Doc' Myers Healthy Kids Corporation Act."
5 (2) LEGISLATIVE INTENT.--
6 (a) The Legislature finds that increased access to
7 health care services could improve children's health and
8 reduce the incidence and costs of childhood illness and
9 disabilities among children in this state. Many children do
10 not have comprehensive, affordable health care services
11 available. It is the intent of the Legislature that the
12 Florida Healthy Kids Corporation provide comprehensive health
13 insurance coverage to such children. The corporation is
14 encouraged to cooperate with any existing health service
15 programs funded by the public or the private sector.
16 (b) It is the intent of the Legislature that the
17 Florida Healthy Kids Corporation serve as one of several
18 providers of services to children eligible for medical
19 assistance under Title XXI of the Social Security Act.
20 Although the corporation may serve other children, the
21 Legislature intends the primary recipients of services
22 provided through the corporation be school-age children with a
23 family income below 200 percent of the federal poverty level,
24 who do not qualify for Medicaid. It is also the intent of the
25 Legislature that state and local government Florida Healthy
26 Kids funds be used to continue coverage, subject to specific
27 appropriations in the General Appropriations Act, to children
28 not eligible for federal matching funds under Title XXI.
29 (3) ELIGIBILITY FOR STATE-FUNDED ASSISTANCE.--Only the
30 following individuals are eligible for state-funded assistance
31 in paying Florida Healthy Kids premiums:
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1 (a) Residents of this state who are eligible for the
2 Florida Kidcare program pursuant to s. 409.814.
3 (b) Notwithstanding s. 409.814, legal aliens who are
4 enrolled in the Florida Healthy Kids program as of January 31,
5 2004, who do not qualify for Title XXI federal funds because
6 they are not qualified aliens as defined in s. 409.811.
7 (3)(4) NONENTITLEMENT.--Nothing in this section shall
8 be construed as providing an individual with an entitlement to
9 health care services. No cause of action shall arise against
10 the state, the Florida Healthy Kids Corporation, or a unit of
11 local government for failure to make health services available
12 under this section.
13 (4)(5) CORPORATION AUTHORIZATION, DUTIES, POWERS.--
14 (a) There is created the Florida Healthy Kids
15 Corporation, a not-for-profit corporation.
16 (b) The Florida Healthy Kids Corporation shall:
17 1. Arrange for the collection of any family, local
18 contributions, or employer payment or premium, in an amount to
19 be determined by the board of directors, to provide for
20 payment of premiums for health benefits comprehensive
21 insurance coverage and for the actual or estimated
22 administrative expenses. No later than July 1, 2009, the
23 collection of family premiums shall be transferred to the
24 Agency for Health Care Administration.
25 2. Arrange for the collection of any voluntary
26 contributions to provide for payment of Florida Kidcare
27 premiums for children who are not eligible for medical
28 assistance under Title XXI of the Social Security Act. No
29 later than July 1, 2009, this function shall be transferred to
30 the Agency for Health Care Administration.
31 3. Subject to the provisions of s. 409.8134, accept
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1 voluntary supplemental local match contributions that comply
2 with the requirements of Title XXI of the Social Security Act
3 for the purpose of providing additional Florida Kidcare
4 coverage in contributing counties under Title XXI. No later
5 than July 1, 2009, this function shall be transferred to the
6 Agency for Health Care Administration.
7 4. Establish the administrative and accounting
8 procedures for the operation of the corporation.
9 5. Establish, with consultation from appropriate
10 professional organizations, standards for preventive health
11 services and providers and comprehensive insurance benefits
12 appropriate to children, provided that the such standards for
13 rural areas do shall not limit primary care providers to
14 board-certified pediatricians.
15 6. Determine eligibility for children seeking to
16 participate in the Title XXI-funded components of the Florida
17 Kidcare program consistent with the requirements specified in
18 s. 409.814, as well as the non-Title-XXI-eligible children as
19 provided in subsection (3). No later than July 1, 2008, this
20 function shall be transferred to the Department of Children
21 and Family Services.
22 7. Establish procedures under which providers of local
23 match to, applicants to and participants in the program may
24 have grievances reviewed by an impartial body and reported to
25 the board of directors of the corporation. No later than July
26 1, 2009, this function shall be transferred to the Agency for
27 Health Care Administration.
28 8. Establish participation criteria and, if
29 appropriate, contract with an authorized insurer, health
30 maintenance organization, or third-party administrator to
31 provide administrative services to the corporation.
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1 9. Establish enrollment criteria which shall include
2 penalties or waiting periods of not fewer than 60 days for
3 reinstatement of coverage upon voluntary cancellation for
4 nonpayment of family premiums.
5 10. Contract with authorized insurers or any provider
6 of health care services, meeting standards established by the
7 corporation, for the provision of comprehensive insurance
8 coverage to participants. Such standards shall include
9 criteria under which the corporation may contract with more
10 than one provider of health care services in program sites.
