Senate Bill sb0930c1
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Florida Senate - 2007 CS for SB 930
By the Committee on Health Policy; and Senator Dawson
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1 A bill to be entitled
2 An act relating to medical assistance; creating
3 s. 14.36, F.S.; creating the Florida Commission
4 on Children's Health within the Executive
5 Office of the Governor; providing for the
6 appointment of members and terms of office;
7 providing for commission members to be
8 reimbursed for per diem and travel expenses;
9 specifying the duties of the commission;
10 requiring the commission to submit an annual
11 report to the Governor; requiring executive
12 branch agencies to assist the commission;
13 authorizing the commission to apply for and
14 accept funds from public and private sources;
15 amending s. 20.43, F.S.; redesignating the
16 Division of Children's Medical Services Network
17 within the Department of Health as the
18 "Division of Children's Medical Services
19 Network and Specialty Programs"; creating the
20 Division of Children's Health Insurance and the
21 Office of Child Health Coordination within the
22 Department of Health; amending s. 391.011,
23 F.S.; redesignating ch. 391, F.S., as the
24 "Children's Health Act"; amending s. 391.016,
25 F.S.; revising legislative intent with respect
26 to certain responsibilities of the Children's
27 Health program; amending s. 391.021, F.S.;
28 revising and providing definitions; amending s.
29 391.025, F.S.; revising the components of the
30 Children's Health program; amending s. 391.026,
31 F.S.; requiring the Department of Health to
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1 administer the Florida Kidcare program;
2 amending s. 391.028, F.S.; revising the duties
3 of the Children's Medical Services Network;
4 designating the network director as the Deputy
5 State Health Office for Children's Health;
6 revising the duties of the director; requiring
7 the Division of Children's Health Insurance to
8 administer the Florida Kidcare program;
9 amending s. 391.029, F.S.; requiring the
10 Department of Health to establish clinical
11 eligibility requirements for Florida Kidcare
12 Plus benefits; providing eligibility criteria;
13 amending s. 409.811, F.S.; revising and
14 providing definitions relating to the Florida
15 Kidcare Act; amending s. 409.812, F.S.;
16 revising the purpose of the Florida Kidcare
17 program; amending s. 409.813, F.S.; revising
18 the funding sources for the health benefits
19 coverage provided to children under the
20 program; amending s. 409.8132, F.S.; providing
21 for the Medikids program component of the
22 Florida Kidcare program to be operated under
23 rules and policies of the Department of Health;
24 amending s. 409.8134, F.S.; revising
25 requirements for the department in conducting
26 enrollment in the Florida Kidcare program;
27 amending s. 409.814, F.S.; revising the
28 eligibility requirements for the program;
29 providing requirements for a child to enroll in
30 Florida Kidcare Plus; providing for an
31 extension of certain coverage benefits in order
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1 to avoid a lapse in coverage; providing for the
2 coverage of certain children whose health
3 benefits have been canceled; providing for
4 nonfederal premium assistance for certain
5 children; deleting provisions authorizing
6 certain limitations on enrollment in Medikids
7 and a reduction in benefits under the Florida
8 Healthy Kids program; providing certain
9 notification requirements if a child is no
10 longer eligible for benefits; requiring the
11 electronic verification of an applicant's
12 family income; amending s. 409.815, F.S.;
13 revising the health benefits coverage of the
14 Florida Kidcare program; amending s. 409.816,
15 F.S.; revising the limitations on premiums and
16 cost-sharing; providing that certain enrollees
17 are exempt from certain fees, premiums,
18 copayments, and deductibles; authorizing the
19 Department of Health to establish penalties or
20 waiting periods for nonpayment of premiums;
21 amending s. 409.8177, F.S.; requiring the
22 department to contract for an evaluation of the
23 Florida Kidcare program; amending s. 409.818,
24 F.S.; requiring a contract for establishing a
25 process for determining the eligibility of
26 certain children for coverage; revising the
27 duties of the Department of Health with respect
28 to reviewing the intake process; requiring the
29 department to publicize the Florida Kidcare
30 program, determine eligibility for Florida
31 Kidcare Plus coverage, and develop standards
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1 for pediatric quality assurance and access;
2 requiring the department to adopt rules;
3 authorizing the department to make certain
4 program modifications upon the approval of the
5 Legislature; repealing s. 409.820, F.S.,
6 relating to quality assurance and access
7 standards; amending s. 409.821, F.S.;
8 clarifying that provisions exempting certain
9 records from public-records requirements does
10 not prevent an enrollee's parent or guardian
11 from obtaining records and information
12 concerning the enrollee; amending s. 409.904,
13 F.S.; revising provisions governing optional
14 payments made under the Medicaid program;
15 requiring that certain children be
16 presumptively eligible for Medicaid; requiring
17 the Agency for Health Care Administration to
18 submit a plan to the Federal Government to
19 implement the Family Opportunity Act; amending
20 s. 409.91211, F.S.; revising certain
21 requirements of a pilot program for capitated
22 managed care to conform to changes made by the
23 act; amending s. 624.91, F.S.; revising
24 provisions of the Florida Healthy Kids
25 Corporation Act; deleting certain eligibility
26 requirements; providing for the transfer of
27 functions to the Department of Health;
28 repealing s. 624.91, F.S., relating to the
29 Florida Healthy Kids Corporation; providing
30 effective dates.
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1 Be It Enacted by the Legislature of the State of Florida:
2
3 Section 1. Section 14.35, Florida Statutes, is created
4 to read:
5 14.35 Florida Commission on Children's Health.--
6 (1)(a) For purposes of this section, the term "health"
7 includes physical, mental, and dental health.
8 (b) The Florida Commission on Children's Health is
9 established in the Executive Office of the Governor. The
10 commission shall be administratively housed within the
11 Executive Office of the Governor. The commission shall consist
12 of 12 members. The Governor, the President of the Senate, the
13 Speaker of the House of Representatives, and the Chief
14 Financial Officer shall each appoint three members.
15 Commissioners shall broadly represent the interests of
16 children in obtaining necessary health care services and
17 health care coverage. Each commissioner shall be appointed to
18 a 4-year term. A commissioner may not serve more than two
19 consecutive terms. A vacancy shall be filled in the same
20 manner as the original appointment. Voting members of the
21 commission may not be employees of the Florida Kidcare partner
22 agencies, the Florida Healthy Kids Corporation, or of other
23 state agencies.
24 (2) The commission shall meet quarterly and upon the
25 call of the chair and two other commissioners. Annually, at
26 the meeting in the first quarter, officers consisting of a
27 chair, vice chair, secretary, and treasurer shall be elected.
28 Each officer shall serve until a successor is elected and
29 qualified. An officer may not serve more than 2 consecutive
30 years in the same office.
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1 (3) Members of the commission shall serve without
2 compensation, but are entitled to reimbursement for per diem
3 and travel expenses in accordance with s. 112.061.
4 (4) The commission shall identify and develop specific
5 strategies for addressing issues related to children's lack of
6 access to high-quality and affordable health care services and
7 health care coverage in this state and shall provide
8 coordinated executive oversight of agencies and departments in
9 the state in order to increase accountability regarding
10 children's health issues. The commission's duties shall
11 include, but are not limited to:
12 (a) Providing recommendations for implementing the
13 consolidation of the Florida Kidcare program.
14 (b) Studying the barriers to children accessing
15 high-quality and affordable health care services and health
16 care coverage in this state.
17 (c) Submitting an annual report to the Governor
18 concerning the status of children's health issues, including,
19 but not limited to, an assessment of the number of uninsured
20 children, the health status of children in this state using
21 public health indicators, the gaps in health care services for
22 children with special health care needs, and the status of
23 programs affecting children's health in this state.
24 (d) Analyzing the responsiveness of state government
25 to the health needs of children and the appropriateness of the
26 response. The commission may submit a plan for recommended
27 restructuring and change to the Governor, the President of the
28 Senate, the Speaker of the House of Representatives, and the
29 Chief Financial Officer at any time it considers appropriate.
30 (e) Receiving quarterly updates from the Department of
31 Health concerning the status of implementing policy changes to
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1 the programs affecting children's health and the
2 implementation of the commission's recommendations.
3 (f) Identifying and providing recommendations for ways
4 to improve the delivery of services for children.
5 (g) Reviewing proposed federal and state legislation
6 affecting children's health and providing recommendations to
7 the Governor on appropriate actions pertaining to this
8 section.
9 (h) Studying and making recommendations to refine the
10 eligibility determination process for the Florida Kidcare
11 program.
12 (5) All executive branch agencies are instructed, and
13 all other state agencies are requested, to aid and assist the
14 commission in any way that helps it accomplish its purpose.
15 (6) The commission may apply for and accept funds,
16 grants, gifts, and services from the state, the Federal
17 Government or any of its agencies, or any other public or
18 private source for the purpose of defraying clerical and
19 administrative costs as may be necessary in carrying out its
20 duties under this section.
21 Section 2. Subsection (3) of section 20.43, Florida
22 Statutes, is amended to read:
23 20.43 Department of Health.--There is created a
24 Department of Health.
25 (3) The following divisions of the Department of
26 Health are established:
27 (a) Division of Administration.
28 (b) Division of Environmental Health.
29 (c) Division of Disease Control.
30 (d) Division of Family Health Services.
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1 (e) Division of Children's Medical Services Network
2 and Specialty Programs.
3 (f) Division of Emergency Medical Operations.
4 (g) Division of Medical Quality Assurance, which is
5 responsible for the following boards and professions
6 established within the division:
7 1. The Board of Acupuncture, created under chapter
8 457.
9 2. The Board of Medicine, created under chapter 458.
10 3. The Board of Osteopathic Medicine, created under
11 chapter 459.
12 4. The Board of Chiropractic Medicine, created under
13 chapter 460.
14 5. The Board of Podiatric Medicine, created under
15 chapter 461.
16 6. Naturopathy, as provided under chapter 462.
17 7. The Board of Optometry, created under chapter 463.
18 8. The Board of Nursing, created under part I of
19 chapter 464.
20 9. Nursing assistants, as provided under part II of
21 chapter 464.
22 10. The Board of Pharmacy, created under chapter 465.
23 11. The Board of Dentistry, created under chapter 466.
24 12. Midwifery, as provided under chapter 467.
25 13. The Board of Speech-Language Pathology and
26 Audiology, created under part I of chapter 468.
27 14. The Board of Nursing Home Administrators, created
28 under part II of chapter 468.
29 15. The Board of Occupational Therapy, created under
30 part III of chapter 468.
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1 16. Respiratory therapy, as provided under part V of
2 chapter 468.
3 17. Dietetics and nutrition practice, as provided
4 under part X of chapter 468.
5 18. The Board of Athletic Training, created under part
6 XIII of chapter 468.
7 19. The Board of Orthotists and Prosthetists, created
8 under part XIV of chapter 468.
9 20. Electrolysis, as provided under chapter 478.
10 21. The Board of Massage Therapy, created under
11 chapter 480.
12 22. The Board of Clinical Laboratory Personnel,
13 created under part III of chapter 483.
14 23. Medical physicists, as provided under part IV of
15 chapter 483.
16 24. The Board of Opticianry, created under part I of
17 chapter 484.
18 25. The Board of Hearing Aid Specialists, created
19 under part II of chapter 484.
20 26. The Board of Physical Therapy Practice, created
21 under chapter 486.
22 27. The Board of Psychology, created under chapter
23 490.
24 28. School psychologists, as provided under chapter
25 490.
26 29. The Board of Clinical Social Work, Marriage and
27 Family Therapy, and Mental Health Counseling, created under
28 chapter 491.
29 (h) Division of Children's Medical Services Prevention
30 and Intervention.
