Senate Bill sb0930c2
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By the Committees on Governmental Operations; Health Policy;
and Senators Dawson, Garcia, Crist, Saunders, Joyner and
Dockery
585-2291-07
1 A bill to be entitled
2 An act relating to medical assistance; creating
3 s. 14.35, F.S.; creating the Florida Council on
4 Children's Health within the Executive Office
5 of the Governor; providing for the appointment
6 of members and terms of office; providing for
7 council members to be reimbursed for per diem
8 and travel expenses; specifying the duties of
9 the council; requiring the council to submit an
10 annual report to the Governor; requiring
11 executive branch agencies to assist the
12 council; amending s. 20.43, F.S.; redesignating
13 the Division of Children's Medical Services
14 Network within the Department of Health as the
15 "Division of Children's Medical Services
16 Network and Specialty Programs"; creating the
17 Division of Children's Health Insurance and the
18 Office of Child Health Coordination within the
19 Department of Health; amending s. 391.011,
20 F.S.; redesignating ch. 391, F.S., as the
21 "Children's Health Act"; amending s. 391.016,
22 F.S.; revising legislative intent with respect
23 to certain responsibilities of the Children's
24 Health program; amending s. 391.021, F.S.;
25 revising and providing definitions; amending s.
26 391.025, F.S.; revising the components of the
27 Children's Health program; amending s. 391.026,
28 F.S.; requiring the Department of Health to
29 administer the Florida Kidcare program;
30 amending s. 391.028, F.S.; revising the duties
31 of the Children's Medical Services Network;
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1 designating the network director as the Deputy
2 State Health Office for Children's Health;
3 revising the duties of the director; requiring
4 the Division of Children's Health Insurance to
5 administer the Florida Kidcare program;
6 amending s. 391.029, F.S.; requiring the
7 Department of Health to establish clinical
8 eligibility requirements for Florida Kidcare
9 Plus benefits; providing eligibility criteria;
10 amending s. 409.811, F.S.; revising and
11 providing definitions relating to the Florida
12 Kidcare Act; amending s. 409.812, F.S.;
13 revising the purpose of the Florida Kidcare
14 program; amending s. 409.813, F.S.; revising
15 the funding sources for the health benefits
16 coverage provided to children under the
17 program; amending s. 409.8132, F.S.; revising
18 the eligibility and enrollment requirements in
19 the Medikids program component; amending s.
20 409.8134, F.S.; revising requirements for the
21 department in conducting enrollment in the
22 Florida Kidcare program; amending s. 409.814,
23 F.S.; revising the eligibility requirements for
24 the program; providing requirements for a child
25 to enroll in Florida Kidcare Plus; providing
26 for an extension of certain coverage benefits
27 in order to avoid a lapse in coverage;
28 providing for the coverage of certain children
29 whose health benefits have been canceled;
30 providing for nonfederal premium assistance for
31 certain children; deleting provisions
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1 authorizing certain limitations on enrollment
2 in Medikids and a reduction in benefits under
3 the Florida Healthy Kids program; providing
4 certain notification requirements if a child is
5 no longer eligible for benefits; requiring the
6 electronic verification of an applicant's
7 family income; amending s. 409.815, F.S.;
8 revising the health benefits coverage of the
9 Florida Kidcare program; amending s. 409.816,
10 F.S.; revising the limitations on premiums and
11 cost-sharing; providing that certain enrollees
12 are exempt from certain fees, premiums,
13 copayments, and deductibles; authorizing the
14 Department of Health to establish penalties or
15 waiting periods for nonpayment of premiums;
16 amending s. 409.8177, F.S.; requiring the
17 department to contract for an evaluation of the
18 Florida Kidcare program; amending s. 409.818,
19 F.S.; requiring a contract for establishing a
20 process for determining the eligibility of
21 certain children for coverage; revising the
22 duties of the Department of Health with respect
23 to reviewing the intake process; requiring the
24 department to publicize the Florida Kidcare
25 program, determine eligibility for Florida
26 Kidcare Plus coverage, and develop standards
27 for pediatric quality assurance and access;
28 requiring the department to adopt rules;
29 authorizing the department to make certain
30 program modifications upon the approval of the
31 Legislature; repealing s. 409.820, F.S.,
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1 relating to quality assurance and access
2 standards; amending s. 409.821, F.S.;
3 clarifying that provisions exempting certain
4 records from public-records requirements does
5 not prevent an enrollee's parent or guardian
6 from obtaining records and information
7 concerning the enrollee; amending s. 409.904,
8 F.S.; revising provisions governing optional
9 payments made under the Medicaid program;
10 requiring that certain children be
11 presumptively eligible for Medicaid; requiring
12 the Agency for Health Care Administration to
13 submit a plan to the Federal Government to
14 implement the Family Opportunity Act; amending
15 s. 409.91211, F.S.; revising certain
16 requirements of a pilot program for capitated
17 managed care to conform to changes made by the
18 act; amending s. 624.91, F.S.; revising
19 provisions of the Florida Healthy Kids
20 Corporation Act; deleting certain eligibility
21 requirements; providing for the transfer of
22 functions to the Department of Health;
23 repealing s. 624.91, F.S., relating to the
24 Florida Healthy Kids Corporation; providing
25 effective dates.
26
27 Be It Enacted by the Legislature of the State of Florida:
28
29 Section 1. Section 14.35, Florida Statutes, is created
30 to read:
31 14.35 Florida Council on Children's Health.--
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1 (1)(a) For purposes of this section, the term "health"
2 includes physical, mental, and dental health.
3 (b) The Florida Council on Children's Health is
4 established in the Executive Office of the Governor. The term
5 "council" means a coordinating council as defined in s. 20.03
6 which is subject to the requirements of s. 20.052, except as
7 otherwise provided in this section. The council shall be
8 administratively housed within the Executive Office of the
9 Governor. The council shall consist of 12 members who shall be
10 appointed by the Governor. Council members shall broadly
11 represent the interests of children in obtaining necessary
12 health care services and health care coverage. Each member of
13 the council shall be appointed to a 4-year term. A member may
14 not serve more than two consecutive terms. A vacancy shall be
15 filled in the same manner as the original appointment. Voting
16 members of the council may not be employees of the Florida
17 Kidcare partner agencies, the Florida Healthy Kids
18 Corporation, or other state agencies.
19 (2) The council shall meet quarterly and upon the call
20 of the chair and two other council members. Annually, at the
21 meeting in the first quarter, officers consisting of a chair,
22 vice chair, secretary, and treasurer shall be elected. Each
23 officer shall serve until a successor is elected and
24 qualified. An officer may not serve more than 2 consecutive
25 years in the same office.
26 (3) Members of the council shall serve without
27 compensation, but are entitled to reimbursement for per diem
28 and travel expenses in accordance with s. 112.061.
29 (4) The council shall identify and develop specific
30 strategies for addressing issues related to children's lack of
31 access to high-quality and affordable health care services and
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1 health care coverage in this state for recommendation to the
2 Governor and the Legislature. The council shall assist in the
3 coordination of agencies and departments in the state in order
4 to increase accountability regarding children's health issues.
5 The council shall:
6 (a) Provide recommendations for implementing the
7 consolidation of the Florida Kidcare program.
8 (b) Study the barriers to children's accessing
9 high-quality and affordable health care services and health
10 care coverage in this state.
11 (c) Submit an annual report to the Governor concerning
12 the status of children's health issues, including, but not
13 limited to, an assessment of the number of uninsured children,
14 the health status of children in this state using public
15 health indicators, the gaps in health care services for
16 children with special health care needs, and the status of
17 programs affecting children's health in this state.
18 (d) Analyze the responsiveness of state government to
19 the health needs of children and the appropriateness of the
20 response. The council may submit a plan for recommended
21 restructuring and change to the Governor, the President of the
22 Senate, the Speaker of the House of Representatives, and the
23 Chief Financial Officer at any time it considers appropriate.
24 (e) Receive quarterly updates from the Department of
25 Health concerning the status of implementing policy changes to
26 the programs affecting children's health and the
27 implementation of the council's recommendations.
28 (f) Identify and provide recommendations for ways to
29 improve the delivery of services for children.
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1 (g) Review proposed federal and state legislation
2 affecting children's health and provide recommendations to the
3 Governor on appropriate actions pertaining to this section.
4 (h) Study and make recommendations to refine the
5 eligibility determination process for the Florida Kidcare
6 program.
7 (5) All executive branch agencies are instructed, and
8 all other state agencies are requested, to aid and assist the
9 council in any way that helps it accomplish its purpose.
10 Section 2. Subsection (3) of section 20.43, Florida
11 Statutes, is amended to read:
12 20.43 Department of Health.--There is created a
13 Department of Health.
14 (3) The following divisions of the Department of
15 Health are established:
16 (a) Division of Administration.
17 (b) Division of Environmental Health.
18 (c) Division of Disease Control.
19 (d) Division of Family Health Services.
20 (e) Division of Children's Medical Services Network
21 and Specialty Programs.
22 (f) Division of Emergency Medical Operations.
23 (g) Division of Medical Quality Assurance, which is
24 responsible for the following boards and professions
25 established within the division:
26 1. The Board of Acupuncture, created under chapter
27 457.
28 2. The Board of Medicine, created under chapter 458.
29 3. The Board of Osteopathic Medicine, created under
30 chapter 459.
31
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1 4. The Board of Chiropractic Medicine, created under
2 chapter 460.
3 5. The Board of Podiatric Medicine, created under
4 chapter 461.
5 6. Naturopathy, as provided under chapter 462.
6 7. The Board of Optometry, created under chapter 463.
7 8. The Board of Nursing, created under part I of
8 chapter 464.
9 9. Nursing assistants, as provided under part II of
10 chapter 464.
11 10. The Board of Pharmacy, created under chapter 465.
12 11. The Board of Dentistry, created under chapter 466.