11 Health plans shall be selected through a competitive bid
12 process. The Florida Healthy Kids Corporation shall purchase
13 goods and services in the most cost-effective manner
14 consistent with the delivery of quality medical care. The
15 maximum administrative cost for a Florida Healthy Kids
16 Corporation contract shall be 15 percent. For health care
17 contracts, the minimum medical loss ratio for a Florida
18 Healthy Kids Corporation contract shall be 85 percent. For
19 dental contracts, the remaining compensation to be paid to the
20 authorized insurer or provider under a Florida Healthy Kids
21 Corporation contract shall be no less than an amount which is
22 85 percent of premium; to the extent any contract provision
23 does not provide for this minimum compensation, this section
24 shall prevail. The health plan selection criteria and scoring
25 system, and the scoring results, shall be available upon
26 request for inspection after the bids have been awarded.
27 11. Establish disenrollment criteria in the event
28 local matching funds are insufficient to cover enrollments.
29 12. Health and dental plans participating in the
30 Florida Healthy Kids program may develop and distribute
31 marketing and other promotional materials and participate in
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1 activities, such as health fairs and public events, as
2 approved by the corporation. The health and dental plans may
3 also contact their current and former enrollees to encourage
4 continued participation in the program and to assist the
5 enrollee in transferring from a Title XIX-financed plan to a
6 Title XXI-financed plan. No later than July 1, 2008, this
7 function shall be transferred to the Department of Children
8 and Family Services. Develop and implement a plan to publicize
9 the Florida Healthy Kids Corporation, the eligibility
10 requirements of the program, and the procedures for enrollment
11 in the program and to maintain public awareness of the
12 corporation and the program.
13 13. Secure staff necessary to properly administer the
14 corporation. Staff costs shall be funded from state and local
15 matching funds and such other private or public funds as
16 become available. The board of directors shall determine the
17 number of staff members necessary to administer the
18 corporation.
19 14. Provide a report annually to the Governor, Chief
20 Financial Officer, Commissioner of Education, Senate
21 President, Speaker of the House of Representatives, and
22 Minority Leaders of the Senate and the House of
23 Representatives.
24 15. Establish benefit packages which conform to the
25 provisions of the Florida Kidcare program, as created in ss.
26 409.810-409.830 ss. 409.810-409.820.
27 (c) Coverage under the corporation's program is
28 secondary to any other available private coverage held by, or
29 applicable to, the participant child or family member.
30 Insurers under contract with the corporation are the payors of
31 last resort and must coordinate benefits with any other
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1 third-party payor that may be liable for the participant's
2 medical care.
3 (d) The Florida Healthy Kids Corporation shall be a
4 private corporation not for profit, organized under pursuant
5 to chapter 617, and shall have all powers necessary to carry
6 out the purposes of this act, including, but not limited to,
7 the power to receive and accept grants, loans, or advances of
8 funds from any public or private agency and to receive and
9 accept from any source contributions of money, property,
10 labor, or any other thing of value, to be held, used, and
11 applied for the purposes of this section act.
12 (5)(6) BOARD OF DIRECTORS.--
13 (a) The Florida Healthy Kids Corporation shall operate
14 subject to the supervision and approval of a board of
15 directors chaired by the Chief Financial Officer or her or his
16 designee, and composed of 10 other members selected for 3-year
17 terms of office as follows:
18 1. The Secretary of Health Care Administration, or his
19 or her designee;
20 2. One member appointed by the Commissioner of
21 Education from the Office of School Health Programs of the
22 Florida Department of Education;
23 3. One member appointed by the Chief Financial Officer
24 from among three members nominated by the Florida Pediatric
25 Society;
26 4. One member, appointed by the Governor, who
27 represents the Children's Medical Services Program;
28 5. One member appointed by the Chief Financial Officer
29 from among three members nominated by the Florida Hospital
30 Association;
31 6. One member, appointed by the Governor, who is an
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1 expert on child health policy;
2 7. One member, appointed by the Chief Financial
3 Officer, from among three members nominated by the Florida
4 Academy of Family Physicians;
5 8. One member, appointed by the Governor, who
6 represents the state Medicaid program;
7 9. One member, appointed by the Chief Financial
8 Officer, from among three members nominated by the Florida
9 Association of Counties; and
10 10. The State Health Officer or her or his designee.
11 (b) A member of the board of directors may be removed
12 by the official who appointed that member. The board shall
13 appoint an executive director, who is responsible for other
14 staff authorized by the board.
15 (c) Board members are entitled to receive, from funds
16 of the corporation, reimbursement for per diem and travel
17 expenses as provided by s. 112.061.
18 (d) There shall be no liability on the part of, and no
19 cause of action shall arise against, any member of the board
20 of directors, or its employees or agents, for any action they
21 take in the performance of their powers and duties under this
22 act.
23 (6)(7) LICENSING NOT REQUIRED; FISCAL OPERATION.--
24 (a) The corporation shall not be deemed an insurer.