31 (i) Division of Information Technology.
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1 (j) Division of Health Access and Tobacco.
2 (k) Division of Disability Determinations.
3 (l) Division of Children's Health Insurance.
4 (m) Office of Child Health Coordination.
5 Section 3. Section 391.011, Florida Statutes, is
6 amended to read:
7 391.011 Short title.--The provisions of this chapter
8 may be cited as the "Children's Health Act." "Children's
9 Medical Services Act."
10 Section 4. Section 391.016, Florida Statutes, is
11 amended to read:
12 391.016 Legislative intent.--The Legislature intends
13 that the Children's Health Medical Services program:
14 (1) Provide to children with special health care needs
15 a family-centered, comprehensive, and coordinated statewide
16 managed system of care that links community-based health care
17 with multidisciplinary, regional, and tertiary pediatric
18 specialty care. The program may provide for the coordination
19 and maintenance of consistency of the medical home for
20 children in families with a Children's Medical Services
21 program participant, in order to achieve family-centered care.
22 (2) Provide essential preventive, evaluative, and
23 early intervention services for children at risk for or having
24 special health care needs, in order to prevent or reduce
25 long-term disabilities.
26 (3) Serve as a principal provider for children with
27 special health care needs under Titles XIX and XXI of the
28 Social Security Act.
29 (4) Be complementary to children's health training
30 programs essential for the maintenance of a skilled pediatric
31 health care workforce for all Floridians.
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1 (5) Consolidate and coordinate Florida Kidcare child
2 health policy, development of pediatric benefit packages,
3 development of budget and federal and state legislative
4 issues, and development of pediatric quality assurance and
5 access standards.
6 Section 5. Section 391.021, Florida Statutes, is
7 amended to read:
8 391.021 Definitions.--When used in this act, unless
9 the context clearly indicates otherwise:
10 (1) "Children's Medical Services network" or "network"
11 means a statewide managed care service system that includes
12 health care providers, health care facilities, or entities
13 licensed or certified to provide health services in this state
14 which meet the pediatric access and quality standards
15 established by the department as defined in this section. The
16 network shall provide Florida Kidcare Plus benefits as defined
17 in s. 409.811.
18 (2) "Children with special health care needs" means
19 those children younger than 21 years of age who have chronic
20 physical, developmental, behavioral, or emotional conditions
21 and who also require health care and related services of a
22 type or amount beyond that which is generally required by
23 children.
24 (3) "Department" means the Department of Health.
25 (4) "Eligible individual" means a child with a special
26 health care need or a female with a high-risk pregnancy, who
27 meets the financial and medical eligibility standards
28 established in s. 391.029.
29 (5) "Health care provider" means a health care
30 professional, health care facility, or entity licensed or
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1 certified to provide health services in this state that meets
2 the criteria as established by the department.
3 (6) "Health services" includes the prevention,
4 diagnosis, and treatment of human disease, pain, injury,
5 deformity, or disabling conditions.
6 (7) "Maximum income threshold" has the same meaning as
7 in s. 409.811.
8 (8)(7) "Participant" means an eligible individual who
9 is enrolled in the Children's Medical Services program.
10 (9)(8) "Program" means the Children's Medical Services
11 program established in the department.
12 (10) "Safety net" means limited services provided to
13 children with special health care needs who are uninsured or
14 underinsured and do not qualify for Title XIX-funded or Title
15 XXI-funded health benefits coverage.
16 Section 6. Section 391.025, Florida Statutes, is
17 amended to read:
18 391.025 Applicability and scope.--
19 (1) The Children's Health Medical Services program
20 consists of the following components:
21 (a) The newborn screening program established in s.
22 383.14.
23 (b) The regional perinatal intensive care centers
24 program established in ss. 383.15-383.21.
25 (c) A federal or state program authorized by the
26 Legislature.
27 (d) The developmental evaluation and intervention
28 program, including the Florida Infants and Toddlers Early
29 Intervention Program.
30 (e) The Children's Medical Services Network.
31 (f) The Division of Children's Health Insurance.
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1 (g) The Office of Child Health Coordination.
2 (2) The Children's Medical Services Network program
3 shall not be deemed an insurer and is not subject to the
4 licensing requirements of the Florida Insurance Code or the
5 rules adopted thereunder, when providing services to children
6 who receive Title XIX-funded Medicaid benefits, other Title
7 XIX-eligible Medicaid-eligible children with special health
8 care needs, or Title XXI-funded and children with special
9 health care needs participating in the Florida Kidcare
10 program.
11 Section 7. Subsection (19) is added to section
12 391.026, Florida Statutes, to read:
13 391.026 Powers and duties of the department.--The
14 department shall have the following powers, duties, and
15 responsibilities:
16 (19) To administer ss. 409.810-409.820, relating to
17 the Florida Kidcare Act.
18 Section 8. Section 391.028, Florida Statutes, is
19 amended to read:
20 391.028 Administration.--The Children's Medical
21 Services Network program shall have a central office and area
22 offices.
23 (1) The Director of Children's Health Medical Services
24 must be a physician licensed under chapter 458 or chapter 459
25 who has specialized training and experience in the provision
26 of health care to children and who has recognized skills in
27 leadership and the promotion of children's health programs.
28 The director shall be the deputy secretary and the Deputy
29 State Health Officer for Children's Health Medical Services
30 and is appointed by and reports to the secretary. The director
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1 may appoint division directors subject to the approval of the
2 secretary.
3 (2) The director shall designate Children's Medical
4 Services Network area offices to perform operational
5 activities for children with special health care needs,
6 including, but not limited to:
7 (a) Providing case management services for the
8 network.
9 (b) Providing local oversight of the program.
10 (c) Determining an individual's clinical medical and
11 financial eligibility for the program.
12 (d) Participating in the determination of a level of
13 care and medical complexity for long-term care services.
14 (e) Authorizing services in the program and developing
15 spending plans.
16 (f) Participating in the development of treatment
17 plans.
18 (g) Taking part in the resolution of complaints and
19 grievances from participants and health care providers.
20 (3) Each Children's Medical Services Network area
21 office shall be directed by a physician licensed under chapter
22 458 or chapter 459 who has specialized training and experience
23 in the provision of health care to children. The director of
24 a Children's Medical Services area office shall be appointed
25 by the director from the active panel of Children's Medical
26 Services physician consultants.
27 (4) The Division of Children's Health Insurance shall
28 be responsible for administering and coordinating the
29 provisions of ss. 409.810-409.820, relating to the Florida
30 Kidcare Act.
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1 (5) The Office of Child Health Coordination is
2 responsible for child health services not directly related to
3 Florida Kidcare health benefits coverage. This office also
4 shall be responsible for providing staff support to the
5 children's health coordinating council and to the Commission
6 on Children's Health if it is authorized.
7 Section 9. Section 391.029, Florida Statutes, is
8 amended to read:
9 391.029 Program eligibility.--
10 (1) The department shall establish clinical
11 eligibility the medical criteria to determine if an applicant
12 for Florida Kidcare Plus benefits the Children's Medical
13 Services program is an eligible individual.
14 (2) The following individuals are financially eligible
15 to receive services through the Children's Medical Services
16 Network program:
17 (a) A high-risk pregnant female who is eligible for
18 Medicaid.
19 (b) Children with special health care needs from birth
20 to 21 years of age who are eligible for Medicaid.
21 (c) Children with special health care needs from birth
22 to 19 years of age who are eligible for a program under Title
23 XXI of the Social Security Act.
24 (3) Subject to the availability of funds, the
25 following individuals may receive services through the
26 program:
27 (a) Children with special health care needs from birth
28 to 21 years of age whose families do not qualify for Title
29 XIX-financed or Title XXI-financed health benefits coverage
30 family income is above the requirements for financial
31 eligibility under Title XXI of the Social Security Act and
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1 whose projected annual cost of care adjusts the family income
2 to Medicaid financial criteria. In cases where the family
3 income is adjusted based on a projected annual cost of care,
4 the family shall participate financially in the cost of care
5 based on criteria established by the department. These
6 children may receive safety net services, subject to the
7 availability of funds.
8 (b) Children with special health care needs from birth
9 to 21 years of age, as provided in Title V of the Social
10 Security Act.
11 (c) An infant who receives an award of compensation
12 under s. 766.31(1). The Florida Birth-Related Neurological
13 Injury Compensation Association shall reimburse the Children's
14 Medical Services Network the state's share of funding, which
15 must thereafter be used to obtain matching federal funds under
16 Title XXI of the Social Security Act.
17 (d) Children with special health care needs having
18 family incomes above the maximum income threshold who receive
19 Title XIX-financed coverage, if it is authorized.
20 (4) The department shall determine the financial and
21 medical eligibility of children with special health care needs
22 for the program. The department shall also determine the
23 financial ability of the parents, or persons or other agencies
24 having legal custody over such individuals, to pay the costs
25 of health services under the program. The department may pay
26 reasonable travel expenses related to the determination of
27 eligibility for or the provision of health services.
28 (5) Any child who has been provided with surgical or
29 medical care or treatment under this act prior to being
30 adopted shall continue to be eligible to be provided with such
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1 care or treatment after his or her adoption, regardless of the
2 financial ability of the persons adopting the child.
3 Section 10. Section 409.811, Florida Statutes, is
4 amended to read:
5 409.811 Definitions relating to Florida Kidcare
6 Act.--As used in ss. 409.810-409.820, the term:
7 (1) "Actuarially equivalent" means that:
8 (a) The aggregate value of the benefits included in
9 health benefits coverage is equal to the value of the benefits
10 in the benchmark benefit plan; and
11 (b) The benefits included in health benefits coverage
12 are substantially similar to the benefits included in the
13 benchmark benefit plan, except that preventive health services
14 must be the same as in the benchmark benefit plan.
15 (2) "Agency" means the Agency for Health Care
16 Administration.
17 (3) "Applicant" means a parent or guardian of a child
18 or a child whose disability of nonage has been removed under
19 chapter 743, who applies for determination of eligibility for
20 health benefits coverage under ss. 409.810-409.820.
21 (4) "Benchmark benefit plan" means the form and level
22 of health benefits coverage established in s. 409.815.
23 (5) "Child" means any person under 19 years of age.
24 (6) "Child with special health care needs" means a
25 child who has a chronic physical, developmental, behavioral,
26 or emotional condition and who also required health care and
27 related services of a type or amount beyond that which is
28 generally required by children. whose serious or chronic
29 physical or developmental condition requires extensive
30 preventive and maintenance care beyond that required by
31 typically healthy children. Health care utilization by such a
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1 child exceeds the statistically expected usage of the normal
2 child adjusted for chronological age, and such a child often
3 needs complex care requiring multiple providers,
4 rehabilitation services, and specialized equipment in a number
5 of different settings.
6 (7) "Children's Medical Services Network" or "network"
7 means a statewide managed care service system as defined in s.
8 391.021(1).
9 (8) "Community rate" means a method used to develop
10 premiums for a health insurance plan that spreads financial
11 risk across a large population and allows adjustments only for
12 age, gender, family composition, and geographic area.
13 (9) "Department" means the Department of Health.
14 (10) "Enrollee" means a child who has been determined
15 eligible for and is receiving coverage under ss.
16 409.810-409.820.
17 (11) "Family" means the group or the individuals whose
18 income is considered in determining eligibility for the
19 Florida Kidcare program. The family includes a child with a
20 custodial parent or caretaker relative who resides in the same
21 house or living unit or, in the case of a child whose
22 disability of nonage has been removed under chapter 743, the
23 child. The family may also include other individuals whose
24 income and resources are considered in whole or in part in
25 determining eligibility of the child.