13 12. Midwifery, as provided under chapter 467.
14 13. The Board of Speech-Language Pathology and
15 Audiology, created under part I of chapter 468.
16 14. The Board of Nursing Home Administrators, created
17 under part II of chapter 468.
18 15. The Board of Occupational Therapy, created under
19 part III of chapter 468.
20 16. Respiratory therapy, as provided under part V of
21 chapter 468.
22 17. Dietetics and nutrition practice, as provided
23 under part X of chapter 468.
24 18. The Board of Athletic Training, created under part
25 XIII of chapter 468.
26 19. The Board of Orthotists and Prosthetists, created
27 under part XIV of chapter 468.
28 20. Electrolysis, as provided under chapter 478.
29 21. The Board of Massage Therapy, created under
30 chapter 480.
31
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1 22. The Board of Clinical Laboratory Personnel,
2 created under part III of chapter 483.
3 23. Medical physicists, as provided under part IV of
4 chapter 483.
5 24. The Board of Opticianry, created under part I of
6 chapter 484.
7 25. The Board of Hearing Aid Specialists, created
8 under part II of chapter 484.
9 26. The Board of Physical Therapy Practice, created
10 under chapter 486.
11 27. The Board of Psychology, created under chapter
12 490.
13 28. School psychologists, as provided under chapter
14 490.
15 29. The Board of Clinical Social Work, Marriage and
16 Family Therapy, and Mental Health Counseling, created under
17 chapter 491.
18 (h) Division of Children's Medical Services Prevention
19 and Intervention.
20 (i) Division of Information Technology.
21 (j) Division of Health Access and Tobacco.
22 (k) Division of Disability Determinations.
23 (l) Division of Children's Health Insurance.
24 (m) Office of Child Health Coordination.
25 Section 3. Section 391.011, Florida Statutes, is
26 amended to read:
27 391.011 Short title.--The provisions of this chapter
28 may be cited as the "Children's Health Act." "Children's
29 Medical Services Act."
30 Section 4. Section 391.016, Florida Statutes, is
31 amended to read:
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1 391.016 Legislative intent.--The Legislature intends
2 that the Children's Health Medical Services program:
3 (1) Provide to children with special health care needs
4 a family-centered, comprehensive, and coordinated statewide
5 managed system of care that links community-based health care
6 with multidisciplinary, regional, and tertiary pediatric
7 specialty care. The program may provide for the coordination
8 and maintenance of consistency of the medical home for
9 children in families with a Children's Medical Services
10 program participant, in order to achieve family-centered care.
11 (2) Provide essential preventive, evaluative, and
12 early intervention services for children at risk for or having
13 special health care needs, in order to prevent or reduce
14 long-term disabilities.
15 (3) Serve as a principal provider for children with
16 special health care needs under Titles XIX and XXI of the
17 Social Security Act.
18 (4) Be complementary to children's health training
19 programs essential for the maintenance of a skilled pediatric
20 health care workforce for all Floridians.
21 (5) Consolidate and coordinate Florida Kidcare child
22 health policy, development of pediatric benefit packages,
23 development of budget and federal and state legislative
24 issues, and development of pediatric quality assurance and
25 access standards.
26 Section 5. Section 391.021, Florida Statutes, is
27 amended to read:
28 391.021 Definitions.--When used in this act, unless
29 the context clearly indicates otherwise:
30 (1) "Children's Medical Services network" or "network"
31 means a statewide managed care service system that includes
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1 health care providers, health care facilities, or entities
2 licensed or certified to provide health services in this state
3 which meet the pediatric access and quality standards
4 established by the department as defined in this section. The
5 network shall provide Florida Kidcare Plus benefits as defined
6 in s. 409.811.
7 (2) "Children with special health care needs" means
8 those children younger than 21 years of age who have chronic
9 physical, developmental, behavioral, or emotional conditions
10 and who also require health care and related services of a
11 type or amount beyond that which is generally required by
12 children.
13 (3) "Department" means the Department of Health.
14 (4) "Eligible individual" means a child with a special
15 health care need or a female with a high-risk pregnancy, who
16 meets the financial and medical eligibility standards
17 established in s. 391.029.
18 (5) "Health care provider" means a health care
19 professional, health care facility, or entity licensed or
20 certified to provide health services in this state that meets
21 the criteria as established by the department.
22 (6) "Health services" includes the prevention,
23 diagnosis, and treatment of human disease, pain, injury,
24 deformity, or disabling conditions.
25 (7) "Maximum income threshold" has the same meaning as
26 in s. 409.811.
27 (8)(7) "Participant" means an eligible individual who
28 is enrolled in the Children's Medical Services program.
29 (9) "Pediatric benefit" means a benefit that is
30 determined to be medically necessary to treat a health
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1 condition. The scope, duration, and frequency of the service
2 are based on medical-necessity criteria.
3 (10)(8) "Program" means the Children's Medical
4 Services program established in the department.
5 (11) "Safety net" means limited services provided to
6 children with special health care needs who are uninsured or
7 underinsured and do not qualify for Title XIX-funded or Title
8 XXI-funded health benefits coverage.
9 Section 6. Section 391.025, Florida Statutes, is
10 amended to read:
11 391.025 Applicability and scope.--
12 (1) The Children's Health Medical Services program
13 consists of the following components:
14 (a) The newborn screening program established in s.
15 383.14.
16 (b) The regional perinatal intensive care centers
17 program established in ss. 383.15-383.21.
18 (c) A federal or state program authorized by the
19 Legislature.
20 (d) The developmental evaluation and intervention
21 program, including the Florida Infants and Toddlers Early
22 Intervention Program.
23 (e) The Children's Medical Services Network.
24 (f) The Division of Children's Health Insurance.
25 (g) The Office of Child Health Coordination.
26 (2) The Children's Medical Services Network program
27 shall not be deemed an insurer and is not subject to the
28 licensing requirements of the Florida Insurance Code or the
29 rules adopted thereunder, when providing services to children
30 who receive Title XIX-funded Medicaid benefits, other Title
31 XIX-eligible Medicaid-eligible children with special health
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1 care needs, or Title XXI-funded and children with special
2 health care needs participating in the Florida Kidcare
3 program.
4 Section 7. Subsection (19) is added to section
5 391.026, Florida Statutes, to read:
6 391.026 Powers and duties of the department.--The
7 department shall have the following powers, duties, and
8 responsibilities:
9 (19) To administer the provisions of the Florida
10 Kidcare Act assigned to the Department of Health in ss.
11 409.810-409.820.
12 Section 8. Section 391.028, Florida Statutes, is
13 amended to read:
14 391.028 Administration.--The Children's Medical
15 Services Network program shall have a central office and area
16 offices.
17 (1) The Director of Children's Health Medical Services
18 must be a physician licensed under chapter 458 or chapter 459
19 who has specialized training and experience in the provision
20 of health care to children and who has recognized skills in
21 leadership and the promotion of children's health programs.
22 The director shall be the deputy secretary and the Deputy
23 State Health Officer for Children's Health Medical Services
24 and is appointed by and reports to the secretary. The director
25 may appoint division directors subject to the approval of the
26 secretary.
27 (2) The director shall designate Children's Medical
28 Services Network area offices to perform operational
29 activities for children with special health care needs,
30 including, but not limited to:
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1 (a) Providing case management services for the
2 network.
3 (b) Providing local oversight of the program.
4 (c) Determining an individual's clinical medical and
5 financial eligibility for the program.
6 (d) Participating in the determination of a level of
7 care and medical complexity for long-term care services.
8 (e) Authorizing services in the program and developing
9 spending plans.
10 (f) Participating in the development of treatment
11 plans.
12 (g) Taking part in the resolution of complaints and
13 grievances from participants and health care providers.
14 (3) Each Children's Medical Services Network area
15 office shall be directed by a physician licensed under chapter
16 458 or chapter 459 who has specialized training and experience
17 in the provision of health care to children. The director of
18 a Children's Medical Services area office shall be appointed
19 by the director from the active panel of Children's Medical
20 Services physician consultants.
21 (4) The Division of Children's Health Insurance shall
22 be responsible for administering the provisions of the Florida
23 Kidcare Act assigned to the Department of Health in ss.
24 409.810-409.820.
25 (5) The Office of Child Health Coordination is
26 responsible for child health services not directly related to
27 Florida Kidcare health benefits coverage. This office also
28 shall be responsible for providing staff support to the
29 Council on Children's Health.
30 Section 9. Section 391.029, Florida Statutes, is
31 amended to read:
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1 391.029 Program eligibility.--
2 (1) The department shall establish clinical
3 eligibility the medical criteria to determine if an applicant
4 for Florida Kidcare Plus benefits the Children's Medical
5 Services program is an eligible individual.
6 (2) The following individuals are financially eligible
7 to receive services through the Children's Medical Services
8 Network program:
9 (a) A high-risk pregnant female who is eligible for
10 Medicaid.
11 (b) Children with special health care needs from birth
12 to 21 years of age who are eligible for Medicaid.
13 (c) Children with special health care needs from birth
14 to 19 years of age who are eligible for a program under Title
15 XXI of the Social Security Act.
16 (3) Subject to the availability of funds, the
17 following individuals may receive services through the
18 program:
19 (a) Children with special health care needs from birth
20 to 21 years of age whose families do not qualify for Title
21 XIX-financed or Title XXI-financed health benefits coverage
22 family income is above the requirements for financial
23 eligibility under Title XXI of the Social Security Act and
24 whose projected annual cost of care adjusts the family income
25 to Medicaid financial criteria. In cases where the family
26 income is adjusted based on a projected annual cost of care,
27 the family shall participate financially in the cost of care
28 based on criteria established by the department. These
29 children may receive safety net services, subject to the
30 availability of funds.
