| 1 | Representative Coley offered the following: |
| 2 |
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| 3 | Amendment to Amendment (940817) (with title amendment) |
| 4 | Remove lines 268-762 and insert: |
| 5 | Section 7. Subsections (6) through (26) of section |
| 6 | 409.811, Florida Statutes, are renumbered as subsections (7) |
| 7 | through (27), respectively, and a new subsection (6) is added to |
| 8 | that section, to read: |
| 9 | 409.811 Definitions relating to Florida Kidcare Act.--As |
| 10 | used in ss. 409.810-409.820, the term: |
| 11 | (6) "Autism spectrum disorder" means any of the following |
| 12 | disorders as defined with most recent edition of the Diagnostic |
| 13 | and Statistical Manual of Mental Disorders of the American |
| 14 | Psychiatric Association: |
| 15 | 1. Autistic disorder; |
| 16 | 2. Asperger syndrome; or |
| 17 | 3. Pervasive developmental disorder not otherwise |
| 18 | specified. |
| 19 | Section 8. Paragraphs (r) through (v) of subsection (2) of |
| 20 | section 409.815, Florida Statutes, are redesignated as |
| 21 | paragraphs (s) through (w), respectively, present paragraphs |
| 22 | (o), (r), and (u) are amended, and a new paragraph (r) is added |
| 23 | to that subsection, to read: |
| 24 | 409.815 Health benefits coverage; limitations.-- |
| 25 | (2) BENCHMARK BENEFITS.--In order for health benefits |
| 26 | coverage to qualify for premium assistance payments for an |
| 27 | eligible child under ss. 409.810-409.820, the health benefits |
| 28 | coverage, except for coverage under Medicaid and Medikids, must |
| 29 | include the following minimum benefits, as medically necessary. |
| 30 | (o) Therapy services.--Covered services include |
| 31 | habilitative and rehabilitative services, including |
| 32 | occupational, physical, respiratory, and speech therapies, with |
| 33 | the following limitations: |
| 34 | 1. Rehabilitative services are limited to: |
| 35 | a.1. Services must be for Short-term rehabilitation when |
| 36 | where significant improvement in the enrollee's condition will |
| 37 | result; and |
| 38 | b.2. Services shall be limited to Not more than 24 |
| 39 | treatment sessions within a 60-day period per episode or injury, |
| 40 | with the 60-day period beginning with the first treatment. |
| 41 | 2. Effective October 1, 2009, habilitative services shall |
| 42 | be offered and are limited to: |
| 43 | a. Habilitation when improvements in and maintenance of |
| 44 | human behavior, skill acquisition, and communication will |
| 45 | result; and |
| 46 | b. Enrollees that are diagnosed with a developmental |
| 47 | disability as defined in s. 393.063 or autism spectrum disorder |
| 48 | as defined in paragraph (r)1. |
| 49 | (r) Behavior analysis services.--Effective October 1, |
| 50 | 2009, behavior analysis and behavior assistant services shall be |
| 51 | covered for enrollees that are diagnosed with a developmental |
| 52 | disability as defined in s. 393.063 or autism spectrum disorder. |
| 53 | For purposes of this paragraph: |
| 54 | 1. "Autism spectrum disorder" means any of the following |
| 55 | disorders as defined with most recent edition of the Diagnostic |
| 56 | and Statistical Manual of Mental Disorders of the American |
| 57 | Psychiatric Association: |
| 58 | a. Autistic disorder; |
| 59 | b. Asperger syndrome; or |
| 60 | c. Pervasive developmental disorder not otherwise |
| 61 | specified. |
| 62 | 2. "Behavior analysis" means the design, implementation, |
| 63 | and evaluation of instructional and environmental modifications |
| 64 | to produce socially significant improvements in human behavior |
| 65 | through skill acquisition and the reduction of problematic |
| 66 | behavior. Behavior analysis shall be provided by an individual |
| 67 | certified pursuant to s. 393.17 or an individual licensed under |
| 68 | chapter 490 or chapter 491. |
| 69 | 3. "Behavior assistant services" means services provided |
| 70 | by an individual with specific training to assist in carrying |
| 71 | out plans designed by a behavior analyst. |
| 72 | (s)(r) Lifetime maximum and limitations.--Health benefits |
| 73 | coverage obtained under ss. 409.810-409.820 shall pay an |
| 74 | enrollee's covered expenses at a lifetime maximum of $1 million |
| 75 | per covered child. However, coverage for the combination of |
| 76 | behavior analysis services and habilitative therapy services for |
| 77 | recipients diagnosed with a developmental disability as defined |
| 78 | in s. 393.063 or autism spectrum disorder as defined in |
| 79 | paragraph (r)1. shall be limited to $36,000 annually and may not |
| 80 | exceed $108,000 in total lifetime benefits. Without prior |
| 81 | authorization by the Florida Healthy Kids plan, not more than 12 |
| 82 | percent of the annual maximum amount for combined habilitative |
| 83 | therapy and behavior analysis services may be used on a monthly |
| 84 | basis. |
| 85 | (v)(u) Enhancements to minimum requirements.-- |
| 86 | 1. This section sets the minimum benefits that must be |