26 (11)(12) "Family income" means cash received at
27 periodic intervals from any source, such as wages, benefits,
28 contributions, or rental property. Family income is calculated
29 using the budget methodologies authorized under Title XIX of
30 the Social Security Act. Income also may include any money
31 that would have been counted as income under the Aid to
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1 Families with Dependent Children (AFDC) state plan in effect
2 prior to August 22, 1996.
3 (12) "Florida Kidcare Plus" means health benefits
4 coverage for children with special health care needs which
5 benefits are delivered through the Children's Medical Services
6 Network established in chapter 391.
7 (13) "Florida Kidcare program," "Kidcare program," or
8 "program" means the health benefits program for children
9 administered through ss. 409.810-409.820.
10 (14) "Guarantee issue" means that health benefits
11 coverage must be offered to an individual regardless of the
12 individual's health status, preexisting condition, or claims
13 history.
14 (15) "Health benefits coverage" means protection that
15 provides payment of benefits for covered health care services
16 or that otherwise provides, either directly or through
17 arrangements with other persons, covered health care services
18 on a prepaid per capita basis or on a prepaid aggregate
19 fixed-sum basis.
20 (16) "Health insurance plan" means health benefits
21 coverage under the following:
22 (a) A health plan offered by any certified health
23 maintenance organization or authorized health insurer, except
24 a plan that is limited to the following: a limited benefit,
25 specified disease, or specified accident; hospital indemnity;
26 accident only; limited benefit convalescent care; Medicare
27 supplement; credit disability; dental; vision; long-term care;
28 disability income; coverage issued as a supplement to another
29 health plan; workers' compensation liability or other
30 insurance; or motor vehicle medical payment only; or
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1 (b) An employee welfare benefit plan that includes
2 health benefits established under the Employee Retirement
3 Income Security Act of 1974, as amended.
4 (17) "Healthy Kids" means a component of the Florida
5 Kidcare program of medical assistance for children who are 5
6 through 18 years of age as authorized under s. 624.91 and
7 administered by the Florida Healthy Kids Corporation.
8 (18) "Maximum income threshold" means a percentage of
9 the current federal poverty level used to determine
10 eligibility for certain program components, as approved by
11 federal waiver or an amendment to the state plan. Unless
12 otherwise approved by a federal waiver or an amendment to the
13 state plan, the maximum income threshold is 200 percent of the
14 most recent federal poverty level.
15 (19)(17) "Medicaid" means the medical assistance
16 program authorized by Title XIX of the Social Security Act,
17 and regulations thereunder, and ss. 409.901-409.920, as
18 administered in this state by the agency.
19 (20)(18) "Medically necessary" means the use of any
20 medical treatment, service, equipment, or supply necessary to
21 palliate the effects of a terminal condition, or to prevent,
22 diagnose, correct, cure, alleviate, or preclude deterioration
23 of a condition that threatens life, causes pain or suffering,
24 or results in illness or infirmity and which is:
25 (a) Consistent with the symptom, diagnosis, and
26 treatment of the enrollee's condition;
27 (b) Provided in accordance with generally accepted
28 standards of medical practice;
29 (c) Not primarily intended for the convenience of the
30 enrollee, the enrollee's family, or the health care provider;
31
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1 (d) The most appropriate level of supply or service
2 for the diagnosis and treatment of the enrollee's condition;
3 and
4 (e) Approved by the appropriate medical body or health
5 care specialty involved as effective, appropriate, and
6 essential for the care and treatment of the enrollee's
7 condition.
8 (21)(19) "Medikids" means a component of the Florida
9 Kidcare program of medical assistance authorized by Title XXI
10 of the Social Security Act, and regulations thereunder, and s.
11 409.8132, as administered in the state by the agency.
12 (22)(20) "Preexisting condition exclusion" means, with
13 respect to coverage, a limitation or exclusion of benefits
14 relating to a condition based on the fact that the condition
15 was present before the date of enrollment for such coverage,
16 whether or not any medical advice, diagnosis, care, or
17 treatment was recommended or received before such date.
18 (23)(21) "Premium" means the entire cost of a health
19 insurance plan, including the administration fee or the risk
20 assumption charge.
21 (24)(22) "Premium assistance payment" means the
22 monthly consideration paid by the agency per enrollee in the
23 Florida Kidcare program towards health insurance premiums.
24 (25)(23) "Qualified alien" means an alien as defined
25 in s. 431 of the Personal Responsibility and Work Opportunity
26 Reconciliation Act of 1996, as amended, Pub. L. No. 104-193.
27 (26)(24) "Resident" means a United States citizen, or
28 qualified alien, who is domiciled in this state.
29 (27)(25) "Rural county" means a county having a
30 population density of less than 100 persons per square mile,
31 or a county defined by the most recent United States Census as
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1 rural, in which there is no prepaid health plan participating
2 in the Medicaid program as of July 1, 1998.
3 (28)(26) "Substantially similar" means that, with
4 respect to additional services as defined in s. 2103(c)(2) of
5 Title XXI of the Social Security Act, these services must have
6 an actuarial value equal to at least 75 percent of the
7 actuarial value of the coverage for that service in the
8 benchmark benefit plan and, with respect to the basic services
9 as defined in s. 2103(c)(1) of Title XXI of the Social
10 Security Act, these services must be the same as the services
11 in the benchmark benefit plan.
12 Section 11. Section 409.812, Florida Statutes, is
13 amended to read:
14 409.812 Program created; purpose.--The Florida Kidcare
15 program is created to provide a defined set of health benefits
16 to previously uninsured, low-income children through the
17 establishment of a variety of affordable health benefits
18 coverage options from which families may select coverage and
19 through which families may contribute financially to the
20 health care of their children.
21 Section 12. Section 409.813, Florida Statutes, is
22 amended to read:
23 409.813 Program components; entitlement and
24 nonentitlement.--The Florida Kidcare program includes health
25 benefits coverage provided to children through the following
26 funding sources, which shall be marketed as the Florida
27 Kidcare program:
28 (1) Title XIX of the Social Security Act Medicaid;
29 (2) Title XXI of the Social Security Act Medikids as
30 created in s. 409.8132;
31
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1 (3) The Title V Program of the Social Security Act, as
2 it relates to children with special health care needs The
3 Florida Healthy Kids Corporation as created in s. 624.91;
4 (4) Employer-sponsored group health insurance plans
5 approved under ss. 409.810-409.820; and
6 (5) Full pay premiums for children with family incomes
7 above the maximum income threshold; and The Children's Medical
8 Services network established in chapter 391.
9 (6) For children with special health care needs with
10 family incomes above the maximum income threshold, the family
11 shall be afforded the opportunity to buy into the Medicaid
12 program, pursuant to s. 409.904.
13
14 Except for Title XIX-funded Florida Kidcare coverage under the
15 Medicaid program, coverage under the Florida Kidcare program
16 is not an entitlement. No cause of action shall arise against
17 the state, the department, the Department of Children and
18 Family Services, or the agency for failure to make health
19 services available to any person under ss. 409.810-409.820.
20 Section 13. Section 409.8132, Florida Statutes, is
21 amended to read:
22 409.8132 Medikids program component.--
23 (1) PROGRAM COMPONENT CREATED; PURPOSE.--The Medikids
24 program component is created in the Agency for Health Care
25 Administration to provide health care services under the
26 Florida Kidcare program to eligible children using the
27 administrative structure and provider network of the Medicaid
28 program. Effective July 1, 2008, the Medikids component shall
29 be operated in accordance with the administrative rules and
30 policies developed by the Department of Health.
31
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1 (2) ADMINISTRATION.--The secretary of the agency shall
2 appoint an administrator of the Medikids program component.
3 The Agency for Health Care Administration is designated as the
4 state agency authorized to make payments for medical
5 assistance and related services for the Medikids program
6 component of the Florida Kidcare program. Payments shall be
7 made, subject to any limitations or directions in the General
8 Appropriations Act, only for covered services provided to
9 eligible children by qualified health care providers under the
10 Florida Kidcare program.
11 (3) INSURANCE LICENSURE NOT REQUIRED.--The Medikids
12 program component shall not be subject to the licensing
13 requirements of the Florida Insurance Code or rules adopted
14 thereunder.
15 (4) APPLICABILITY OF LAWS RELATING TO MEDICAID.--The
16 provisions of ss. 409.902, 409.905, 409.906, 409.907, 409.908,
17 409.912, 409.9121, 409.9122, 409.9123, 409.9124, 409.9127,
18 409.9128, 409.913, 409.916, 409.919, 409.920, and 409.9205
19 apply to the administration of the Medikids program component
20 of the Florida Kidcare program, except that s. 409.9122
21 applies to Medikids as modified by the provisions of
22 subsection (7).
23 (5) BENEFITS.--Benefits provided under the Medikids
24 program component shall be the same benefits provided to
25 children as specified in ss. 409.905 and 409.906.
26 (6) ELIGIBILITY.--
27 (a) A child who has attained the age of 1 year but who
28 is under the age of 5 years is eligible to enroll in the
29 Medikids program component of the Florida Kidcare program, if
30 the child is a member of a family that has a family income
31 which exceeds the Medicaid applicable income level as
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1 specified in s. 409.903, but which is equal to or below the
2 maximum income threshold 200 percent of the current federal
3 poverty level. In determining the eligibility of such a
4 child, an assets test is not required. A child who is eligible
5 for Medikids may elect to enroll in Florida Healthy Kids
6 coverage or employer-sponsored group coverage. Effective July
7 1, 2009, age eligibility for the Medikids program component
8 will increase to children who are up to age 19 and who do not
9 have special health care needs. However, a child who is
10 eligible for Medikids may participate in the Florida Healthy
11 Kids program only if the child has a sibling participating in
12 the Florida Healthy Kids program and the child's county of
13 residence permits such enrollment.
14 (b) The provisions of s. 409.814(3), (5) (4), and (7)
15 (5) shall be applicable 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
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1 (8) PENALTIES FOR VOLUNTARY CANCELLATION.--The agency
2 shall establish enrollment criteria that must include
3 penalties or waiting periods of not fewer than 60 days for
4 reinstatement of coverage upon voluntary cancellation for
5 nonpayment of premiums.
6 Section 14. Section 409.8134, Florida Statutes, is
7 amended to read:
8 409.8134 Program expenditure ceiling; enrollment.--
9 (1) Except for the Medicaid program, a ceiling shall
10 be placed on annual federal and state expenditures for the
11 Florida Kidcare program as provided each year in the General
12 Appropriations Act.
13 (2) The Florida Kidcare program shall may conduct
14 enrollment continuously at any time throughout the year for
15 the purpose of enrolling children eligible for all program
16 components listed in s. 409.813 except Medicaid. The four
17 Florida Kidcare administrators shall work together to ensure
18 that the year-round enrollment period is announced statewide.
19 Children eligible for Title XXI-funded Florida Kidcare
20 coverage Eligible children shall be enrolled on a first-come,
21 first-served basis using the date the enrollment application
22 is received. Enrollment shall immediately cease when the
23 expenditure ceiling is reached. Year-round enrollment shall
24 only be held if the Social Services Estimating Conference
25 determines that sufficient federal and state funds will be
26 available to finance the increased enrollment through federal
27 fiscal year 2007. Any individual who is not enrolled must
28 reapply by submitting a new application. The application for
29 the Florida Kidcare program is shall be valid for a period of
30 120 days after the date it was received. At the end of the
31 120-day period, if the applicant has not been enrolled in the
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1 program, the application is shall be invalid and the applicant
2 shall be notified of the action. The applicant may reactivate
3 resubmit the application after notification of the action
4 taken by the program. Except for the Medicaid program,
5 whenever the Social Services Estimating Conference determines
6 that there are presently, or will be by the end of the current
7 fiscal year, insufficient funds to finance the current or
8 projected enrollment in the Florida Kidcare program, all
9 additional enrollment must cease and additional enrollment may
10 not resume until sufficient funds are available to finance
11 such enrollment.