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1 (b) Children with special health care needs from birth
2 to 21 years of age, as provided in Title V of the Social
3 Security Act.
4 (c) An infant who receives an award of compensation
5 under s. 766.31(1). The Florida Birth-Related Neurological
6 Injury Compensation Association shall reimburse the Children's
7 Medical Services Network the state's share of funding, which
8 must thereafter be used to obtain matching federal funds under
9 Title XXI of the Social Security Act.
10 (d) Children with special health care needs with
11 family incomes above the maximum income threshold may receive
12 Florida Kidcare Plus health benefits coverage if the Family
13 Opportunity Act is authorized.
14 (4) The department shall determine the financial and
15 medical eligibility of children with special health care needs
16 for the program. The department shall also determine the
17 financial ability of the parents, or persons or other agencies
18 having legal custody over such individuals, to pay the costs
19 of health services under the program. The department may pay
20 reasonable travel expenses related to the determination of
21 eligibility for or the provision of health services.
22 (5) Any child who has been provided with surgical or
23 medical care or treatment under this act prior to being
24 adopted shall continue to be eligible to be provided with such
25 care or treatment after his or her adoption, regardless of the
26 financial ability of the persons adopting the child.
27 Section 10. Section 409.811, Florida Statutes, is
28 amended to read:
29 409.811 Definitions relating to Florida Kidcare
30 Act.--As used in ss. 409.810-409.820, the term:
31 (1) "Actuarially equivalent" means that:
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1 (a) The aggregate value of the benefits included in
2 health benefits coverage is equal to the value of the benefits
3 in the benchmark benefit plan; and
4 (b) The benefits included in health benefits coverage
5 are substantially similar to the benefits included in the
6 benchmark benefit plan, except that preventive health services
7 must be the same as in the benchmark benefit plan.
8 (2) "Agency" means the Agency for Health Care
9 Administration.
10 (3) "Applicant" means a parent or guardian of a child
11 or a child whose disability of nonage has been removed under
12 chapter 743, who applies for determination of eligibility for
13 health benefits coverage under ss. 409.810-409.820.
14 (4) "Benchmark benefit plan" means the form and level
15 of health benefits coverage established in s. 409.815.
16 (5) "Child" means any person under 19 years of age.
17 (6) "Child with special health care needs" means a
18 child who has a chronic physical, developmental, behavioral,
19 or emotional condition and who also required health care and
20 related services of a type or amount beyond that which is
21 generally required by children. whose serious or chronic
22 physical or developmental condition requires extensive
23 preventive and maintenance care beyond that required by
24 typically healthy children. Health care utilization by such a
25 child exceeds the statistically expected usage of the normal
26 child adjusted for chronological age, and such a child often
27 needs complex care requiring multiple providers,
28 rehabilitation services, and specialized equipment in a number
29 of different settings.
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1 (7) "Children's Medical Services Network" or "network"
2 means a statewide managed care service system as defined in s.
3 391.021(1).
4 (8) "Community rate" means a method used to develop
5 premiums for a health insurance plan that spreads financial
6 risk across a large population and allows adjustments only for
7 age, gender, family composition, and geographic area.
8 (9) "Department" means the Department of Health.
9 (10) "Enrollee" means a child who has been determined
10 eligible for and is receiving coverage under ss.
11 409.810-409.820.
12 (11) "Family" means the group or the individuals whose
13 income is considered in determining eligibility for the
14 Florida Kidcare program. The family includes a child with a
15 custodial parent or caretaker relative who resides in the same
16 house or living unit or, in the case of a child whose
17 disability of nonage has been removed under chapter 743, the
18 child. The family may also include other individuals whose
19 income and resources are considered in whole or in part in
20 determining eligibility of the child.
21 (11)(12) "Family income" means cash received at
22 periodic intervals from any source, such as wages, benefits,
23 contributions, or rental property. Family income is calculated
24 using the budget methodologies authorized under Title XIX of
25 the Social Security Act. Income also may include any money
26 that would have been counted as income under the Aid to
27 Families with Dependent Children (AFDC) state plan in effect
28 prior to August 22, 1996.
29 (12) "Florida Kidcare Plus" means health benefits
30 coverage for children with special health care needs which
31
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1 benefits are delivered through the Children's Medical Services
2 Network established in chapter 391.
3 (13) "Florida Kidcare program," "Kidcare program," or
4 "program" means the health benefits program for children
5 administered through ss. 409.810-409.820.
6 (14) "Guarantee issue" means that health benefits
7 coverage must be offered to an individual regardless of the
8 individual's health status, preexisting condition, or claims
9 history.
10 (15) "Health benefits coverage" means protection that
11 provides payment of benefits for covered health care services
12 or that otherwise provides, either directly or through
13 arrangements with other persons, covered health care services
14 on a prepaid per capita basis or on a prepaid aggregate
15 fixed-sum basis.
16 (16) "Health insurance plan" means health benefits
17 coverage under the following:
18 (a) A health plan offered by any certified health
19 maintenance organization or authorized health insurer, except
20 a plan that is limited to the following: a limited benefit,
21 specified disease, or specified accident; hospital indemnity;
22 accident only; limited benefit convalescent care; Medicare
23 supplement; credit disability; dental; vision; long-term care;
24 disability income; coverage issued as a supplement to another
25 health plan; workers' compensation liability or other
26 insurance; or motor vehicle medical payment only; or
27 (b) An employee welfare benefit plan that includes
28 health benefits established under the Employee Retirement
29 Income Security Act of 1974, as amended.
30 (17) "Healthy Kids" means a component of the Florida
31 Kidcare program of medical assistance for children who are 5
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1 through 18 years of age as authorized under s. 624.91 and
2 administered by the Florida Healthy Kids Corporation.
3 (18) "Maximum income threshold" means a percentage of
4 the current federal poverty level used to determine
5 eligibility for certain program components, as approved by
6 federal waiver or an amendment to the state plan. Unless
7 otherwise approved by a federal waiver or an amendment to the
8 state plan, the maximum income threshold is 200 percent of the
9 most recent federal poverty level.
10 (19)(17) "Medicaid" means the medical assistance
11 program authorized by Title XIX of the Social Security Act,
12 and regulations thereunder, and ss. 409.901-409.920, as
13 administered in this state by the agency.
14 (20)(18) "Medically necessary" means the use of any
15 medical treatment, service, equipment, or supply necessary to
16 palliate the effects of a terminal condition, or to prevent,
17 diagnose, correct, cure, alleviate, or preclude deterioration
18 of a condition that threatens life, causes pain or suffering,
19 or results in illness or infirmity and which is:
20 (a) Consistent with the symptom, diagnosis, and
21 treatment of the enrollee's condition;
22 (b) Provided in accordance with generally accepted
23 standards of medical practice;
24 (c) Not primarily intended for the convenience of the
25 enrollee, the enrollee's family, or the health care provider;
26 (d) The most appropriate level of supply or service
27 for the diagnosis and treatment of the enrollee's condition;
28 and
29 (e) Approved by the appropriate medical body or health
30 care specialty involved as effective, appropriate, and
31
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1 essential for the care and treatment of the enrollee's
2 condition.
3 (21)(19) "Medikids" means a component of the Florida
4 Kidcare program of medical assistance authorized by Title XXI
5 of the Social Security Act, and regulations thereunder, and s.
6 409.8132, as administered in the state by the agency.
7 (22) "Pediatric benefit" means a benefit that is
8 determined to be medically necessary to treat a health
9 condition. The scope, duration, and frequency of the service
10 are based on medical-necessity criteria.
11 (23)(20) "Preexisting condition exclusion" means, with
12 respect to coverage, a limitation or exclusion of benefits
13 relating to a condition based on the fact that the condition
14 was present before the date of enrollment for such coverage,
15 whether or not any medical advice, diagnosis, care, or
16 treatment was recommended or received before such date.
17 (24)(21) "Premium" means the entire cost of a health
18 insurance plan, including the administration fee or the risk
19 assumption charge.
20 (25)(22) "Premium assistance payment" means the
21 monthly consideration paid by the agency per enrollee in the
22 Florida Kidcare program towards health insurance premiums.
23 (26)(23) "Qualified alien" means an alien as defined
24 in s. 431 of the Personal Responsibility and Work Opportunity
25 Reconciliation Act of 1996, as amended, Pub. L. No. 104-193.
26 (27)(24) "Resident" means a United States citizen, or
27 qualified alien, who is domiciled in this state.
28 (28)(25) "Rural county" means a county having a
29 population density of less than 100 persons per square mile,
30 or a county defined by the most recent United States Census as
31
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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 (29)(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, if the Family Opportunity Act is authorized.
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.
29 (2) ADMINISTRATION.--The secretary of the agency shall
30 appoint an administrator of the Medikids program component.
31 The Agency for Health Care Administration is designated as the
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1 state agency authorized to make payments for medical
2 assistance and related services for the Medikids program
3 component of the Florida Kidcare program. Payments shall be
4 made, subject to any limitations or directions in the General
5 Appropriations Act, only for covered services provided to
6 eligible children by qualified health care providers under the
7 Florida Kidcare program.
8 (3) INSURANCE LICENSURE NOT REQUIRED.--The Medikids
9 program component shall not be subject to the licensing
10 requirements of the Florida Insurance Code or rules adopted
11 thereunder.
12 (4) APPLICABILITY OF LAWS RELATING TO MEDICAID.--The
13 provisions of ss. 409.902, 409.905, 409.906, 409.907, 409.908,
14 409.912, 409.9121, 409.9122, 409.9123, 409.9124, 409.9127,
15 409.9128, 409.913, 409.916, 409.919, 409.920, and 409.9205
16 apply to the administration of the Medikids program component
17 of the Florida Kidcare program, except that s. 409.9122
18 applies to Medikids as modified by the provisions of
19 subsection (7).
20 (5) BENEFITS.--Benefits provided under the Medikids
21 program component shall be the same benefits provided to
22 children as specified in ss. 409.905 and 409.906.