| 87 | included in any health benefits coverage, other than Medicaid or |
| 88 | Medikids coverage, offered under ss. 409.810-409.820. Health |
| 89 | benefits coverage may include additional benefits not included |
| 90 | under this subsection, but may not include benefits excluded |
| 91 | under paragraph (t) (s). |
| 92 | 2. Health benefits coverage may extend any limitations |
| 93 | beyond the minimum benefits described in this section. |
| 94 |
|
| 95 | Except for the Children's Medical Services Network, the agency |
| 96 | may not increase the premium assistance payment for either |
| 97 | additional benefits provided beyond the minimum benefits |
| 98 | described in this section or the imposition of less restrictive |
| 99 | service limitations. |
| 100 | Section 9. Paragraph (b) of subsection (1) of section |
| 101 | 409.818, Florida Statutes, is amended to read: |
| 102 | 409.818 Administration.--In order to implement ss. |
| 103 | 409.810-409.820, the following agencies shall have the following |
| 104 | duties: |
| 105 | (1) The Department of Children and Family Services shall: |
| 106 | (b) Establish and maintain the eligibility determination |
| 107 | process under the program except as specified in subsection (5). |
| 108 | The department shall directly, or through the services of a |
| 109 | contracted third-party administrator, establish and maintain a |
| 110 | process for determining eligibility of children for coverage |
| 111 | under the program. The eligibility determination process must be |
| 112 | used solely for determining eligibility of applicants for health |
| 113 | benefits coverage under the program. The eligibility |
| 114 | determination process must include an initial determination of |
| 115 | eligibility for any coverage offered under the program, as well |
| 116 | as a redetermination or reverification of eligibility each |
| 117 | subsequent 12 6 months. Effective January 1, 1999, a child who |
| 118 | has not attained the age of 5 and who has been determined |
| 119 | eligible for the Medicaid program is eligible for coverage for |
| 120 | 12 months without a redetermination or reverification of |
| 121 | eligibility. In conducting an eligibility determination, the |
| 122 | department shall determine if the child has special health care |
| 123 | needs. The department, in consultation with the Agency for |
| 124 | Health Care Administration and the Florida Healthy Kids |
| 125 | Corporation, shall develop procedures for redetermining |
| 126 | eligibility which enable a family to easily update any change in |
| 127 | circumstances which could affect eligibility. The department may |
| 128 | accept changes in a family's status as reported to the |
| 129 | department by the Florida Healthy Kids Corporation without |
| 130 | requiring a new application from the family. Redetermination of |
| 131 | a child's eligibility for Medicaid may not be linked to a |
| 132 | child's eligibility determination for other programs. |
| 133 | Section 10. Subsection (26) is added to section 409.906, |
| 134 | Florida Statutes, to read: |
| 135 | 409.906 Optional Medicaid services.--Subject to specific |
| 136 | appropriations, the agency may make payments for services which |
| 137 | are optional to the state under Title XIX of the Social Security |
| 138 | Act and are furnished by Medicaid providers to recipients who |
| 139 | are determined to be eligible on the dates on which the services |
| 140 | were provided. Any optional service that is provided shall be |
| 141 | provided only when medically necessary and in accordance with |
| 142 | state and federal law. Optional services rendered by providers |
| 143 | in mobile units to Medicaid recipients may be restricted or |
| 144 | prohibited by the agency. Nothing in this section shall be |
| 145 | construed to prevent or limit the agency from adjusting fees, |
| 146 | reimbursement rates, lengths of stay, number of visits, or |
| 147 | number of services, or making any other adjustments necessary to |
| 148 | comply with the availability of moneys and any limitations or |
| 149 | directions provided for in the General Appropriations Act or |
| 150 | chapter 216. If necessary to safeguard the state's systems of |
| 151 | providing services to elderly and disabled persons and subject |
| 152 | to the notice and review provisions of s. 216.177, the Governor |
| 153 | may direct the Agency for Health Care Administration to amend |
| 154 | the Medicaid state plan to delete the optional Medicaid service |
| 155 | known as "Intermediate Care Facilities for the Developmentally |
| 156 | Disabled." Optional services may include: |
| 157 | (26) HOME AND COMMUNITY-BASED SERVICES FOR AUTISM SPECTRUM |
| 158 | DISORDER AND OTHER DEVELOPMENTAL DISABILITIES.--The agency is |
| 159 | authorized to seek federal approval through a Medicaid waiver or |
| 160 | a state plan amendment for the provision of occupational |
| 161 | therapy, speech therapy, physical therapy, behavior analysis, |
| 162 | and behavior assistant services to individuals who are 5 years |