12 (3) Upon determination by the Social Services
13 Estimating Conference that there are insufficient funds to
14 finance the current enrollment in the Florida Kidcare program
15 within current appropriations, the program shall initiate
16 disenrollment procedures to remove enrollees, except those
17 children who receive Florida Kidcare Plus benefits enrolled in
18 the Children's Medical Services Network, on a last-in,
19 first-out basis until the expenditure and appropriation levels
20 are balanced.
21 (4) The agencies that administer the Florida Kidcare
22 program components shall collect and analyze the data needed
23 to project program enrollment costs, including price level
24 adjustments, participation and attrition rates, current and
25 projected caseloads, the estimated number of children in the
26 state who are uninsured based on data from the most recent
27 United States Census, utilization, and current and projected
28 expenditures for the next 3 years. The agencies shall report
29 caseload and expenditure trends and estimated numbers of
30 uninsured children to the Social Services Estimating
31 Conference in accordance with chapter 216.
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1 Section 15. Section 409.814, Florida Statutes, is
2 amended to read:
3 409.814 Eligibility.--A child who has not reached 19
4 years of age whose family income is equal to or below the
5 maximum income threshold 200 percent of the federal poverty
6 level is eligible for the Florida Kidcare program as provided
7 in this section. For enrollment in Florida Kidcare Plus the
8 Children's Medical Services Network, a complete application
9 includes clinical eligibility the medical or behavioral health
10 screening. If, subsequently, an individual is determined to be
11 ineligible for coverage, he or she must immediately be
12 disenrolled from the respective Florida Kidcare program
13 component.
14 (1) A child who is eligible for Medicaid coverage
15 under s. 409.903 or s. 409.904 must be enrolled in Medicaid
16 and is not eligible to receive health benefits under any other
17 health benefits coverage authorized under the Florida Kidcare
18 program.
19 (2) A child who is not eligible for Medicaid, but who
20 is eligible for the Florida Kidcare program, may obtain health
21 benefits coverage under any of the other components listed in
22 s. 409.813 if such coverage is approved and available in the
23 county in which the child resides. However, a child who is
24 eligible for Medikids may participate in the Florida Healthy
25 Kids program only if the child has a sibling participating in
26 the Florida Healthy Kids program and the child's county of
27 residence permits such enrollment.
28 (3) A child who is eligible for the Florida Kidcare
29 program who is a child with special health care needs, as
30 determined through a clinical-eligibility medical or
31 behavioral screening instrument, shall receive Florida Kidcare
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1 is eligible for health benefits coverage from and shall be
2 referred to the Children's Medical Services Network. A Title
3 XIX-funded child with special health care needs may opt out of
4 Florida Kidcare Plus health benefits coverage and make another
5 selection for the delivery of the child's health benefits
6 coverage.
7 (4) A child who becomes ineligible for Title
8 XIX-funded Florida Kidcare health benefits coverage due to
9 exceeding income or age limits shall have 60 days of continued
10 eligibility following redetermination before premium payments
11 are required in order to allow for a transition to Title
12 XXI-funded Florida Kidcare without a lapse in coverage.
13 (5)(4) The following children are not eligible to
14 receive Title XXI-funded premium assistance for health
15 benefits coverage under the Florida Kidcare program, except
16 under Medicaid if the child would have been eligible for
17 Medicaid under s. 409.903 or s. 409.904 as of June 1, 1997:
18 (a) A child who is eligible for coverage under a state
19 health benefit plan on the basis of a family member's
20 employment with a public agency in the state.
21 (b) A child who is currently eligible for or covered
22 under a family member's group health benefit plan or under
23 other employer health insurance coverage, excluding full pay
24 Florida Kidcare health benefits coverage provided under the
25 Florida Healthy Kids Corporation as established under s.
26 624.91, if provided that the cost of the child's participation
27 is not greater than 5 percent of the family's income. This
28 provision shall be applied during redetermination for children
29 who were enrolled prior to July 1, 2004. These enrollees shall
30 have 6 months of eligibility following redetermination to
31 allow for a transition to the other health benefit plan.
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1 (c) A child who is seeking premium assistance for the
2 Florida Kidcare program through employer-sponsored group
3 coverage, if the child has been covered by the same employer's
4 group coverage during the 60 days 6 months prior to the
5 family's submitting an application for determination of
6 eligibility under the program.
7 (d) A child who is an alien, but who does not meet the
8 definition of qualified alien, in the United States.
9 (e) A child who is an inmate of a public institution
10 or a patient in an institution for mental diseases.
11 (f) A child who has had his or her coverage in an
12 employer-sponsored health benefit plan or a private health
13 benefit plan voluntarily canceled in the last 60 days 6
14 months, except those children whose coverage was canceled for
15 good cause, including, but not limited to:
16 1. The cost of participation in an employer-sponsored
17 health benefit plan is greater than 5 percent of the family's
18 income;
19 2. The parent lost a job that provided an
20 employer-sponsored health benefit plan for children;
21 3. The parent who had health benefits coverage for the
22 child is deceased;
23 4. The child has a medical condition that, without
24 medical care, would cause serious disability, loss of
25 function, or death;
26 5. The employer of the parent canceled health benefits
27 coverage for children;
28 6. The child's health benefits coverage ended because
29 the child reached the maximum lifetime coverage amount;
30 7. The child has exhausted coverage under a COBRA
31 continuation provision;
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1 8. The health benefits coverage does not cover the
2 child's health care needs; or
3 9. Domestic violence led to loss of coverage. who were
4 on the waiting list prior to March 12, 2004.
5 (g) A child who is otherwise eligible for Kidcare and
6 who has a preexisting condition that prevents coverage under
7 another insurance plan as described in paragraph (b) which
8 would have disqualified the child for Kidcare if the child
9 were able to enroll in the plan shall be eligible for Kidcare
10 coverage when enrollment is possible.
11 (6) Subject to a specific appropriation for this
12 purpose, the following children are eligible to receive
13 nonfederal premium assistance for health benefits coverage
14 under the Florida Kidcare program if the child would otherwise
15 qualify:
16 (a) A child who is eligible for coverage under a
17 health benefit plan on the basis of a family member's
18 employment with a public agency in the state.
19 (b) A child who is an alien, but who does not meet the
20 definition of a qualified alien, in the United States.
21 (7)(5) A child whose family income is above the
22 maximum income threshold 200 percent of the federal poverty
23 level or a child who is excluded under the provisions of
24 subsection (5) (4) may participate in the Florida Kidcare
25 program if Medikids program as provided in s. 409.8132 or, if
26 the child is ineligible for Medikids by reason of age, in the
27 Florida Healthy Kids program, subject to the following
28 provisions:
29 (a) the family is not eligible for premium assistance
30 payments and must pay the full cost of the premium, including
31 any administrative costs.
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1 (b) The agency is authorized to place limits on
2 enrollment in Medikids by these children in order to avoid
3 adverse selection. The number of children participating in
4 Medikids whose family income exceeds 200 percent of the
5 federal poverty level must not exceed 10 percent of total
6 enrollees in the Medikids program.
7 (c) The board of directors of the Florida Healthy Kids
8 Corporation is authorized to place limits on enrollment of
9 these children in order to avoid adverse selection. In
10 addition, the board is authorized to offer a reduced benefit
11 package to these children in order to limit program costs for
12 such families. The number of children participating in the
13 Florida Healthy Kids program whose family income exceeds 200
14 percent of the federal poverty level must not exceed 10
15 percent of total enrollees in the Florida Healthy Kids
16 program.
17 (8)(6) Once a child is enrolled in the Florida Kidcare
18 program, the child is eligible for coverage under the program
19 for 12 months without a redetermination or reverification of
20 eligibility, if the family continues to pay the applicable
21 premium. Eligibility for Florida Kidcare coverage program
22 components funded through Title XXI of the Social Security Act
23 shall terminate when a child attains the age of 19. Effective
24 January 1, 1999, A child who has not attained the age of 19 5
25 and who has been determined eligible for the Medicaid program
26 is eligible for coverage for 12 months without a
27 redetermination or reverification of eligibility.
28 (9)(7) When determining or reviewing a child's
29 eligibility under the Florida Kidcare program, the applicant
30 shall be provided with reasonable notice of changes in
31 eligibility which may affect the funding source of the child's
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1 Florida Kidcare health benefits coverage enrollment in one or
2 more of the program components. When a transition from one
3 program component to another is authorized, there shall be
4 cooperation between the program components, and the affected
5 family, the child's health plan, and providers which promotes
6 continuity of health benefits care coverage. When a child is
7 no longer eligible for Title XIX-funded Florida Kidcare health
8 benefits coverage, the child's health plan and other providers
9 shall be notified at the same time the family is notified so
10 that the health plans and providers may assist the family in
11 maintaining continuous health care coverage in the Florida
12 Kidcare program. Any authorized transfers must be managed
13 within the program's overall appropriated or authorized levels
14 of funding. Each component of the program shall establish a
15 reserve to ensure that transfers between components will be
16 accomplished within current year appropriations. These
17 reserves shall be reviewed by each convening of the Social
18 Services Estimating Conference to determine the adequacy of
19 such reserves to meet actual experience.
20 (10)(8) In determining the eligibility of a child, an
21 assets test is not required. During the application process
22 and the redetermination process:
23 (a) Each applicant's family income shall be verified
24 electronically to determine financial eligibility for the
25 Florida Kidcare program. Written documentation, which may
26 include wages and earning statements such as pay stubs, W-2
27 forms, or a copy of the applicant's most recent federal income
28 tax return, shall be required only if the electronic
29 verification does not substantiate the applicant's income.
30 Each applicant shall provide written documentation during the
31
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1 application process and the redetermination process,
2 including, but not limited to, the following:
3 (a) Proof of family income, which must include a copy
4 of the applicant's most recent federal income tax return. In
5 the absence of a federal income tax return, an applicant may
6 submit wages and earnings statements (pay stubs), W-2 forms,
7 or other appropriate documents.
8 (b) Each applicant shall provide a statement from all
9 applicable family members that:
10 1. Their employers do employer does not sponsor a
11 health benefit plans plan for employees; or
12 2. The potential enrollee is not covered by an the
13 employer-sponsored health benefit plan because the potential
14 enrollee is not eligible for coverage, or, if the potential
15 enrollee is eligible but not covered, a statement of the cost
16 to enroll the potential enrollee in the employer-sponsored
17 health benefit plan.
18 (11)(9) Subject to paragraph (5) (4)(b) and s.
19 624.91(4), the Florida Kidcare program shall withhold benefits
20 from an enrollee if the program obtains evidence that the
21 enrollee is no longer eligible, submitted incorrect or
22 fraudulent information in order to establish eligibility, or
23 failed to provide verification of eligibility. The applicant
24 or enrollee shall be notified that because of such evidence
25 program benefits will be withheld unless the applicant or
26 enrollee contacts a designated representative of the program
27 by a specified date, which must be within 14 working 10 days
28 after the date of notice, to discuss and resolve the matter.
29 The program shall make every effort to resolve the matter
30 within a timeframe that will not cause benefits to be withheld
31 from an eligible enrollee.
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1 (12)(10) The following individuals may be subject to
2 prosecution in accordance with s. 414.39:
3 (a) An applicant obtaining or attempting to obtain
4 benefits for a potential enrollee under the Florida Kidcare
5 program when the applicant knows or should have known the
6 potential enrollee does not qualify for the Florida Kidcare
7 program.