23 (6) ELIGIBILITY.--
24 (a) A child who has attained the age of 1 year but who
25 is under the age of 5 years is eligible to enroll in the
26 Medikids program component of the Florida Kidcare program, if
27 the child is a member of a family that has a family income
28 which exceeds the Medicaid applicable income level as
29 specified in s. 409.903, but which is equal to or below the
30 maximum income threshold 200 percent of the current federal
31 poverty level. In determining the eligibility of such a
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1 child, an assets test is not required. A child who is eligible
2 for Medikids may elect to enroll in Florida Healthy Kids
3 coverage or employer-sponsored group coverage. Effective July
4 1, 2009, age eligibility for the Medikids program component
5 will increase to children who are up to age 19 and who do not
6 have special health care needs. However, a child who is
7 eligible for Medikids may participate in the Florida Healthy
8 Kids program only if the child has a sibling participating in
9 the Florida Healthy Kids program and the child's county of
10 residence permits such enrollment.
11 (b) The provisions of s. 409.814(3), (5) (4), and (7)
12 (5) shall be applicable to the Medikids program.
13 (7) ENROLLMENT.--Enrollment in the Medikids program
14 component may occur at any time throughout the year. A child
15 may not receive services under the Medikids program until the
16 child is enrolled in a managed care plan or MediPass. Once
17 determined eligible, an applicant may receive choice
18 counseling and select a managed care plan or MediPass. The
19 agency may initiate mandatory assignment for a Medikids
20 applicant who has not chosen a managed care plan or MediPass
21 provider after the applicant's voluntary choice period ends.
22 An applicant may select MediPass under the Medikids program
23 component only in counties that have fewer than two managed
24 care plans available to serve Medicaid recipients and only if
25 the federal Health Care Financing Administration determines
26 that MediPass constitutes "health insurance coverage" as
27 defined in Title XXI of the Social Security Act.
28 (8) PENALTIES FOR VOLUNTARY CANCELLATION.--The agency
29 shall establish enrollment criteria that must include
30 penalties or waiting periods of not fewer than 60 days for
31
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1 reinstatement of coverage upon voluntary cancellation for
2 nonpayment of premiums.
3 Section 14. Section 409.8134, Florida Statutes, is
4 amended to read:
5 409.8134 Program expenditure ceiling; enrollment.--
6 (1) Except for the Medicaid program, a ceiling shall
7 be placed on annual federal and state expenditures for the
8 Florida Kidcare program as provided each year in the General
9 Appropriations Act.
10 (2) The Florida Kidcare program shall may conduct
11 enrollment continuously at any time throughout the year for
12 the purpose of enrolling children eligible for all program
13 components listed in s. 409.813 except Medicaid. The four
14 Florida Kidcare administrators shall work together to ensure
15 that the year-round enrollment period is announced statewide.
16 Children eligible for Title XXI-funded Florida Kidcare
17 coverage Eligible children shall be enrolled on a first-come,
18 first-served basis using the date the enrollment application
19 is received. Enrollment shall immediately cease when the
20 expenditure ceiling is reached. Year-round enrollment shall
21 only be held if the Social Services Estimating Conference
22 determines that sufficient federal and state funds will be
23 available to finance the increased enrollment through federal
24 fiscal year 2007. Any individual who is not enrolled must
25 reapply by submitting a new application. The application for
26 the Florida Kidcare program is shall be valid for a period of
27 120 days after the date it was received. At the end of the
28 120-day period, if the applicant has not been enrolled in the
29 program, the application is shall be invalid and the applicant
30 shall be notified of the action. The applicant may reactivate
31 resubmit the application after notification of the action
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1 taken by the program. Except for the Medicaid program,
2 whenever the Social Services Estimating Conference determines
3 that there are presently, or will be by the end of the current
4 fiscal year, insufficient funds to finance the current or
5 projected enrollment in the Florida Kidcare program, all
6 additional enrollment must cease and additional enrollment may
7 not resume until sufficient funds are available to finance
8 such enrollment.
9 (3) Upon determination by the Social Services
10 Estimating Conference that there are insufficient funds to
11 finance the current enrollment in the Florida Kidcare program
12 within current appropriations, the program shall initiate
13 disenrollment procedures to remove enrollees, except those
14 children who receive Florida Kidcare Plus benefits enrolled in
15 the Children's Medical Services Network, on a last-in,
16 first-out basis until the expenditure and appropriation levels
17 are balanced.
18 (4) The agencies that administer the Florida Kidcare
19 program components shall collect and analyze the data needed
20 to project program enrollment costs, including price level
21 adjustments, participation and attrition rates, current and
22 projected caseloads, the estimated number of children in the
23 state who are uninsured based on data from the most recent
24 United States Census, utilization, and current and projected
25 expenditures for the next 3 years. The agencies shall report
26 caseload and expenditure trends and estimated numbers of
27 uninsured children to the Social Services Estimating
28 Conference in accordance with chapter 216.
29 Section 15. Section 409.814, Florida Statutes, is
30 amended to read:
31
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1 409.814 Eligibility.--A child who has not reached 19
2 years of age whose family income is equal to or below the
3 maximum income threshold 200 percent of the federal poverty
4 level is eligible for the Florida Kidcare program as provided
5 in this section. For enrollment in Florida Kidcare Plus the
6 Children's Medical Services Network, a complete application
7 includes clinical eligibility the medical or behavioral health
8 screening. If, subsequently, an individual is determined to be
9 ineligible for coverage, he or she must immediately be
10 disenrolled from the respective Florida Kidcare program
11 component.
12 (1) A child who is eligible for Medicaid coverage
13 under s. 409.903 or s. 409.904 must be enrolled in Medicaid
14 and is not eligible to receive health benefits under any other
15 health benefits coverage authorized under the Florida Kidcare
16 program.
17 (2) A child who is not eligible for Medicaid, but who
18 is eligible for the Florida Kidcare program, may obtain health
19 benefits coverage under any of the other components listed in
20 s. 409.813 if such coverage is approved and available in the
21 county in which the child resides. However, a child who is
22 eligible for Medikids may participate in the Florida Healthy
23 Kids program only if the child has a sibling participating in
24 the Florida Healthy Kids program and the child's county of
25 residence permits such enrollment.
26 (3) A child who is eligible for the Florida Kidcare
27 program who is a child with special health care needs, as
28 determined through a clinical-eligibility medical or
29 behavioral screening instrument, shall receive Florida Kidcare
30 is eligible for health benefits coverage from and shall be
31 referred to the Children's Medical Services Network. A Title
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1 XIX-funded child with special health care needs may opt out of
2 Florida Kidcare Plus health benefits coverage and make another
3 selection for the delivery of the child's health benefits
4 coverage.
5 (4) A child who becomes ineligible for Title
6 XIX-funded Florida Kidcare health benefits coverage due to
7 exceeding income or age limits shall have 60 days of continued
8 eligibility following redetermination before premium payments
9 are required in order to allow for a transition to Title
10 XXI-funded Florida Kidcare without a lapse in coverage.
11 (5)(4) The following children are not eligible to
12 receive Title XXI-funded premium assistance for health
13 benefits coverage under the Florida Kidcare program, except
14 under Medicaid if the child would have been eligible for
15 Medicaid under s. 409.903 or s. 409.904 as of June 1, 1997:
16 (a) A child who is eligible for coverage under a state
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 currently eligible for or covered
20 under a family member's group health benefit plan or under
21 other employer health insurance coverage, excluding full pay
22 Florida Kidcare health benefits coverage provided under the
23 Florida Healthy Kids Corporation as established under s.
24 624.91, if provided that the cost of the child's participation
25 is not greater than 5 percent of the family's income. This
26 provision shall be applied during redetermination for children
27 who were enrolled prior to July 1, 2004. These enrollees shall
28 have 6 months of eligibility following redetermination to
29 allow for a transition to the other health benefit plan.
30 (c) A child who is seeking premium assistance for the
31 Florida Kidcare program through employer-sponsored group
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1 coverage, if the child has been covered by the same employer's
2 group coverage during the 60 days 6 months prior to the
3 family's submitting an application for determination of
4 eligibility under the program.
5 (d) A child who is an alien, but who does not meet the
6 definition of qualified alien, in the United States.
7 (e) A child who is an inmate of a public institution
8 or a patient in an institution for mental diseases.
9 (f) A child who has had his or her coverage in an
10 employer-sponsored health benefit plan or a private health
11 benefit plan voluntarily canceled in the last 60 days 6
12 months, except those children whose coverage was canceled for
13 good cause, including, but not limited to:
14 1. The cost of participation in an employer-sponsored
15 health benefit plan is greater than 5 percent of the family's
16 income;
17 2. The parent lost a job that provided an
18 employer-sponsored health benefit plan for children;
19 3. The parent who had health benefits coverage for the
20 child is deceased;
21 4. The child has a medical condition that, without
22 medical care, would cause serious disability, loss of
23 function, or death;
24 5. The employer of the parent canceled health benefits
25 coverage for children;
26 6. The child's health benefits coverage ended because
27 the child reached the maximum lifetime coverage amount;
28 7. The child has exhausted coverage under a COBRA
29 continuation provision;
30 8. The health benefits coverage does not cover the
31 child's health care needs; or
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1 9. Domestic violence led to loss of coverage. who were
2 on the waiting list prior to March 12, 2004.
3 (g) A child who is otherwise eligible for Kidcare and
4 who has a preexisting condition that prevents coverage under
5 another insurance plan as described in paragraph (b) which
6 would have disqualified the child for Kidcare if the child
7 were able to enroll in the plan shall be eligible for Kidcare
8 coverage when enrollment is possible.
9 (6) Subject to a specific appropriation for this
10 purpose, the following children are eligible to receive
11 nonfederal premium assistance for health benefits coverage
12 under the Florida Kidcare program if the child would otherwise
13 qualify:
14 (a) A child who is eligible for coverage under a
15 health benefit plan on the basis of a family member's
16 employment with a public agency in the state.