| 163 | of age and under and have a diagnosed developmental disability |
| 164 | as defined in s. 393.063 or autism spectrum disorder as defined |
| 165 | in s. 391.026(2)(r)1. Coverage for such services shall be |
| 166 | limited to $36,000 annually and may not exceed $108,000 in total |
| 167 | lifetime benefits. The agency shall submit an annual report |
| 168 | beginning on January 1, 2009, to the President of the Senate, |
| 169 | the Speaker of the House of Representatives, and the relevant |
| 170 | committees of the Senate and the House of Representatives |
| 171 | regarding progress on obtaining federal approval and |
| 172 | recommendations for the implementation of these home and |
| 173 | community-based services. The agency may not implement this |
| 174 | subsection without prior legislative approval. |
| 175 | Section 11. Section 456.0291, Florida Statutes, is created |
| 176 | to read: |
| 177 | 456.0291 Requirement for instruction on developmental |
| 178 | disabilities.-- |
| 179 | (1)(a) The appropriate board shall require each person |
| 180 | licensed or certified under part I of chapter 464, chapter 490, |
| 181 | or chapter 491 to complete a 2-hour continuing education course, |
| 182 | approved by the board, on developmental disabilities, as defined |
| 183 | in s. 393.063, with the addition of autism spectrum disorder as |
| 184 | defined in paragraph (r)1., as part of every third biennial |
| 185 | relicensure or recertification. The course shall consist of |
| 186 | information on the diagnosis and treatment of developmental |
| 187 | disabilities and information on counseling and education of a |
| 188 | parent whose child is diagnosed with a developmental disability, |
| 189 | with an emphasis on autism spectrum disorder as defined in |
| 190 | paragraph (r)1. |
| 191 | (b) The Board of Medicine and the Board of Osteopathic |
| 192 | Medicine shall require each physician with a primary care |
| 193 | specialty of pediatrics to complete a 2-hour continuing |
| 194 | education course, approved by the appropriate board, on |
| 195 | developmental disabilities, as defined in s. 393.063, with the |
| 196 | addition of autism spectrum disorder as defined in s. |
| 197 | 391.026(2)(r)1., as part of every third biennial relicensure. |
| 198 | The course shall consist of information on the diagnosis and |
| 199 | treatment of developmental disabilities and information on |
| 200 | counseling and education of a parent whose child is diagnosed |
| 201 | with a developmental disability, with an emphasis on autism |
| 202 | spectrum disorder as defined in s. 391.026(2)(r)1.. |
| 203 | (c) Each such licensee or certificateholder shall submit |
| 204 | confirmation of having completed the course, on a form provided |
| 205 | by the board, when submitting fees for every third biennial |
| 206 | renewal. |
| 207 | (d) The board may approve additional equivalent courses |
| 208 | that may be used to satisfy the requirements of paragraph (a). |
| 209 | Each licensing board that requires a licensee to complete an |
| 210 | educational course pursuant to this subsection may include the |
| 211 | hours required for completion of the course in the total hours |
| 212 | of continuing education required by law for such profession |
| 213 | unless the continuing education requirements for such profession |
| 214 | consist of fewer than 30 hours biennially. |
| 215 | (e) Any person holding two or more licenses subject to the |
| 216 | provisions of this subsection shall be permitted to show proof |
| 217 | of having taken one board-approved course on developmental |
| 218 | disabilities for purposes of relicensure or recertification for |
| 219 | additional licenses. |
| 220 | (f) Failure to comply with the requirements of this |
| 221 | subsection shall constitute grounds for disciplinary action |
| 222 | under each respective practice act and under s. 456.072(1)(k). |
| 223 | In addition to discipline by the board, the licensee shall be |
| 224 | required to complete such course. |
| 225 | (2) Each board may adopt rules pursuant to ss. 120.536(1) |
| 226 | and 120.54 to carry out the provisions of this section. |
| 227 | (3) The department shall implement a plan to promote |
| 228 | awareness of developmental disabilities, with a focus on autism |
| 229 | spectrum disorder as defined in s. 391.026(2)(r)1., to |
| 230 | physicians licensed under chapter 458 or chapter 459 and |
| 231 | parents. The department shall develop the plan in consultation |
| 232 | with organizations representing allopathic and osteopathic |
| 233 | physicians, the Board of Medicine, the Board of Osteopathic |
| 234 | Medicine, and nationally recognized organizations that promote |
| 235 | awareness of developmental disabilities. The department's plan |
| 236 | shall include the distribution of educational materials for |
| 237 | parents, including a developmental assessment tool. |
| 238 | Section 12. Paragraph (b) of subsection (2) and paragraph |
| 239 | (b) of subsection (5) of section 624.91, Florida Statutes, are |
| 240 | amended to read: |