8 (b) An individual who assists an applicant in
9 obtaining or attempting to obtain benefits for a potential
10 enrollee under the Florida Kidcare program when the individual
11 knows or should have known the potential enrollee does not
12 qualify for the Florida Kidcare program.
13 Section 16. Section 409.815, Florida Statutes, is
14 amended to read:
15 409.815 Health benefits coverage; limitations.--
16 (1) MEDICAID BENEFITS.--For purposes of the Florida
17 Kidcare program, benefits available under Medicaid and
18 Medikids include those goods and services provided under the
19 medical assistance program authorized by Title XIX of the
20 Social Security Act, and regulations thereunder, as
21 administered in this state by the agency. This includes those
22 mandatory Medicaid services authorized under s. 409.905 and
23 optional Medicaid services authorized under s. 409.906,
24 rendered on behalf of eligible individuals by qualified
25 providers, in accordance with federal requirements for Title
26 XIX, subject to any limitations or directions provided for in
27 the General Appropriations Act or chapter 216, and according
28 to methodologies and limitations set forth in agency rules and
29 policy manuals and handbooks incorporated by reference
30 thereto.
31
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1 (2) BENCHMARK BENEFITS.--In order for health benefits
2 coverage to qualify for premium assistance payments for an
3 eligible child under ss. 409.810-409.820, the health benefits
4 coverage must be equivalent to the pediatric Medicaid benefit
5 package and be based upon a standard and appropriate
6 assessment of need for the services consistent with Early and
7 Periodic Screening, Diagnosis, and Treatment requirements as
8 specified in s. 409.905(2) and Title XIX of the Social
9 Security Act, except for coverage under Medicaid and Medikids,
10 must include the following minimum benefits, as medically
11 necessary.
12 (a) Preventive health services.--Covered services
13 include:
14 1. Well-child care, including services recommended in
15 the Guidelines for Health Supervision of Children and Youth as
16 developed by the American Academy of Pediatrics;
17 2. Immunizations and injections;
18 3. Health education counseling and clinical services;
19 4. Vision screening; and
20 5. Hearing screening.
21 (b) Inpatient hospital services.--All covered services
22 provided for the medical care and treatment of an enrollee who
23 is admitted as an inpatient to a hospital licensed under part
24 I of chapter 395, with the following exceptions:
25 1. All admissions must be authorized by the enrollee's
26 health benefits coverage provider.
27 2. The length of the patient stay shall be determined
28 based on the medical condition of the enrollee in relation to
29 the necessary and appropriate level of care.
30
31
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1 3. Room and board may be limited to semiprivate
2 accommodations, unless a private room is considered medically
3 necessary or semiprivate accommodations are not available.
4 4. Admissions for rehabilitation and physical therapy
5 are limited to 15 days per contract year.
6 (c) Emergency services.--Covered services include
7 visits to an emergency room or other licensed facility if
8 needed immediately due to an injury or illness and delay means
9 risk of permanent damage to the enrollee's health. Health
10 maintenance organizations shall comply with the provisions of
11 s. 641.513.
12 (d) Maternity services.--Covered services include
13 maternity and newborn care, including prenatal and postnatal
14 care, with the following limitations:
15 1. Coverage may be limited to the fee for vaginal
16 deliveries; and
17 2. Initial inpatient care for newborn infants of
18 enrolled adolescents shall be covered, including normal
19 newborn care, nursery charges, and the initial pediatric or
20 neonatal examination, and the infant may be covered for up to
21 3 days following birth.
22 (e) Organ transplantation services.--Covered services
23 include pretransplant, transplant, and postdischarge services
24 and treatment of complications after transplantation for
25 transplants deemed necessary and appropriate within the
26 guidelines set by the Organ Transplant Advisory Council under
27 s. 765.53 or the Bone Marrow Transplant Advisory Panel under
28 s. 627.4236.
29 (f) Outpatient services.--Covered services include
30 preventive, diagnostic, therapeutic, palliative care, and
31 other services provided to an enrollee in the outpatient
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1 portion of a health facility licensed under chapter 395,
2 except for the following limitations:
3 1. Services must be authorized by the enrollee's
4 health benefits coverage provider; and
5 2. Treatment for temporomandibular joint disease (TMJ)
6 is specifically excluded.
7 (g) Behavioral health services.--
8 1. Mental health benefits include:
9 a. Inpatient services, limited to not more than 30
10 inpatient days per contract year for psychiatric admissions,
11 or residential services in facilities licensed under s.
12 394.875(8) or s. 395.003 in lieu of inpatient psychiatric
13 admissions; however, a minimum of 10 of the 30 days shall be
14 available only for inpatient psychiatric services when
15 authorized by a physician; and
16 b. Outpatient services, including outpatient visits
17 for psychological or psychiatric evaluation, diagnosis, and
18 treatment by a licensed mental health professional, limited to
19 a maximum of 40 outpatient visits each contract year.
20 2. Substance abuse services include:
21 a. Inpatient services, limited to not more than 7
22 inpatient days per contract year for medical detoxification
23 only and 30 days of residential services; and
24 b. Outpatient services, including evaluation,
25 diagnosis, and treatment by a licensed practitioner, limited
26 to a maximum of 40 outpatient visits per contract year.
27 (h) Durable medical equipment.--Covered services
28 include equipment and devices that are medically indicated to
29 assist in the treatment of a medical condition and
30 specifically prescribed as medically necessary, with the
31 following limitations:
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1 1. Low-vision and telescopic aides are not included.
2 2. Corrective lenses and frames may be limited to one
3 pair every 2 years, unless the prescription or head size of
4 the enrollee changes.
5 3. Hearing aids shall be covered only when medically
6 indicated to assist in the treatment of a medical condition.
7 4. Covered prosthetic devices include artificial eyes
8 and limbs, braces, and other artificial aids.
9 (i) Health practitioner services.--Covered services
10 include services and procedures rendered to an enrollee when
11 performed to diagnose and treat diseases, injuries, or other
12 conditions, including care rendered by health practitioners
13 acting within the scope of their practice, with the following
14 exceptions:
15 1. Chiropractic services shall be provided in the same
16 manner as in the Florida Medicaid program.
17 2. Podiatric services may be limited to one visit per
18 day totaling two visits per month for specific foot disorders.
19 (j) Home health services.--Covered services include
20 prescribed home visits by both registered and licensed
21 practical nurses to provide skilled nursing services on a
22 part-time intermittent basis, subject to the following
23 limitations:
24 1. Coverage may be limited to include skilled nursing
25 services only;
26 2. Meals, housekeeping, and personal comfort items may
27 be excluded; and
28 3. Private duty nursing is limited to circumstances
29 where such care is medically necessary.
30 (k) Hospice services.--Covered services include
31 reasonable and necessary services for palliation or management
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1 of an enrollee's terminal illness, with the following
2 exceptions:
3 1. Once a family elects to receive hospice care for an
4 enrollee, other services that treat the terminal condition
5 will not be covered; and
6 2. Services required for conditions totally unrelated
7 to the terminal condition are covered to the extent that the
8 services are included in this section.
9 (l) Laboratory and X-ray services.--Covered services
10 include diagnostic testing, including clinical radiologic,
11 laboratory, and other diagnostic tests.
12 (m) Nursing facility services.--Covered services
13 include regular nursing services, rehabilitation services,
14 drugs and biologicals, medical supplies, and the use of
15 appliances and equipment furnished by the facility, with the
16 following limitations:
17 1. All admissions must be authorized by the health
18 benefits coverage provider.
19 2. The length of the patient stay shall be determined
20 based on the medical condition of the enrollee in relation to
21 the necessary and appropriate level of care, but is limited to
22 not more than 100 days per contract year.
23 3. Room and board may be limited to semiprivate
24 accommodations, unless a private room is considered medically
25 necessary or semiprivate accommodations are not available.
26 4. Specialized treatment centers and independent
27 kidney disease treatment centers are excluded.
28 5. Private duty nurses, television, and custodial care
29 are excluded.
30 6. Admissions for rehabilitation and physical therapy
31 are limited to 15 days per contract year.
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1 (n) Prescribed drugs.--
2 1. Coverage shall include drugs prescribed for the
3 treatment of illness or injury when prescribed by a licensed
4 health practitioner acting within the scope of his or her
5 practice.
6 2. Prescribed drugs may be limited to generics if
7 available and brand name products if a generic substitution is
8 not available, unless the prescribing licensed health
9 practitioner indicates that a brand name is medically
10 necessary.
11 3. Prescribed drugs covered under this section shall
12 include all prescribed drugs covered under the Florida
13 Medicaid program.
14 (o) Therapy services.--Covered services include
15 rehabilitative services, including occupational, physical,
16 respiratory, and speech therapies, with the following
17 limitations:
18 1. Services must be for short-term rehabilitation
19 where significant improvement in the enrollee's condition will
20 result; and
21 2. Services shall be limited to not more than 24
22 treatment sessions within a 60-day period per episode or
23 injury, with the 60-day period beginning with the first
24 treatment.
25 (p) Transportation services.--Covered services include
26 emergency transportation required in response to an emergency
27 situation.
28 (q) Dental services.--Dental services shall be covered
29 and may include those dental benefits provided to children by
30 the Florida Medicaid program under s. 409.906(6).
31
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1 (r) Lifetime maximum.--Health benefits coverage
2 obtained under ss. 409.810-409.820 shall pay an enrollee's
3 covered expenses at a lifetime maximum of $1 million per
4 covered child.
5 (a)(s) Cost-sharing.--Cost-sharing provisions must
6 comply with s. 409.816.
7 (b)(t) Exclusions.--
8 1. Experimental or investigational procedures that
9 have not been clinically proven by reliable evidence are
10 excluded;
11 2. Services performed for cosmetic purposes only or
12 for the convenience of the enrollee are excluded; and
13 3. Abortion may be covered only if necessary to save
14 the life of the mother or if the pregnancy is the result of an
15 act of rape or incest.
16 (c)(u) Enhancements to minimum requirements.--
17 1. This section sets the minimum benefits that must be
18 included in any health benefits coverage, other than Medicaid
19 or Medikids coverage, offered under ss. 409.810-409.820.
20 Health benefits coverage may include additional benefits not
21 included in the pediatric Medicaid benefit package under this
22 subsection, but may not include benefits excluded under
23 paragraph (b) (s).
24 2. Health benefits coverage may extend any limitations
25 beyond the minimum benefits described in this section.
26
27 Except for Florida Kidcare Plus benefits the Children's
28 Medical Services Network, the agency may not increase the
29 premium assistance payment for either additional benefits
30 provided beyond the minimum benefits described in this section
31 or the imposition of less restrictive service limitations.
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1 (d)(v) Applicability of other state laws.--Health
2 insurers, health maintenance organizations, and their agents
3 are subject to the provisions of the Florida Insurance Code,
4 except for any such provisions waived in this section.
5 1. Except as expressly provided in this section, a law
6 requiring coverage for a specific health care service or
7 benefit, or a law requiring reimbursement, utilization, or
8 consideration of a specific category of licensed health care
9 practitioner, does not apply to a health insurance plan policy
10 or contract offered or delivered under ss. 409.810-409.820
11 unless that law is made expressly applicable to such policies
12 or contracts.
13 2. Notwithstanding chapter 641, a health maintenance
14 organization may issue contracts providing benefits equal to,
15 exceeding, or actuarially equivalent to the benchmark benefit
16 plan authorized by this section and may pay providers located
17 in a rural county negotiated fees or Medicaid reimbursement
18 rates for services provided to enrollees who are residents of
19 the rural county.