17 (b) A child who is an alien, but who does not meet the
18 definition of a qualified alien, in the United States.
19 (7)(5) A child whose family income is above the
20 maximum income threshold 200 percent of the federal poverty
21 level or a child who is excluded under the provisions of
22 subsection (5) (4) may participate in the Florida Kidcare
23 program if Medikids program as provided in s. 409.8132 or, if
24 the child is ineligible for Medikids by reason of age, in the
25 Florida Healthy Kids program, subject to the following
26 provisions:
27 (a) the family is not eligible for premium assistance
28 payments and must pay the full cost of the premium, including
29 any administrative costs.
30 (b) The agency is authorized to place limits on
31 enrollment in Medikids by these children in order to avoid
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1 adverse selection. The number of children participating in
2 Medikids whose family income exceeds 200 percent of the
3 federal poverty level must not exceed 10 percent of total
4 enrollees in the Medikids program.
5 (c) The board of directors of the Florida Healthy Kids
6 Corporation is authorized to place limits on enrollment of
7 these children in order to avoid adverse selection. In
8 addition, the board is authorized to offer a reduced benefit
9 package to these children in order to limit program costs for
10 such families. The number of children participating in the
11 Florida Healthy Kids program whose family income exceeds 200
12 percent of the federal poverty level must not exceed 10
13 percent of total enrollees in the Florida Healthy Kids
14 program.
15 (8)(6) Once a child is enrolled in the Florida Kidcare
16 program, the child is eligible for coverage under the program
17 for 12 months without a redetermination or reverification of
18 eligibility, if the family continues to pay the applicable
19 premium. Eligibility for Florida Kidcare coverage program
20 components funded through Title XXI of the Social Security Act
21 shall terminate when a child attains the age of 19. Effective
22 January 1, 1999, A child who has not attained the age of 19 5
23 and who has been determined eligible for the Medicaid program
24 is eligible for coverage for 12 months without a
25 redetermination or reverification of eligibility.
26 (9)(7) When determining or reviewing a child's
27 eligibility under the Florida Kidcare program, the applicant
28 shall be provided with reasonable notice of changes in
29 eligibility which may affect the funding source of the child's
30 Florida Kidcare health benefits coverage enrollment in one or
31 more of the program components. When a transition from one
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1 program component to another is authorized, there shall be
2 cooperation between the program components, and the affected
3 family, the child's health plan, and providers which promotes
4 continuity of health benefits care coverage. When a child is
5 no longer eligible for Title XIX-funded Florida Kidcare health
6 benefits coverage, the child's health plan and other providers
7 shall be notified at the same time the family is notified so
8 that the health plans and providers may assist the family in
9 maintaining continuous health care coverage in the Florida
10 Kidcare program. Any authorized transfers must be managed
11 within the program's overall appropriated or authorized levels
12 of funding. Each component of the program shall establish a
13 reserve to ensure that transfers between components will be
14 accomplished within current year appropriations. These
15 reserves shall be reviewed by each convening of the Social
16 Services Estimating Conference to determine the adequacy of
17 such reserves to meet actual experience.
18 (10)(8) In determining the eligibility of a child, an
19 assets test is not required. During the application process
20 and the redetermination process:
21 (a) Each applicant's family income shall be verified
22 electronically to determine financial eligibility for the
23 Florida Kidcare program. Written documentation, which may
24 include wages and earning statements such as pay stubs, W-2
25 forms, or a copy of the applicant's most recent federal income
26 tax return, shall be required only if the electronic
27 verification does not substantiate the applicant's income.
28 Each applicant shall provide written documentation during the
29 application process and the redetermination process,
30 including, but not limited to, the following:
31
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1 (a) Proof of family income, which must include a copy
2 of the applicant's most recent federal income tax return. In
3 the absence of a federal income tax return, an applicant may
4 submit wages and earnings statements (pay stubs), W-2 forms,
5 or other appropriate documents.
6 (b) Each applicant shall provide a statement from all
7 applicable family members that:
8 1. Their employers do employer does not sponsor a
9 health benefit plans plan for employees; or
10 2. The potential enrollee is not covered by an the
11 employer-sponsored health benefit plan because the potential
12 enrollee is not eligible for coverage, or, if the potential
13 enrollee is eligible but not covered, a statement of the cost
14 to enroll the potential enrollee in the employer-sponsored
15 health benefit plan.
16 (11)(9) Subject to paragraph (5) (4)(b) and s.
17 624.91(4), the Florida Kidcare program shall withhold benefits
18 from an enrollee if the program obtains evidence that the
19 enrollee is no longer eligible, submitted incorrect or
20 fraudulent information in order to establish eligibility, or
21 failed to provide verification of eligibility. The applicant
22 or enrollee shall be notified that because of such evidence
23 program benefits will be withheld unless the applicant or
24 enrollee contacts a designated representative of the program
25 by a specified date, which must be within 14 working 10 days
26 after the date of notice, to discuss and resolve the matter.
27 The program shall make every effort to resolve the matter
28 within a timeframe that will not cause benefits to be withheld
29 from an eligible enrollee.
30 (12)(10) The following individuals may be subject to
31 prosecution in accordance with s. 414.39:
34
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1 (a) An applicant obtaining or attempting to obtain
2 benefits for a potential enrollee under the Florida Kidcare
3 program when the applicant knows or should have known the
4 potential enrollee does not qualify for the Florida Kidcare
5 program.
6 (b) An individual who assists an applicant in
7 obtaining or attempting to obtain benefits for a potential
8 enrollee under the Florida Kidcare program when the individual
9 knows or should have known the potential enrollee does not
10 qualify for the Florida Kidcare program.
11 Section 16. Section 409.815, Florida Statutes, is
12 amended to read:
13 409.815 Health benefits coverage; limitations.--
14 (1) MEDICAID BENEFITS.--For purposes of the Florida
15 Kidcare program, benefits available under Medicaid and
16 Medikids include those goods and services provided under the
17 medical assistance program authorized by Title XIX of the
18 Social Security Act, and regulations thereunder, as
19 administered in this state by the agency. This includes those
20 mandatory Medicaid services authorized under s. 409.905 and
21 optional Medicaid services authorized under s. 409.906,
22 rendered on behalf of eligible individuals by qualified
23 providers, in accordance with federal requirements for Title
24 XIX, subject to any limitations or directions provided for in
25 the General Appropriations Act or chapter 216, and according
26 to methodologies and limitations set forth in agency rules and
27 policy manuals and handbooks incorporated by reference
28 thereto.
29 (2) BENCHMARK BENEFITS.--In order for health benefits
30 coverage to qualify for premium assistance payments for an
31 eligible child under ss. 409.810-409.820, except for waiver
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1 services provided to eligible Title XIX-funded children, the
2 health benefits coverage must be equivalent to the pediatric
3 Medicaid benefit package and be based upon a standard and
4 appropriate assessment of need for the services consistent
5 with Early and Periodic Screening, Diagnosis, and Treatment
6 requirements as specified in s. 409.905(2) and Title XIX of
7 the Social Security Act, except for coverage under Medicaid
8 and Medikids, must include the following minimum benefits, as
9 medically necessary.
10 (a) Preventive health services.--Covered services
11 include:
12 1. Well-child care, including services recommended in
13 the Guidelines for Health Supervision of Children and Youth as
14 developed by the American Academy of Pediatrics;
15 2. Immunizations and injections;
16 3. Health education counseling and clinical services;
17 4. Vision screening; and
18 5. Hearing screening.
19 (b) Inpatient hospital services.--All covered services
20 provided for the medical care and treatment of an enrollee who
21 is admitted as an inpatient to a hospital licensed under part
22 I of chapter 395, with the following exceptions:
23 1. All admissions must be authorized by the enrollee's
24 health benefits coverage provider.
25 2. The length of the patient stay shall be determined
26 based on the medical condition of the enrollee in relation to
27 the necessary and appropriate level of care.
28 3. Room and board may be limited to semiprivate
29 accommodations, unless a private room is considered medically
30 necessary or semiprivate accommodations are not available.
31
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1 4. Admissions for rehabilitation and physical therapy
2 are limited to 15 days per contract year.
3 (c) Emergency services.--Covered services include
4 visits to an emergency room or other licensed facility if
5 needed immediately due to an injury or illness and delay means
6 risk of permanent damage to the enrollee's health. Health
7 maintenance organizations shall comply with the provisions of
8 s. 641.513.
9 (d) Maternity services.--Covered services include
10 maternity and newborn care, including prenatal and postnatal
11 care, with the following limitations:
12 1. Coverage may be limited to the fee for vaginal
13 deliveries; and
14 2. Initial inpatient care for newborn infants of
15 enrolled adolescents shall be covered, including normal
16 newborn care, nursery charges, and the initial pediatric or
17 neonatal examination, and the infant may be covered for up to
18 3 days following birth.
19 (e) Organ transplantation services.--Covered services
20 include pretransplant, transplant, and postdischarge services
21 and treatment of complications after transplantation for
22 transplants deemed necessary and appropriate within the
23 guidelines set by the Organ Transplant Advisory Council under
24 s. 765.53 or the Bone Marrow Transplant Advisory Panel under
25 s. 627.4236.
26 (f) Outpatient services.--Covered services include
27 preventive, diagnostic, therapeutic, palliative care, and
28 other services provided to an enrollee in the outpatient
29 portion of a health facility licensed under chapter 395,
30 except for the following limitations:
31
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1 1. Services must be authorized by the enrollee's
2 health benefits coverage provider; and
3 2. Treatment for temporomandibular joint disease (TMJ)
4 is specifically excluded.
5 (g) Behavioral health services.--
6 1. Mental health benefits include:
7 a. Inpatient services, limited to not more than 30
8 inpatient days per contract year for psychiatric admissions,
9 or residential services in facilities licensed under s.