25 The officers, directors, and employees of the corporation
26 shall not be deemed to be agents of an insurer. Neither the
27 corporation nor any officer, director, or employee of the
28 corporation is subject to the licensing requirements of the
29 insurance code or the rules of the Department of Financial
30 Services. However, any marketing representative utilized and
31 compensated by the corporation must be appointed as a
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1 representative of the insurers or health services providers
2 with which the corporation contracts.
3 (b) The board has complete fiscal control over the
4 corporation and is responsible for all corporate operations.
5 (c) The Department of Financial Services shall
6 supervise any liquidation or dissolution of the corporation
7 and shall have, with respect to such liquidation or
8 dissolution, all power granted to it pursuant to the insurance
9 code.
10 (7)(8) ACCESS TO RECORDS; CONFIDENTIALITY;
11 PENALTIES.--Notwithstanding any other laws to the contrary,
12 the Florida Healthy Kids Corporation shall have access to the
13 medical records of a student upon receipt of permission from a
14 parent or guardian of the student. Such medical records may be
15 maintained by state and local agencies. Any identifying
16 information, including medical records and family financial
17 information, obtained by the corporation pursuant to this
18 subsection is confidential and is exempt from the provisions
19 of s. 119.07(1). Neither the corporation nor the staff or
20 agents of the corporation may release, without the written
21 consent of the participant or the parent or guardian of the
22 participant, to any state or federal agency, to any private
23 business or person, or to any other entity, any confidential
24 information received pursuant to this subsection. A violation
25 of this subsection is a misdemeanor of the second degree,
26 punishable as provided in s. 775.082 or s. 775.083.
27 (8) The venue for all civil and administrative actions
28 against the Florida Healthy Kids Corporation shall be in Leon
29 County.
30 Section 18. Effective July 1, 2009, section 624.91,
31 Florida Statutes, as amended by this act, is repealed.
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1 Section 19. The Agency for Health Care Administration
2 shall provide a consolidation transition plan that identifies
3 budget, statutory, and administrative issues that need to be
4 addressed in order to implement the provisions of s. 409.830,
5 Florida Statutes. The transition plan shall be provided to the
6 Governor, the President of the Senate, and the Speaker of the
7 House of Representatives by January 1, 2008.
8 Section 20. Except as otherwise expressly provided in
9 this act, this act shall take effect July 1, 2007.
10
11
12 ================ T I T L E A M E N D M E N T ===============
13 And the title is amended as follows:
14 Delete everything before the enacting clause
15
16 and insert:
17 A bill to be entitled
18 An act relating to medical assistance; amending
19 s. 409.811, F.S.; revising and providing
20 definitions relating to the Florida Kidcare
21 Act; amending s. 409.812, F.S.; revising the
22 purpose of the Florida Kidcare program;
23 amending s. 409.813, F.S.; revising the funding
24 sources for the health benefits coverage
25 provided to children under the program;
26 amending s. 409.8132, F.S.; revising the
27 eligibility and enrollment requirements in the
28 Medikids program component; amending s.
29 409.8134, F.S.; revising enrollment procedures;
30 amending s. 409.814, F.S.; revising eligibility
31 requirements for the program; creating s.
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1 409.8141, F.S.; specifying requirements for
2 premium assistance eligibility; creating s.
3 409.8142, F.S.; specifying penalties for
4 fraudulent actions, failure to verify
5 eligibility, and nonpayment of premiums;
6 creating s. 409.8149, F.S.; specifying
7 enrollment procedures and requirements for plan
8 choice; amending s. 409.815, F.S.; revising the
9 health benefits coverage of the Florida Kidcare
10 program; amending s. 409.816, F.S.; revising
11 the limitations on premiums and cost-sharing;
12 amending s. 409.817, F.S.; revising the
13 qualifications for health insurance plans
14 serving the program; amending s. 409.818, F.S.;
15 specifying the duties and responsibilities of
16 the Department of Children and Family Services,
17 the Department of Health, the Agency for Health
18 Care Administration, the Florida Healthy Kids
19 Corporation, and the Office of Insurance
20 Regulation pertaining to the administration of
21 the Florida Kidcare program; repealing s.
22 409.820, F.S., relating to quality assurance
23 and access standards; amending s. 409.821,
24 F.S.; clarifying that provisions exempting
25 certain records from public-records
26 requirements does not prevent an enrollee's
27 parent or guardian from obtaining records and
28 information concerning the enrollee; creating
29 s. 409.830, F.S.; establishing the Florida
30 Kidcare Program Consolidation Initiative, which
31 shall combine the administration of the
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1 program; creating a deputy secretary of Florida
2 Kidcare within the Agency for Health Care
3 Administration; amending s. 624.91, F.S.;
4 revising provisions of the Florida Healthy Kids
5 Corporation Act; deleting certain eligibility
6 requirements; providing for the transfer of
7 functions to the Agency for Health Care
8 Administration and the Department of Children
9 and Family Services; repealing s. 624.91, F.S.,
10 relating to the Florida Healthy Kids
11 Corporation; requiring a consolidation
12 transition plan; providing effective dates.
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
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