20 Section 17. Section 409.816, Florida Statutes, is
21 amended to read:
22 409.816 Limitations on premiums and cost-sharing;
23 penalties for nonpayment of premiums.--The following
24 limitations on premiums and cost-sharing are established for
25 the program.
26 (1) Enrollees who receive coverage under Title XIX of
27 the Social Security Act the Medicaid program may not be
28 required to pay:
29 (a) Enrollment fees, premiums, or similar charges; or
30 (b) Copayments, deductibles, coinsurance, or similar
31 charges.
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1 (2) Enrollees in families with a family income equal
2 to or below 150 percent of the federal poverty level, who are
3 not receiving coverage under the Medicaid program, may not be
4 required to pay:
5 (a) Enrollment fees, premiums, or similar charges that
6 exceed the maximum monthly charge permitted under s.
7 1916(b)(1) of the Social Security Act; or
8 (b) Copayments, deductibles, coinsurance, or similar
9 charges that exceed a nominal amount, as determined consistent
10 with regulations referred to in s. 1916(a)(3) of the Social
11 Security Act. However, such charges may not be imposed for
12 preventive services, including well-baby and well-child care,
13 age-appropriate immunizations, and routine hearing and vision
14 screenings.
15 (3) Enrollees in families with a family income above
16 150 percent of the federal poverty level, who are not
17 receiving coverage under the Medicaid program or who are not
18 eligible under s. 409.814(7) s. 409.814(5), may be required to
19 pay enrollment fees, premiums, copayments, deductibles,
20 coinsurance, or similar charges on a sliding scale related to
21 income, except that the total annual aggregate cost-sharing
22 with respect to all children in a family may not exceed 5
23 percent of the family's income. However, copayments,
24 deductibles, coinsurance, or similar charges may not be
25 imposed for preventive services, including well-baby and
26 well-child care, age-appropriate immunizations, and routine
27 hearing and vision screenings.
28 (4) Enrollees in families having a family income up to
29 the maximum income threshold who receive Florida Kidcare Plus
30 benefits may not be required to pay:
31 (a) Enrollment fees, premiums, or similar charges; or
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1 (b) Copayments, deductibles, coinsurance, or similar
2 charges.
3 (5) The Department of Health may establish penalties
4 or waiting periods of not more than 30 days for reinstatement
5 of coverage upon cancellation for nonpayment of premiums.
6 Section 18. Paragraph (i) of subsection (1) of section
7 409.8177, Florida Statutes, is amended to read:
8 409.8177 Program evaluation.--
9 (1) The agency, in consultation with the Department of
10 Health, the Department of Children and Family Services, and
11 the Florida Healthy Kids Corporation, shall contract for an
12 evaluation of the Florida Kidcare program and shall by January
13 1 of each year submit to the Governor, the President of the
14 Senate, and the Speaker of the House of Representatives a
15 report of the program. In addition to the items specified
16 under s. 2108 of Title XXI of the Social Security Act, the
17 report shall include an assessment of crowd-out and access to
18 health care, as well as the following:
19 (i) An assessment of the effectiveness of the Florida
20 Kidcare program Medikids, Children's Medical Services network,
21 and other public and private programs in the state in
22 increasing the availability of affordable quality health
23 insurance and health care for children. Effective July 1,
24 2008, the Department of Health shall assume responsibility for
25 contracting for an evaluation of the Florida Kidcare program.
26 Section 19. Section 409.818, Florida Statutes, is
27 amended to read:
28 409.818 Administration.--In order to implement ss.
29 409.810-409.820, the following agencies shall have the
30 following duties:
31
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1 (1) The Department of Children and Family Services
2 shall:
3 (a) Develop a simplified eligibility application
4 mail-in form to be used for determining the eligibility of
5 children for coverage under the Florida Kidcare program, in
6 consultation with the agency, the Department of Health, and
7 the Florida Healthy Kids Corporation. The simplified
8 eligibility application form must include an item that
9 provides an opportunity for the applicant to indicate whether
10 coverage is being sought for a child with special health care
11 needs. Families applying for children's Medicaid coverage must
12 also be able to use the simplified application form without
13 having to pay a premium.
14 (b) Establish and maintain the eligibility
15 determination process under the program except as specified in
16 subsections (2) and (4) subsection (5). No later than October
17 1, 2008, the department also shall directly, or through the
18 services of a contracted third-party administrator, establish
19 and maintain a process for determining non-Title XIX
20 eligibility of children for coverage under the program, which
21 shall be conducted in accordance with administrative rules and
22 policies established by the Department of Health. The
23 eligibility determination process must be used solely for
24 determining eligibility of applicants for health benefits
25 coverage under the program. The eligibility determination
26 process must include an initial determination of eligibility
27 for any coverage offered under the program, as well as a
28 redetermination or reverification of eligibility each
29 subsequent 12 6 months. Effective July 1, 2007 January 1,
30 1999, a child who has not attained the age of 19 5 and who has
31 been determined eligible for the Medicaid program is eligible
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1 for coverage for 12 months without a redetermination or
2 reverification of eligibility. In conducting an eligibility
3 determination, the department shall determine if the child has
4 special health care needs. The department, in consultation
5 with the Agency for Health Care Administration and the Florida
6 Healthy Kids Corporation, shall develop procedures for
7 redetermining eligibility which enable a family to easily
8 update any change in circumstances which could affect
9 eligibility. The department may accept changes in a family's
10 status as reported to the department by the Florida Healthy
11 Kids Corporation without requiring a new application from the
12 family. Redetermination of a child's eligibility for Medicaid
13 may not be linked to a child's eligibility determination for
14 other programs.
15 (c) Inform program applicants about eligibility
16 determinations and provide information about eligibility of
17 applicants to the Florida Kidcare program Medicaid, Medikids,
18 the Children's Medical Services Network, and the Florida
19 Healthy Kids Corporation, and to insurers and their agents,
20 through a centralized coordinating office.
21 (d) Adopt rules necessary for conducting program
22 eligibility functions.
23 (2) The Department of Health shall:
24 (a) Design an eligibility intake process and policies
25 for non-Title XXI eligibility determination for the program,
26 in coordination with the Department of Children and Family
27 Services, the agency, and the Florida Healthy Kids
28 Corporation. The eligibility intake process may include local
29 intake points that are determined by the Department of Health
30 in coordination with the Department of Children and Family
31 Services.
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1 (b) Chair a state-level children's health coordinating
2 council to review and make recommendations concerning the
3 implementation and operation of children's health programs the
4 program. The coordinating council shall include
5 representatives from the department, the Department of
6 Children and Family Services, the agency, the Florida Healthy
7 Kids Corporation, the Office of Insurance Regulation of the
8 Financial Services Commission, local government, health
9 insurers, health maintenance organizations, health care
10 providers, families participating in the program, and
11 organizations representing low-income families.
12 (c) In consultation with the agency, the Department of
13 Children and Family Services and the Florida Healthy Kids
14 Corporation, adopt rules necessary to implement the Florida
15 Kidcare program.
16 (d) In consultation with the children's health
17 coordinating council, develop and implement a plan to
18 publicize the Florida Kidcare program, the eligibility
19 requirements of the program, and the procedures for enrollment
20 in the program and to maintain public awareness of and
21 outreach for the Florida Kidcare program.
22 (e) Determine clinical eligibility for and administer
23 Florida Kidcare Plus health benefits coverage.
24 (f) In consultation with the agency, develop a minimum
25 set of pediatric quality assurance and access standards,
26 including reporting requirements, for the Florida Kidcare
27 program. The standards must include a process for granting
28 exceptions to specific requirements for quality assurance and
29 access. Compliance with the standards shall be a condition of
30 program participation by health benefits coverage providers.
31 These standards shall comply with the provisions of this
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1 chapter and chapter 641 and Title XXI of the Social Security
2 Act.
3 (g) Effective July 1, 2008, coordinate Florida Kidcare
4 administrative activities, including, but not limited to:
5 1. Florida Kidcare policy development;
6 2. Federal and state legislative and budget issue
7 development; and
8 3. Administrative rules and policies, except for
9 eligibility determination or redetermination for the Title
10 XIX-funded component of Florida Kidcare.
11 (c) In consultation with the Florida Healthy Kids
12 Corporation and the Department of Children and Family
13 Services, establish a toll-free telephone line to assist
14 families with questions about the program.
15 (d) Adopt rules necessary to implement outreach
16 activities.
17 (3) The Agency for Health Care Administration, under
18 the authority granted in s. 409.914(1), shall:
19 (a) Calculate the premium assistance payment necessary
20 to comply with the premium and cost-sharing limitations
21 specified in s. 409.816. The premium assistance payment for
22 each enrollee in a health insurance plan participating in the
23 Florida Healthy Kids Corporation shall equal the premium
24 approved by the Florida Healthy Kids Corporation and the
25 Office of Insurance Regulation of the Financial Services
26 Commission pursuant to ss. 627.410 and 641.31, less any
27 enrollee's share of the premium established within the
28 limitations specified in s. 409.816. The premium assistance
29 payment for each enrollee in an employer-sponsored health
30 insurance plan approved under ss. 409.810-409.820 shall equal
31 the premium for the plan adjusted for any benchmark benefit
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1 plan actuarial equivalent benefit rider approved by the Office
2 of Insurance Regulation pursuant to ss. 627.410 and 641.31,
3 less any enrollee's share of the premium established within
4 the limitations specified in s. 409.816. In calculating the
5 premium assistance payment levels for children with family
6 coverage, the agency shall set the premium assistance payment
7 levels for each child proportionately to the total cost of
8 family coverage.
9 (b) Make premium assistance payments to health
10 insurance plans on a periodic basis. The agency may use its
11 Medicaid fiscal agent or a contracted third-party
12 administrator in making these payments. The agency may
13 require health insurance plans that participate in the
14 Medikids program or employer-sponsored group health insurance
15 to collect premium payments from an enrollee's family.
16 Participating health insurance plans shall report premium
17 payments collected on behalf of enrollees in the program to
18 the agency in accordance with a schedule established by the
19 agency.
20 (c) Monitor compliance with pediatric quality
21 assurance and access standards developed by the Department of
22 Health under s. 409.820.
23 (d) Establish a mechanism for investigating and
24 resolving complaints and grievances from program applicants,
25 enrollees, and health benefits coverage providers, and
26 maintain a record of complaints and confirmed problems. In the
27 case of a child who is enrolled in a health maintenance
28 organization, the agency must use the provisions of s. 641.511
29 to address grievance reporting and resolution requirements.
30 Effective July 1, 2008, the Department of Health shall assume
31 responsibility for this function.
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1 (e) Approve health benefits coverage for participation
2 in the program, following certification by the Office of
3 Insurance Regulation under subsection (4). Effective July 1,
4 2008, the Department of Health shall assume responsibility for
5 this function.
6 (f) Adopt all rules necessary to comply with or
7 administer ss. 409.810-409.820 and all rules necessary to
8 comply with federal requirements, including, at a minimum,
9 rules specifying policies, procedures, and criteria for the
10 following activities:
11 1. Calculating premium assistance payment levels;
12 2. Making premium assistance payments;
13 3. Monitoring access and quality assurance standards;
14 4. Investigating and resolving complaints and
15 grievances;
16 5. Administering the Medikids program;
17 6. Approving health benefits coverage; and
18 7. Determining application and enrollment
19 requirements, including documentation requirements,
20 eligibility determinations and redeterminations, enrollee
21 premium payment requirements, cancellation of coverage,
22 reinstatement of coverage, disenrollment procedures, applicant
23 and enrollee notification requirements, application and
24 enrollment time processing standards, and call center
25 standards.