10 394.875(8) or s. 395.003 in lieu of inpatient psychiatric
11 admissions; however, a minimum of 10 of the 30 days shall be
12 available only for inpatient psychiatric services when
13 authorized by a physician; and
14 b. Outpatient services, including outpatient visits
15 for psychological or psychiatric evaluation, diagnosis, and
16 treatment by a licensed mental health professional, limited to
17 a maximum of 40 outpatient visits each contract year.
18 2. Substance abuse services include:
19 a. Inpatient services, limited to not more than 7
20 inpatient days per contract year for medical detoxification
21 only and 30 days of residential services; and
22 b. Outpatient services, including evaluation,
23 diagnosis, and treatment by a licensed practitioner, limited
24 to a maximum of 40 outpatient visits per contract year.
25 (h) Durable medical equipment.--Covered services
26 include equipment and devices that are medically indicated to
27 assist in the treatment of a medical condition and
28 specifically prescribed as medically necessary, with the
29 following limitations:
30 1. Low-vision and telescopic aides are not included.
31
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1 2. Corrective lenses and frames may be limited to one
2 pair every 2 years, unless the prescription or head size of
3 the enrollee changes.
4 3. Hearing aids shall be covered only when medically
5 indicated to assist in the treatment of a medical condition.
6 4. Covered prosthetic devices include artificial eyes
7 and limbs, braces, and other artificial aids.
8 (i) Health practitioner services.--Covered services
9 include services and procedures rendered to an enrollee when
10 performed to diagnose and treat diseases, injuries, or other
11 conditions, including care rendered by health practitioners
12 acting within the scope of their practice, with the following
13 exceptions:
14 1. Chiropractic services shall be provided in the same
15 manner as in the Florida Medicaid program.
16 2. Podiatric services may be limited to one visit per
17 day totaling two visits per month for specific foot disorders.
18 (j) Home health services.--Covered services include
19 prescribed home visits by both registered and licensed
20 practical nurses to provide skilled nursing services on a
21 part-time intermittent basis, subject to the following
22 limitations:
23 1. Coverage may be limited to include skilled nursing
24 services only;
25 2. Meals, housekeeping, and personal comfort items may
26 be excluded; and
27 3. Private duty nursing is limited to circumstances
28 where such care is medically necessary.
29 (k) Hospice services.--Covered services include
30 reasonable and necessary services for palliation or management
31
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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 July 1,
17 2009, 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) Effective July 1, 2009, maintain a toll-free
22 telephone line to assist families with questions about the
23 program.
24 (e)(d) Adopt rules necessary for conducting program
25 eligibility functions.
26 (2) The Department of Health shall:
27 (a) Design an eligibility intake process and policies
28 for non-Title XIX eligibility determination for the program,
29 in coordination with the Department of Children and Family
30 Services, the agency, and the Florida Healthy Kids
31 Corporation. The eligibility intake process may include local
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1 intake points that are determined by the Department of Health
2 in coordination with the Department of Children and Family
3 Services.
4 (b) Chair a state-level coordinating council to review
5 and make recommendations concerning the implementation and
6 operation of the program. The coordinating council shall
7 include representatives from the department, the Department of
8 Children and Family Services, the agency, the Florida Healthy
9 Kids Corporation, the Office of Insurance Regulation of the
10 Financial Services Commission, local government, health
11 insurers, health maintenance organizations, health care
12 providers, families participating in the program, and
13 organizations representing low-income families.
14 (b) In consultation with the Council on Children's
15 Health, develop and implement a plan to publicize the Florida
16 Kidcare program, the eligibility requirements of the program,
17 and the procedures for enrollment in the program and to
18 maintain public awareness of and outreach for the Florida
19 Kidcare program.
20 (c) Determine clinical eligibility for and administer
21 Florida Kidcare Plus health benefits coverage.
22 (d) In consultation with the agency, develop a minimum
23 set of pediatric quality assurance and access standards,
24 including reporting requirements, for the Florida Kidcare
25 program. The standards must include a process for granting
26 exceptions to specific requirements for quality assurance and
27 access. Compliance with the standards shall be a condition of
28 program participation by health benefits coverage providers.
29 These standards shall comply with the provisions of this
30 chapter and chapter 641 and Title XXI of the Social Security
31 Act.
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1 (e) In consultation with the agency, the Department of
2 Children and Family Services, and the Florida Healthy Kids
3 Corporation and effective July 1, 2008, coordinate non-Title
4 XIX-funded Florida Kidcare administrative activities,
5 including, but not limited to:
6 1. Florida Kidcare policy development;
7 2. Federal and state legislative and budget request
8 issue development; and
9 3. Administrative rules as assigned by this act.
10 (f) In consultation with the agency, develop pediatric
11 benefit packages for Florida Kidcare enrollees.
12 (c) In consultation with the Florida Healthy Kids
13 Corporation and the Department of Children and Family
14 Services, establish a toll-free telephone line to assist
15 families with questions about the program.
16 (d) Adopt rules necessary to implement outreach
17 activities.
18 (3) The Agency for Health Care Administration, under
19 the authority granted in s. 409.914(1), shall:
20 (a) Calculate the premium assistance payment necessary
21 to comply with the premium and cost-sharing limitations
22 specified in s. 409.816. The premium assistance payment for
23 each enrollee in a health insurance plan participating in the
24 Florida Healthy Kids Corporation shall equal the premium
25 approved by the Florida Healthy Kids Corporation and the
26 Office of Insurance Regulation of the Financial Services
27 Commission pursuant to ss. 627.410 and 641.31, less any
28 enrollee's share of the premium established within the
29 limitations specified in s. 409.816. The premium assistance
30 payment for each enrollee in an employer-sponsored health
31 insurance plan approved under ss. 409.810-409.820 shall equal
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1 the premium for the plan adjusted for any benchmark benefit
2 plan actuarial equivalent benefit rider approved by the Office
3 of Insurance Regulation pursuant to ss. 627.410 and 641.31,
4 less any enrollee's share of the premium established within
5 the limitations specified in s. 409.816. In calculating the
6 premium assistance payment levels for children with family
7 coverage, the agency shall set the premium assistance payment
8 levels for each child proportionately to the total cost of
9 family coverage.
10 (b) Make premium assistance payments to health
11 insurance plans on a periodic basis. The agency may use its
12 Medicaid fiscal agent or a contracted third-party
13 administrator in making these payments. The agency may
14 require health insurance plans that participate in the
15 Medikids program or employer-sponsored group health insurance
16 to collect premium payments from an enrollee's family.
17 Participating health insurance plans shall report premium
18 payments collected on behalf of enrollees in the program to
19 the agency in accordance with a schedule established by the
20 agency.
21 (c) Monitor compliance with pediatric quality
22 assurance and access standards developed by the Department of
23 Health under s. 409.820.
24 (d) Establish a mechanism for investigating and
25 resolving complaints and grievances from program applicants,
26 enrollees, and health benefits coverage providers, and
27 maintain a record of complaints and confirmed problems. In the
28 case of a child who is enrolled in a health maintenance
29 organization, the agency must use the provisions of s. 641.511
30 to address grievance reporting and resolution requirements.
31
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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).
4 (f) Adopt all rules necessary to comply with or
5 administer ss. 409.810-409.820 and all rules necessary to
6 comply with federal requirements, including, at a minimum,
7 rules specifying policies, procedures, and criteria for the
8 following activities:
9 1. Calculating premium assistance payment levels;
10 2. Making premium assistance payments;
11 3. Monitoring access and quality assurance standards;
12 4. Investigating and resolving complaints and
13 grievances;
14 5. Administering the Medikids program;
15 6. Approving health benefits coverage; and
16 7. Except for Title XIX-funded Florida Kidcare,
17 determining application and enrollment requirements, including
18 documentation requirements, eligibility determinations and
19 redeterminations, enrollee premium payment requirements,
20 cancellation of coverage, reinstatement of coverage,
21 disenrollment procedures, applicant and enrollee notification
22 requirements, application and enrollment time processing
23 standards, and call center standards.
24
25 Effective July 1, 2008, the Department of Health shall assume
26 responsibility for administrative rulemaking activities
27 specified in subparagraphs 3, 4, 6, and 7. Adopt rules
28 necessary for calculating premium assistance payment levels,
29 making premium assistance payments, monitoring access and
30 quality assurance standards, investigating and resolving
31 complaints and grievances, administering the Medikids program,
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1 and approving health benefits coverage. The agency is
2 designated the lead state agency for Title XXI of the Social
3 Security Act for purposes of receipt of federal funds, for
4 reporting purposes, and for ensuring compliance with federal
5 and state regulations and rules.
6 (4) The Office of Insurance Regulation shall certify
7 that health benefits coverage plans that seek to provide
8 services under the Florida Kidcare program, except those
9 offered through the Florida Healthy Kids Corporation or the
10 Children's Medical Services Network, meet, exceed, or are
11 actuarially equivalent to the benchmark benefit plan and that
12 health insurance plans will be offered at an approved rate. In
13 determining actuarial equivalence of benefits coverage, the
14 Office of Insurance Regulation and health insurance plans must
15 comply with the requirements of s. 2103 of Title XXI of the
16 Social Security Act. The department shall adopt rules
17 necessary for certifying health benefits coverage plans.
18 (4)(a)(5) The Florida Healthy Kids Corporation shall
19 retain its functions as authorized in s. 624.91, including
20 eligibility determination for participation in the non-Title
21 XIX-funded Florida Kidcare program Healthy Kids program.
22 Effective July 1, 2008, non-Title XIX-funded Florida Kidcare
23 eligibility determinations shall be conducted in accordance
24 with administrative rules and policies established by the
25 Department of Health.
26 (5) The Department of Health, in consultation with the
27 agency, the Department of Children and Family Services, and
28 the Florida Healthy Kids Corporation, and
29 (6) The agency, the Department of Health, the
30 Department of Children and Family Services, the Florida
31 Healthy Kids Corporation, and the Office of Insurance
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1 Regulation, after consultation with and approval of the
2 Speaker of the House of Representatives and the President of
3 the Senate, are authorized to make program modifications that
4 are necessary to overcome any objections of the United States
5 Department of Health and Human Services to obtain approval of
6 the state's child health insurance plan under Title XXI of the
7 Social Security Act.
8 Section 20. Section 409.820, Florida Statutes, is
9 repealed.
10 Section 21. Section 409.821, Florida Statutes, is
11 amended to read:
12 409.821 Florida Kidcare program public records
13 exemption.--Notwithstanding any other law to the contrary, any
14 information identifying a Florida Kidcare program applicant or
15 enrollee, as defined in s. 409.811, held by the Agency for
16 Health Care Administration, the Department of Children and
17 Family Services, the Department of Health, or the Florida
18 Healthy Kids Corporation is confidential and exempt from s.
19 119.07(1) and s. 24(a), Art. I of the State Constitution. Such
20 information may be disclosed to another governmental entity
21 only if disclosure is necessary for the entity to perform its
22 duties and responsibilities under the Florida Kidcare program
23 and shall be disclosed to the Department of Revenue for
24 purposes of administering the state Title IV-D program. The
25 receiving governmental entity must maintain the confidential
26 and exempt status of such information. Furthermore, such
27 information may not be released to any person without the
28 written consent of the program applicant. This exemption
29 applies to any information identifying a Florida Kidcare
30 program applicant or enrollee held by the Agency for Health
31 Care Administration, the Department of Children and Family
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1 Services, the Department of Health, or the Florida Healthy
2 Kids Corporation before, on, or after the effective date of
3 this exemption. A violation of this section is a misdemeanor
4 of the second degree, punishable as provided in s. 775.082 or
5 s. 775.083. This section does not prohibit an enrollee's
6 parent or legal guardian from obtaining any record relating to
7 the enrollee's Florida Kidcare application or coverage,
8 including, but not limited to, confirmation of coverage, the
9 dates of coverage, the name of the enrollee's health plan, and
10 the amount of premium.
11 Section 22. Section 409.904, Florida Statutes, is
12 amended to read:
13 409.904 Optional payments for eligible persons.--The
14 agency may make payments for medical assistance and related
15 services on behalf of the following persons who are determined
16 to be eligible subject to the income, assets, and categorical
17 eligibility tests set forth in federal and state law. Payment
18 on behalf of these Medicaid eligible persons is subject to the
19 availability of moneys and any limitations established by the
20 General Appropriations Act or chapter 216.
21 (1)(a) From July 1, 2005, through December 31, 2005, a
22 person who is age 65 or older or is determined to be disabled,
23 whose income is at or below 88 percent of federal poverty
24 level, and whose assets do not exceed established limitations.
25 (b) Effective January 1, 2006, and subject to federal
26 waiver approval, a person who is age 65 or older or is
27 determined to be disabled, whose income is at or below 88
28 percent of the federal poverty level, whose assets do not
29 exceed established limitations, and who is not eligible for
30 Medicare or, if eligible for Medicare, is also eligible for
31 and receiving Medicaid-covered institutional care services,
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1 hospice services, or home and community-based services. The
2 agency shall seek federal authorization through a waiver to
3 provide this coverage.
4 (2) A family, a pregnant woman, a child under age 21,
5 a person age 65 or over, or a blind or disabled person, who
6 would be eligible under any group listed in s. 409.903(1),
7 (2), or (3), except that the income or assets of such family
8 or person exceed established limitations. For a family or
9 person in one of these coverage groups, medical expenses are
10 deductible from income in accordance with federal requirements
11 in order to make a determination of eligibility. A family or
12 person eligible under the coverage known as the "medically
13 needy," is eligible to receive the same services as other
14 Medicaid recipients, with the exception of services in skilled
15 nursing facilities and intermediate care facilities for the
16 developmentally disabled.
17 (3) A person who is in need of the services of a
18 licensed nursing facility, a licensed intermediate care
19 facility for the developmentally disabled, or a state mental
20 hospital, whose income does not exceed 300 percent of the SSI
21 income standard, and who meets the assets standards
22 established under federal and state law. In determining the
23 person's responsibility for the cost of care, the following
24 amounts must be deducted from the person's income:
25 (a) The monthly personal allowance for residents as
26 set based on appropriations.
27 (b) The reasonable costs of medically necessary
28 services and supplies that are not reimbursable by the
29 Medicaid program.
30 (c) The cost of premiums, copayments, coinsurance, and
31 deductibles for supplemental health insurance.
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1 (4) A low-income person who meets all other
2 requirements for Medicaid eligibility except citizenship and
3 who is in need of emergency medical services. The eligibility
4 of such a recipient is limited to the period of the emergency,
5 in accordance with federal regulations.
6 (5) Subject to specific federal authorization, a woman
7 living in a family that has an income that is at or below 200
8 185 percent of the most current federal poverty level is
9 eligible for family planning services as specified in s.
10 409.905(3) for a period of up to 24 months following a loss of
11 Medicaid benefits.
12 (6) A child who has not attained the age of 19 who has
13 been determined eligible for the Medicaid program is deemed to
14 be eligible for a total of 12 6 months, regardless of changes
15 in circumstances other than attainment of the maximum age.
16 Effective January 1, 1999, a child who has not attained the
17 age of 5 and who has been determined eligible for the Medicaid
18 program is deemed to be eligible for a total of 12 months
19 regardless of changes in circumstances other than attainment
20 of the maximum age.
21 (7) A pregnant woman for the duration of her pregnancy
22 and for the postpartum period as defined by federal law and
23 rules, or a child under 1 year of age, who lives in a family
24 that has an income above 185 percent of the most recently
25 published federal poverty level, but which is at or below 200
26 percent of such poverty level. In determining the eligibility
27 of such pregnant woman or child, an assets test is not
28 required. A child who is eligible for Medicaid under this
29 subsection must be offered the opportunity, subject to federal
30 rules, to be made presumptively eligible. A pregnant woman or
31 child who has been deemed presumptively eligible for Medicaid
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1 shall not be enrolled in a managed care plan until full
2 eligibility for Medicaid has been determined.
3 (8) A child who has attained the age of 6 but has not
4 attained the age of 19 and who lives in a family that has an
5 income above 100 percent of the most recently published
6 federal poverty level, which is at or below 133 percent of
7 such poverty level. In determining the eligibility of such
8 child, an assets test is not required. A child who is eligible
9 for Medicaid under this subsection must be offered the
10 opportunity, subject to federal rules, to be made
11 presumptively eligible.
12 (9)(8) A Medicaid-eligible individual for the
13 individual's health insurance premiums, if the agency
14 determines that such payments are cost-effective.
15 (10)(9) Eligible women with incomes at or below 200
16 percent of the federal poverty level and under age 65, for
17 cancer treatment pursuant to the federal Breast and Cervical
18 Cancer Prevention and Treatment Act of 2000, screened through
19 the Mary Brogan Breast and Cervical Cancer Early Detection
20 Program established under s. 381.93.
21 (11) The agency shall submit a state plan amendment to
22 the Federal Government to implement the provisions of the
23 Family Opportunity Act, pursuant to the Deficit Reduction Act
24 of 2005.
25 Section 23. Paragraph (a) of subsection (2) of section
26 409.91211, Florida Statutes, is amended to read:
27 409.91211 Medicaid managed care pilot program.--
28 (2) The Legislature intends for the capitated managed
29 care pilot program to:
30 (a) Provide, except for those enrolled in the Florida
31 Kidcare program, recipients in Medicaid fee-for-service or the
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1 MediPass program a comprehensive and coordinated capitated
2 managed care system for all health care services specified in
3 ss. 409.905 and 409.906.
4 Section 24. Section 624.91, Florida Statutes, is
5 amended to read:
6 624.91 The Florida Healthy Kids Corporation Act.--
7 (1) SHORT TITLE.--This section may be cited as the
8 "William G. 'Doc' Myers Healthy Kids Corporation Act."
9 (2) LEGISLATIVE INTENT.--
10 (a) The Legislature finds that increased access to
11 health care services could improve children's health and
12 reduce the incidence and costs of childhood illness and
13 disabilities among children in this state. Many children do
14 not have comprehensive, affordable health care services
15 available. It is the intent of the Legislature that the
16 Florida Healthy Kids Corporation provide comprehensive health
17 insurance coverage to such children. The corporation is
18 encouraged to cooperate with any existing health service
19 programs funded by the public or the private sector.
20 (b) It is the intent of the Legislature that the
21 Florida Healthy Kids Corporation serve as one of several
22 providers of services to children eligible for medical
23 assistance under Title XXI of the Social Security Act.
24 Although the corporation may serve other children, the
25 Legislature intends the primary recipients of services
26 provided through the corporation be school-age children with a
27 family income below 200 percent of the federal poverty level,
28 who do not qualify for Medicaid. It is also the intent of the
29 Legislature that state and local government Florida Healthy
30 Kids funds be used to continue coverage, subject to specific
31
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1 appropriations in the General Appropriations Act, to children
2 not eligible for federal matching funds under Title XXI.
3 (3) ELIGIBILITY FOR STATE-FUNDED ASSISTANCE.--Only the
4 following individuals are eligible for state-funded assistance
5 in paying Florida Healthy Kids premiums:
6 (a) Residents of this state who are eligible for the
7 Florida Kidcare program pursuant to s. 409.814.
8 (b) Notwithstanding s. 409.814, legal aliens who are
9 enrolled in the Florida Healthy Kids program as of January 31,
10 2004, who do not qualify for Title XXI federal funds because
11 they are not qualified aliens as defined in s. 409.811.