26
27 Effective July 1, 2008, the Department of Health shall assume
28 responsibility for administrative rulemaking activities
29 specified in subparagraphs 3, 4, 6, and 7. Adopt rules
30 necessary for calculating premium assistance payment levels,
31 making premium assistance payments, monitoring access and
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1 quality assurance standards, investigating and resolving
2 complaints and grievances, administering the Medikids program,
3 and approving health benefits coverage. The agency is
4 designated the lead state agency for Title XXI of the Social
5 Security Act for purposes of receipt of federal funds, for
6 reporting purposes, and for ensuring compliance with federal
7 and state regulations and rules.
8 (4) The Office of Insurance Regulation shall certify
9 that health benefits coverage plans that seek to provide
10 services under the Florida Kidcare program, except those
11 offered through the Florida Healthy Kids Corporation or the
12 Children's Medical Services Network, meet, exceed, or are
13 actuarially equivalent to the benchmark benefit plan and that
14 health insurance plans will be offered at an approved rate. In
15 determining actuarial equivalence of benefits coverage, the
16 Office of Insurance Regulation and health insurance plans must
17 comply with the requirements of s. 2103 of Title XXI of the
18 Social Security Act. The department shall adopt rules
19 necessary for certifying health benefits coverage plans.
20 (4)(a)(5) The Florida Healthy Kids Corporation shall
21 retain its functions as authorized in s. 624.91, including
22 eligibility determination for participation in the non-Title
23 XIX-funded Florida Kidcare program Healthy Kids program.
24 Effective July 1, 2008, non-Title XIX-funded Florida Kidcare
25 eligibility determinations shall be conducted in accordance
26 with administrative rules and policies established by the
27 Department of Health.
28 (5) The Department of Health, in consultation with the
29 agency, the Department of Children and Family Services, and
30 the Florida Healthy Kids Corporation, and
31
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1 (6) The agency, the Department of Health, the
2 Department of Children and Family Services, the Florida
3 Healthy Kids Corporation, and the Office of Insurance
4 Regulation, after consultation with and approval of the
5 Speaker of the House of Representatives and the President of
6 the Senate, are authorized to make program modifications that
7 are necessary to overcome any objections of the United States
8 Department of Health and Human Services to obtain approval of
9 the state's child health insurance plan under Title XXI of the
10 Social Security Act.
11 Section 20. Section 409.820, Florida Statutes, is
12 repealed.
13 Section 21. Section 409.821, Florida Statutes, is
14 amended to read:
15 409.821 Florida Kidcare program public records
16 exemption.--Notwithstanding any other law to the contrary, any
17 information identifying a Florida Kidcare program applicant or
18 enrollee, as defined in s. 409.811, held by the Agency for
19 Health Care Administration, the Department of Children and
20 Family Services, the Department of Health, or the Florida
21 Healthy Kids Corporation is confidential and exempt from s.
22 119.07(1) and s. 24(a), Art. I of the State Constitution. Such
23 information may be disclosed to another governmental entity
24 only if disclosure is necessary for the entity to perform its
25 duties and responsibilities under the Florida Kidcare program
26 and shall be disclosed to the Department of Revenue for
27 purposes of administering the state Title IV-D program. The
28 receiving governmental entity must maintain the confidential
29 and exempt status of such information. Furthermore, such
30 information may not be released to any person without the
31 written consent of the program applicant. This exemption
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1 applies to any information identifying a Florida Kidcare
2 program applicant or enrollee held by the Agency for Health
3 Care Administration, the Department of Children and Family
4 Services, the Department of Health, or the Florida Healthy
5 Kids Corporation before, on, or after the effective date of
6 this exemption. A violation of this section is a misdemeanor
7 of the second degree, punishable as provided in s. 775.082 or
8 s. 775.083. This section does not prohibit an enrollee's
9 parent or legal guardian from obtaining any record relating to
10 the enrollee's Florida Kidcare application or coverage,
11 including, but not limited to, confirmation of coverage, the
12 dates of coverage, the name of the enrollee's health plan, and
13 the amount of premium.
14 Section 22. Section 409.904, Florida Statutes, is
15 amended to read:
16 409.904 Optional payments for eligible persons.--The
17 agency may make payments for medical assistance and related
18 services on behalf of the following persons who are determined
19 to be eligible subject to the income, assets, and categorical
20 eligibility tests set forth in federal and state law. Payment
21 on behalf of these Medicaid eligible persons is subject to the
22 availability of moneys and any limitations established by the
23 General Appropriations Act or chapter 216.
24 (1)(a) From July 1, 2005, through December 31, 2005, a
25 person who is age 65 or older or is determined to be disabled,
26 whose income is at or below 88 percent of federal poverty
27 level, and whose assets do not exceed established limitations.
28 (b) Effective January 1, 2006, and subject to federal
29 waiver approval, a person who is age 65 or older or is
30 determined to be disabled, whose income is at or below 88
31 percent of the federal poverty level, whose assets do not
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1 exceed established limitations, and who is not eligible for
2 Medicare or, if eligible for Medicare, is also eligible for
3 and receiving Medicaid-covered institutional care services,
4 hospice services, or home and community-based services. The
5 agency shall seek federal authorization through a waiver to
6 provide this coverage.
7 (2) A family, a pregnant woman, a child under age 21,
8 a person age 65 or over, or a blind or disabled person, who
9 would be eligible under any group listed in s. 409.903(1),
10 (2), or (3), except that the income or assets of such family
11 or person exceed established limitations. For a family or
12 person in one of these coverage groups, medical expenses are
13 deductible from income in accordance with federal requirements
14 in order to make a determination of eligibility. A family or
15 person eligible under the coverage known as the "medically
16 needy," is eligible to receive the same services as other
17 Medicaid recipients, with the exception of services in skilled
18 nursing facilities and intermediate care facilities for the
19 developmentally disabled.
20 (3) A person who is in need of the services of a
21 licensed nursing facility, a licensed intermediate care
22 facility for the developmentally disabled, or a state mental
23 hospital, whose income does not exceed 300 percent of the SSI
24 income standard, and who meets the assets standards
25 established under federal and state law. In determining the
26 person's responsibility for the cost of care, the following
27 amounts must be deducted from the person's income:
28 (a) The monthly personal allowance for residents as
29 set based on appropriations.
30
31
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1 (b) The reasonable costs of medically necessary
2 services and supplies that are not reimbursable by the
3 Medicaid program.
4 (c) The cost of premiums, copayments, coinsurance, and
5 deductibles for supplemental health insurance.
6 (4) A low-income person who meets all other
7 requirements for Medicaid eligibility except citizenship and
8 who is in need of emergency medical services. The eligibility
9 of such a recipient is limited to the period of the emergency,
10 in accordance with federal regulations.
11 (5) Subject to specific federal authorization, a woman
12 living in a family that has an income that is at or below 200
13 185 percent of the most current federal poverty level is
14 eligible for family planning services as specified in s.
15 409.905(3) for a period of up to 24 months following a loss of
16 Medicaid benefits.
17 (6) A child who has not attained the age of 19 who has
18 been determined eligible for the Medicaid program is deemed to
19 be eligible for a total of 12 6 months, regardless of changes
20 in circumstances other than attainment of the maximum age.
21 Effective January 1, 1999, a child who has not attained the
22 age of 5 and who has been determined eligible for the Medicaid
23 program is deemed to be eligible for a total of 12 months
24 regardless of changes in circumstances other than attainment
25 of the maximum age.
26 (7) A pregnant woman for the duration of her pregnancy
27 and for the postpartum period as defined by federal law and
28 rules, or a child under 1 year of age, who lives in a family
29 that has an income above 185 percent of the most recently
30 published federal poverty level, but which is at or below 200
31 percent of such poverty level. In determining the eligibility
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1 of such pregnant woman or child, an assets test is not
2 required. A child who is eligible for Medicaid under this
3 subsection must be offered the opportunity, subject to federal
4 rules, to be made presumptively eligible. A pregnant woman or
5 child who has been deemed presumptively eligible for Medicaid
6 shall not be enrolled in a managed care plan until full
7 eligibility for Medicaid has been determined.
8 (8) A child who has attained the age of 6 but has not
9 attained the age of 19 and who lives in a family that has an
10 income above 100 percent of the most recently published
11 federal poverty level, which is at or below 133 percent of
12 such poverty level. In determining the eligibility of such
13 child, an assets test is not required. A child who is eligible
14 for Medicaid under this subsection must be offered the
15 opportunity, subject to federal rules, to be made
16 presumptively eligible.
17 (9)(8) A Medicaid-eligible individual for the
18 individual's health insurance premiums, if the agency
19 determines that such payments are cost-effective.
20 (10)(9) Eligible women with incomes at or below 200
21 percent of the federal poverty level and under age 65, for
22 cancer treatment pursuant to the federal Breast and Cervical
23 Cancer Prevention and Treatment Act of 2000, screened through
24 the Mary Brogan Breast and Cervical Cancer Early Detection
25 Program established under s. 381.93.
26 (11) The agency shall submit a state plan amendment to
27 the Federal Government to implement the provisions of the
28 Family Opportunity Act, pursuant to the Deficit Reduction Act
29 of 2005.
30 Section 23. Paragraph (a) of subsection (2) of section
31 409.91211, Florida Statutes, is amended to read:
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1 409.91211 Medicaid managed care pilot program.--
2 (2) The Legislature intends for the capitated managed
3 care pilot program to:
4 (a) Provide, except for those enrolled in the Florida
5 Kidcare program, recipients in Medicaid fee-for-service or the
6 MediPass program a comprehensive and coordinated capitated
7 managed care system for all health care services specified in
8 ss. 409.905 and 409.906.
9 Section 24. Section 624.91, Florida Statutes, is
10 amended to read:
11 624.91 The Florida Healthy Kids Corporation Act.--
12 (1) SHORT TITLE.--This section may be cited as the
13 "William G. 'Doc' Myers Healthy Kids Corporation Act."
14 (2) LEGISLATIVE INTENT.--
15 (a) The Legislature finds that increased access to
16 health care services could improve children's health and
17 reduce the incidence and costs of childhood illness and
18 disabilities among children in this state. Many children do
19 not have comprehensive, affordable health care services
20 available. It is the intent of the Legislature that the
21 Florida Healthy Kids Corporation provide comprehensive health
22 insurance coverage to such children. The corporation is
23 encouraged to cooperate with any existing health service
24 programs funded by the public or the private sector.
25 (b) It is the intent of the Legislature that the
26 Florida Healthy Kids Corporation serve as one of several
27 providers of services to children eligible for medical
28 assistance under Title XXI of the Social Security Act.
29 Although the corporation may serve other children, the
30 Legislature intends the primary recipients of services
31 provided through the corporation be school-age children with a
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1 family income below 200 percent of the federal poverty level,
2 who do not qualify for Medicaid. It is also the intent of the
3 Legislature that state and local government Florida Healthy
4 Kids funds be used to continue coverage, subject to specific
5 appropriations in the General Appropriations Act, to children
6 not eligible for federal matching funds under Title XXI.
7 (3) ELIGIBILITY FOR STATE-FUNDED ASSISTANCE.--Only the
8 following individuals are eligible for state-funded assistance
9 in paying Florida Healthy Kids premiums:
10 (a) Residents of this state who are eligible for the
11 Florida Kidcare program pursuant to s. 409.814.
12 (b) Notwithstanding s. 409.814, legal aliens who are
13 enrolled in the Florida Healthy Kids program as of January 31,
14 2004, who do not qualify for Title XXI federal funds because
15 they are not qualified aliens as defined in s. 409.811.
16 (3)(4) NONENTITLEMENT.--Nothing in this section shall
17 be construed as providing an individual with an entitlement to
18 health care services. No cause of action shall arise against
19 the state, the Florida Healthy Kids Corporation, or a unit of
20 local government for failure to make health services available
21 under this section.