12 (3)(4) NONENTITLEMENT.--Nothing in this section shall
13 be construed as providing an individual with an entitlement to
14 health care services. No cause of action shall arise against
15 the state, the Florida Healthy Kids Corporation, or a unit of
16 local government for failure to make health services available
17 under this section.
18 (4)(5) CORPORATION AUTHORIZATION, DUTIES, POWERS.--
19 (a) There is created the Florida Healthy Kids
20 Corporation, a not-for-profit corporation.
21 (b) The Florida Healthy Kids Corporation shall:
22 1. Arrange for the collection of any family, local
23 contributions, or employer payment or premium, in an amount to
24 be determined by the board of directors, to provide for
25 payment of premiums for health benefits comprehensive
26 insurance coverage and for the actual or estimated
27 administrative expenses.
28 2. Arrange for the collection of any voluntary
29 contributions to provide for payment of Florida Kidcare
30 premiums for children who are not eligible for medical
31
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1 assistance under Title XIX or Title XXI of the Social Security
2 Act.
3 3. Subject to the provisions of s. 409.8134, accept
4 voluntary supplemental local match contributions that comply
5 with the requirements of Title XXI of the Social Security Act
6 for the purpose of providing additional Florida Kidcare
7 coverage in contributing counties under Title XXI.
8 4. Establish the administrative and accounting
9 procedures for the operation of the corporation.
10 5. Establish, with consultation from appropriate
11 professional organizations, standards for preventive health
12 services and providers and comprehensive insurance benefits
13 appropriate to children, provided that such standards for
14 rural areas shall not limit primary care providers to
15 board-certified pediatricians.
16 6. Determine eligibility for children seeking to
17 participate in the Title XXI-funded components of the Florida
18 Kidcare program consistent with the requirements specified in
19 s. 409.814, as well as the non-Title-XXI-eligible children as
20 provided in subsection (3). Effective July 1, 2008, this
21 function shall be performed in accordance with administrative
22 rules and policies established by the Department of Health.
23 7. Establish procedures under which providers of local
24 match to, applicants to and participants in the program may
25 have grievances reviewed by an impartial body and reported to
26 the board of directors of the corporation.
27 8. Establish participation criteria and, if
28 appropriate, Contract with an authorized insurer, health
29 maintenance organization, or third-party administrator to
30 provide administrative services for Florida Kidcare to the
31 corporation. Effective July 1, 2008, this function shall be
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1 performed in accordance with administrative rules and policies
2 established by the Department of Health.
3 9. Establish enrollment criteria which shall include
4 penalties or waiting periods of not fewer than 60 days for
5 reinstatement of coverage upon voluntary cancellation for
6 nonpayment of family premiums.
7 9.10. Contract with authorized insurers or any
8 provider of health care services, meeting quality assurance
9 and access standards established by the Department of Health
10 corporation, for the provision of comprehensive insurance
11 coverage to participants. Such standards shall include
12 criteria under which the corporation may contract with more
13 than one provider of health care services in program sites.
14 Health plans shall be selected through a competitive bid
15 process. The Florida Healthy Kids Corporation shall purchase
16 goods and services in the most cost-effective manner
17 consistent with the delivery of quality medical care. The
18 maximum administrative cost for a Florida Healthy Kids
19 Corporation contract shall be 15 percent. For health care
20 contracts, the minimum medical loss ratio for a Florida
21 Healthy Kids Corporation contract shall be 85 percent. For
22 dental contracts, the remaining compensation to be paid to the
23 authorized insurer or provider under a Florida Healthy Kids
24 Corporation contract shall be no less than an amount which is
25 85 percent of premium; to the extent any contract provision
26 does not provide for this minimum compensation, this section
27 shall prevail. The health plan selection criteria and scoring
28 system, and the scoring results, shall be available upon
29 request for inspection after the bids have been awarded.
30 10.11. Establish disenrollment criteria in the event
31 local matching funds are insufficient to cover enrollments.
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1 11. Maintain a toll-free telephone line to assist
2 families with questions about the program. Effective July 1,
3 2008, this function shall be performed in accordance with
4 administrative rules and policies established by the
5 Department of Health.
6 12. Develop and implement a plan to publicize the
7 Florida Healthy Kids Corporation, the eligibility requirements
8 of the program, and the procedures for enrollment in the
9 program and to maintain public awareness of the corporation
10 and the program.
11 12.13. Secure staff necessary to properly administer
12 the corporation. Staff costs shall be funded from state and
13 local matching funds and such other private or public funds as
14 become available. The board of directors shall determine the
15 number of staff members necessary to administer the
16 corporation.
17 13. No later than January 1, 2008, the health benefits
18 coverage provided by the corporation's authorized insurers and
19 health maintenance organizations shall conform with the
20 benchmark benefits specified in s. 409.815.
21 14. Provide a report annually to the Governor, Chief
22 Financial Officer, Commissioner of Education, Senate
23 President, Speaker of the House of Representatives, and
24 Minority Leaders of the Senate and the House of
25 Representatives.
26 15. Establish benefit packages which conform to the
27 provisions of the Florida Kidcare program, as created in ss.
28 409.810-409.820.
29 (c) Coverage under the corporation's program is
30 secondary to any other available private coverage held by, or
31 applicable to, the participant child or family member.
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1 Insurers under contract with the corporation are the payors of
2 last resort and must coordinate benefits with any other
3 third-party payor that may be liable for the participant's
4 medical care.
5 (d) The Florida Healthy Kids Corporation shall be a
6 private corporation not for profit, organized pursuant to
7 chapter 617, and shall have all powers necessary to carry out
8 the purposes of this act, including, but not limited to, the
9 power to receive and accept grants, loans, or advances of
10 funds from any public or private agency and to receive and
11 accept from any source contributions of money, property,
12 labor, or any other thing of value, to be held, used, and
13 applied for the purposes of this act.
14 (6) BOARD OF DIRECTORS.--
15 (a) The Florida Healthy Kids Corporation shall operate
16 subject to the supervision and approval of a board of
17 directors chaired by the Chief Financial Officer or her or his
18 designee, and composed of 10 other members selected for 3-year
19 terms of office as follows:
20 1. The Secretary of Health Care Administration, or his
21 or her designee;
22 2. One member appointed by the Commissioner of
23 Education from the Office of School Health Programs of the
24 Florida Department of Education;
25 3. One member appointed by the Chief Financial Officer
26 from among three members nominated by the Florida Pediatric
27 Society;
28 4. One member, appointed by the Governor, who
29 represents the Children's Medical Services Program;
30
31
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1 5. One member appointed by the Chief Financial Officer
2 from among three members nominated by the Florida Hospital
3 Association;
4 6. One member, appointed by the Governor, who is an
5 expert on child health policy;
6 7. One member, appointed by the Chief Financial
7 Officer, from among three members nominated by the Florida
8 Academy of Family Physicians;
9 8. One member, appointed by the Governor, who
10 represents the state Medicaid program;
11 9. One member, appointed by the Chief Financial
12 Officer, from among three members nominated by the Florida
13 Association of Counties; and
14 10. The State Health Officer or her or his designee.
15 (b) A member of the board of directors may be removed
16 by the official who appointed that member. The board shall
17 appoint an executive director, who is responsible for other
18 staff authorized by the board.
19 (c) Board members are entitled to receive, from funds
20 of the corporation, reimbursement for per diem and travel
21 expenses as provided by s. 112.061.
22 (d) There shall be no liability on the part of, and no
23 cause of action shall arise against, any member of the board
24 of directors, or its employees or agents, for any action they
25 take in the performance of their powers and duties under this
26 act.
27 (7) LICENSING NOT REQUIRED; FISCAL OPERATION.--
28 (a) The corporation shall not be deemed an insurer.
29 The officers, directors, and employees of the corporation
30 shall not be deemed to be agents of an insurer. Neither the
31 corporation nor any officer, director, or employee of the
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1 corporation is subject to the licensing requirements of the
2 insurance code or the rules of the Department of Financial
3 Services. However, any marketing representative utilized and
4 compensated by the corporation must be appointed as a
5 representative of the insurers or health services providers
6 with which the corporation contracts.
7 (b) The board has complete fiscal control over the
8 corporation and is responsible for all corporate operations.
9 (c) The Department of Financial Services shall
10 supervise any liquidation or dissolution of the corporation
11 and shall have, with respect to such liquidation or
12 dissolution, all power granted to it pursuant to the insurance
13 code.
14 (8) ACCESS TO RECORDS; CONFIDENTIALITY;
15 PENALTIES.--Notwithstanding any other laws to the contrary,
16 the Florida Healthy Kids Corporation shall have access to the
17 medical records of a student upon receipt of permission from a
18 parent or guardian of the student. Such medical records may be
19 maintained by state and local agencies. Any identifying
20 information, including medical records and family financial
21 information, obtained by the corporation pursuant to this
22 subsection is confidential and is exempt from the provisions
23 of s. 119.07(1). Neither the corporation nor the staff or
24 agents of the corporation may release, without the written
25 consent of the participant or the parent or guardian of the
26 participant, to any state or federal agency, to any private
27 business or person, or to any other entity, any confidential
28 information received pursuant to this subsection. A violation
29 of this subsection is a misdemeanor of the second degree,
30 punishable as provided in s. 775.082 or s. 775.083.
31
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1 Section 25. Effective June 30, 2009, section 624.91,
2 Florida Statutes, as amended by this act, is repealed.
3 Section 26. Except as otherwise expressly provided in
4 this act, this act shall take effect July 1, 2007.
5
6 STATEMENT OF SUBSTANTIAL CHANGES CONTAINED IN
COMMITTEE SUBSTITUTE FOR
7 CS/SB 930
8
9 Recreates the Florida Commission on Children's Health as a
coordinating council and establishes appointments to the
10 council.
11 Repeals the coordinating council chaired by the Department of
Health.
12
Makes technical and conforming changes to clarify which
13 functions are reassigned to the Department of Health.
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