22 (4)(5) CORPORATION AUTHORIZATION, DUTIES, POWERS.--
23 (a) There is created the Florida Healthy Kids
24 Corporation, a not-for-profit corporation.
25 (b) The Florida Healthy Kids Corporation shall:
26 1. Arrange for the collection of any family, local
27 contributions, or employer payment or premium, in an amount to
28 be determined by the board of directors, to provide for
29 payment of premiums for health benefits comprehensive
30 insurance coverage and for the actual or estimated
31 administrative expenses.
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1 2. Arrange for the collection of any voluntary
2 contributions to provide for payment of Florida Kidcare
3 premiums for children who are not eligible for medical
4 assistance under Title XIX or Title XXI of the Social Security
5 Act.
6 3. Subject to the provisions of s. 409.8134, accept
7 voluntary supplemental local match contributions that comply
8 with the requirements of Title XXI of the Social Security Act
9 for the purpose of providing additional Florida Kidcare
10 coverage in contributing counties under Title XXI.
11 4. Establish the administrative and accounting
12 procedures for the operation of the corporation.
13 5. Establish, with consultation from appropriate
14 professional organizations, standards for preventive health
15 services and providers and comprehensive insurance benefits
16 appropriate to children, provided that such standards for
17 rural areas shall not limit primary care providers to
18 board-certified pediatricians.
19 6. Determine eligibility for children seeking to
20 participate in the Title XXI-funded components of the Florida
21 Kidcare program consistent with the requirements specified in
22 s. 409.814, as well as the non-Title-XXI-eligible children as
23 provided in subsection (3). Effective July 1, 2008, this
24 function shall be performed in accordance with administrative
25 rules and policies established by the Department of Health.
26 7. Establish procedures under which providers of local
27 match to, applicants to and participants in the program may
28 have grievances reviewed by an impartial body and reported to
29 the board of directors of the corporation.
30 8. Establish participation criteria and, if
31 appropriate, Contract with an authorized insurer, health
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1 maintenance organization, or third-party administrator to
2 provide administrative services for Florida Kidcare to the
3 corporation. Effective July 1, 2008, this function shall be
4 performed in accordance with administrative rules and policies
5 established by the Department of Health.
6 9. Establish enrollment criteria which shall include
7 penalties or waiting periods of not fewer than 60 days for
8 reinstatement of coverage upon voluntary cancellation for
9 nonpayment of family premiums.
10 9.10. Contract with authorized insurers or any
11 provider of health care services, meeting quality assurance
12 and access standards established by the Department of Health
13 corporation, for the provision of comprehensive insurance
14 coverage to participants. Such standards shall include
15 criteria under which the corporation may contract with more
16 than one provider of health care services in program sites.
17 Health plans shall be selected through a competitive bid
18 process. The Florida Healthy Kids Corporation shall purchase
19 goods and services in the most cost-effective manner
20 consistent with the delivery of quality medical care. The
21 maximum administrative cost for a Florida Healthy Kids
22 Corporation contract shall be 15 percent. For health care
23 contracts, the minimum medical loss ratio for a Florida
24 Healthy Kids Corporation contract shall be 85 percent. For
25 dental contracts, the remaining compensation to be paid to the
26 authorized insurer or provider under a Florida Healthy Kids
27 Corporation contract shall be no less than an amount which is
28 85 percent of premium; to the extent any contract provision
29 does not provide for this minimum compensation, this section
30 shall prevail. The health plan selection criteria and scoring
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1 system, and the scoring results, shall be available upon
2 request for inspection after the bids have been awarded.
3 10.11. Establish disenrollment criteria in the event
4 local matching funds are insufficient to cover enrollments.
5 11. Maintain a toll-free telephone line to assist
6 families with questions about the program. Effective July 1,
7 2008, this function shall be performed in accordance with
8 administrative rules and policies established by the
9 Department of Health.
10 12. Develop and implement a plan to publicize the
11 Florida Healthy Kids Corporation, the eligibility requirements
12 of the program, and the procedures for enrollment in the
13 program and to maintain public awareness of the corporation
14 and the program.
15 12.13. Secure staff necessary to properly administer
16 the corporation. Staff costs shall be funded from state and
17 local matching funds and such other private or public funds as
18 become available. The board of directors shall determine the
19 number of staff members necessary to administer the
20 corporation.
21 13. No later than January 1, 2008, the health benefits
22 coverage provided by the corporation's authorized insurers and
23 health maintenance organizations shall conform with the
24 benchmark benefits specified in s. 409.815.
25 14. Provide a report annually to the Governor, Chief
26 Financial Officer, Commissioner of Education, Senate
27 President, Speaker of the House of Representatives, and
28 Minority Leaders of the Senate and the House of
29 Representatives.
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1 15. Establish benefit packages which conform to the
2 provisions of the Florida Kidcare program, as created in ss.
3 409.810-409.820.
4 (c) Coverage under the corporation's program is
5 secondary to any other available private coverage held by, or
6 applicable to, the participant child or family member.
7 Insurers under contract with the corporation are the payors of
8 last resort and must coordinate benefits with any other
9 third-party payor that may be liable for the participant's
10 medical care.
11 (d) The Florida Healthy Kids Corporation shall be a
12 private corporation not for profit, organized pursuant to
13 chapter 617, and shall have all powers necessary to carry out
14 the purposes of this act, including, but not limited to, the
15 power to receive and accept grants, loans, or advances of
16 funds from any public or private agency and to receive and
17 accept from any source contributions of money, property,
18 labor, or any other thing of value, to be held, used, and
19 applied for the purposes of this act.
20 (6) BOARD OF DIRECTORS.--
21 (a) The Florida Healthy Kids Corporation shall operate
22 subject to the supervision and approval of a board of
23 directors chaired by the Chief Financial Officer or her or his
24 designee, and composed of 10 other members selected for 3-year
25 terms of office as follows:
26 1. The Secretary of Health Care Administration, or his
27 or her designee;
28 2. One member appointed by the Commissioner of
29 Education from the Office of School Health Programs of the
30 Florida Department of Education;
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1 3. One member appointed by the Chief Financial Officer
2 from among three members nominated by the Florida Pediatric
3 Society;
4 4. One member, appointed by the Governor, who
5 represents the Children's Medical Services Program;
6 5. One member appointed by the Chief Financial Officer
7 from among three members nominated by the Florida Hospital
8 Association;
9 6. One member, appointed by the Governor, who is an
10 expert on child health policy;
11 7. One member, appointed by the Chief Financial
12 Officer, from among three members nominated by the Florida
13 Academy of Family Physicians;
14 8. One member, appointed by the Governor, who
15 represents the state Medicaid program;
16 9. One member, appointed by the Chief Financial
17 Officer, from among three members nominated by the Florida
18 Association of Counties; and
19 10. The State Health Officer or her or his designee.
20 (b) A member of the board of directors may be removed
21 by the official who appointed that member. The board shall
22 appoint an executive director, who is responsible for other
23 staff authorized by the board.
24 (c) Board members are entitled to receive, from funds
25 of the corporation, reimbursement for per diem and travel
26 expenses as provided by s. 112.061.
27 (d) There shall be no liability on the part of, and no
28 cause of action shall arise against, any member of the board
29 of directors, or its employees or agents, for any action they
30 take in the performance of their powers and duties under this
31 act.
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1 (7) LICENSING NOT REQUIRED; FISCAL OPERATION.--
2 (a) The corporation shall not be deemed an insurer.
3 The officers, directors, and employees of the corporation
4 shall not be deemed to be agents of an insurer. Neither the
5 corporation nor any officer, director, or employee of the
6 corporation is subject to the licensing requirements of the
7 insurance code or the rules of the Department of Financial
8 Services. However, any marketing representative utilized and
9 compensated by the corporation must be appointed as a
10 representative of the insurers or health services providers
11 with which the corporation contracts.
12 (b) The board has complete fiscal control over the
13 corporation and is responsible for all corporate operations.
14 (c) The Department of Financial Services shall
15 supervise any liquidation or dissolution of the corporation
16 and shall have, with respect to such liquidation or
17 dissolution, all power granted to it pursuant to the insurance
18 code.
19 (8) ACCESS TO RECORDS; CONFIDENTIALITY;
20 PENALTIES.--Notwithstanding any other laws to the contrary,
21 the Florida Healthy Kids Corporation shall have access to the
22 medical records of a student upon receipt of permission from a
23 parent or guardian of the student. Such medical records may be
24 maintained by state and local agencies. Any identifying
25 information, including medical records and family financial
26 information, obtained by the corporation pursuant to this
27 subsection is confidential and is exempt from the provisions
28 of s. 119.07(1). Neither the corporation nor the staff or
29 agents of the corporation may release, without the written
30 consent of the participant or the parent or guardian of the
31 participant, to any state or federal agency, to any private
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1 business or person, or to any other entity, any confidential
2 information received pursuant to this subsection. A violation
3 of this subsection is a misdemeanor of the second degree,
4 punishable as provided in s. 775.082 or s. 775.083.
5 Section 25. Effective June 30, 2009, section 624.91,
6 Florida Statutes, as amended by this act, is repealed.
7 Section 26. Except as otherwise expressly provided in
8 this act, this act shall take effect July 1, 2007.
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1 STATEMENT OF SUBSTANTIAL CHANGES CONTAINED IN
COMMITTEE SUBSTITUTE FOR
2 Senate Bill 930
3
4 The committee substitute creates the Florida Commission on
Children's Health in the Executive Office of the Governor;
5 creates the Division of Children's Health Insurance and Office
of Child Health Coordination in the Department of Health, and
6 specifies their responsibilities.
7 The committee substitute renames the Children's Medical
Services Program to the Children's Health Program and provides
8 it the responsibility to consolidate and coordinate Florida
Kidcare child health policy, development of pediatric benefit
9 packages, development of budget and federal and state
legislative issues, and development of pediatric quality
10 assurance and access standards.
11 The committee substitute also clarifies and adds definitions
relating to the Florida Kidcare Program; revises the
12 components of the program; allows certain persons to buy into
the Medicaid program; changes eligibility criteria for
13 children so they can participate in certain components;
repeals penalties for voluntary cancellation of policies for
14 non-payment of premiums; requires the AHCA to estimate the
number of uninsured children; expands Medicaid eligibility for
15 a limited time to allow families to transition from Title XIX
funded components to Title XXI funded components without a gap
16 in coverage; eliminates contradictory eligibility criteria;
extends eligibility for reasons of good cause for voluntary
17 cancellation of employer-sponsored health coverage; extends
premium assistance eligibility to children who are dependents
18 of state employees and non-qualified legal aliens; repeals the
10 percent limit on full-pay enrollees in Medikids and Florida
19 Healthy Kids; requires that health plans and other providers
are notified of their members losing Medicaid or Medikids
20 eligibility so they may assist them in maintaining continuous
coverage in the Florida Kidcare program; requires eligibility
21 information to be electronically verified to the extent
possible; redefines the benchmark benefit package for the
22 program; prohibits requiring children with special health care
needs from paying premiums and copayments in certain
23 situations; transfers and consolidates most administrative
functions in the entire Florida Kidcare program under the
24 Department of Health effective July 1, 2008; clarifies that
parents and legal guardians have access to certain enrollment
25 information; extends Medicaid coverage to certain pregnant
women; extends Medicaid coverage to children between 6 and 19
26 years of age who have incomes between 100 and 133 percent of
the federal poverty level; modifies the legislative intent
27 related to the Medicaid managed care pilot program; and
repeals the Florida Healthy Kids Corporation effective June
28 30, 2009.
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