| 241 | 624.91 The Florida Healthy Kids Corporation Act.-- |
| 242 | (2) LEGISLATIVE INTENT.-- |
| 243 | (b) It is the intent of the Legislature that the Florida |
| 244 | Healthy Kids Corporation serve as one of several providers of |
| 245 | services to children eligible for medical assistance under Title |
| 246 | XXI of the Social Security Act. Although the corporation may |
| 247 | serve other children, the Legislature intends the primary |
| 248 | recipients of services provided through the corporation be |
| 249 | school-age children with a family income below 200 percent of |
| 250 | the federal poverty level, who do not qualify for Medicaid. It |
| 251 | is also the intent of the Legislature that state and local |
| 252 | government Florida Healthy Kids funds be used to continue |
| 253 | coverage, subject to specific appropriations in the General |
| 254 | Appropriations Act, to children not eligible for federal |
| 255 | matching funds under Title XXI. |
| 256 | (5) CORPORATION AUTHORIZATION, DUTIES, POWERS.-- |
| 257 | (b) The Florida Healthy Kids Corporation shall: |
| 258 | 1. Arrange for the collection of any family, local |
| 259 | contributions, or employer payment or premium, in an amount to |
| 260 | be determined by the board of directors, to provide for payment |
| 261 | of premiums for comprehensive insurance coverage and for the |
| 262 | actual or estimated administrative expenses. |
| 263 | 2. Arrange for the collection of any voluntary |
| 264 | contributions to provide for payment of premiums for children |
| 265 | who are not eligible for medical assistance under Title XXI of |
| 266 | the Social Security Act. |
| 267 | 3. Subject to the provisions of s. 409.8134, accept |
| 268 | voluntary supplemental local match contributions that comply |
| 269 | with the requirements of Title XXI of the Social Security Act |
| 270 | for the purpose of providing additional coverage in contributing |
| 271 | counties under Title XXI. |
| 272 | 4. Establish the administrative and accounting procedures |
| 273 | for the operation of the corporation. |
| 274 | 5. Establish, with consultation from appropriate |
| 275 | professional organizations, standards for preventive health |
| 276 | services and providers and comprehensive insurance benefits |
| 277 | appropriate to children, provided that such standards for rural |
| 278 | areas shall not limit primary care providers to board-certified |
| 279 | pediatricians. |
| 280 | 6. Determine eligibility for children seeking to |
| 281 | participate in the Title XXI-funded components of the Florida |
| 282 | Kidcare program consistent with the requirements specified in s. |
| 283 | 409.814, as well as the non-Title-XXI-eligible children as |
| 284 | provided in subsection (3). |
| 285 | 7. Establish procedures under which providers of local |
| 286 | match to, applicants to and participants in the program may have |
| 287 | grievances reviewed by an impartial body and reported to the |
| 288 | board of directors of the corporation. |
| 289 | 8. Establish participation criteria and, if appropriate, |
| 290 | contract with an authorized insurer, health maintenance |
| 291 | organization, or third-party administrator to provide |
| 292 | administrative services to the corporation. |
| 293 | 9. Establish enrollment criteria which shall include |
| 294 | penalties or waiting periods of not fewer than 60 days for |
| 295 | reinstatement of coverage upon voluntary cancellation for |
| 296 | nonpayment of family premiums. |
| 297 | 10. Contract with authorized insurers or any provider of |
| 298 | health care services, meeting standards established by the |
| 299 | corporation, for the provision of comprehensive insurance |
| 300 | coverage to participants. Such standards shall include criteria |
| 301 | under which the corporation may contract with more than one |
| 302 | provider of health care services in program sites. Health plans |
| 303 | shall be selected through a competitive bid process. The Florida |
| 304 | Healthy Kids Corporation shall purchase goods and services in |
| 305 | the most cost-effective manner consistent with the delivery of |
| 306 | quality medical care. The maximum administrative cost for a |
| 307 | Florida Healthy Kids Corporation contract shall be 15 percent. |
| 308 | For health care contracts, the minimum medical loss ratio for a |
| 309 | Florida Healthy Kids Corporation contract shall be 85 percent. |
| 310 | For dental contracts, the remaining compensation to be paid to |
| 311 | the authorized insurer or provider under a Florida Healthy Kids |
| 312 | Corporation contract shall be no less than an amount which is 85 |
| 313 | percent of premium; to the extent any contract provision does |
| 314 | not provide for this minimum compensation, this section shall |
| 315 | prevail. The health plan selection criteria and scoring system, |
| 316 | and the scoring results, shall be available upon request for |
| 317 | inspection after the bids have been awarded. |
| 318 | 11. Establish disenrollment criteria in the event local |
| 319 | matching funds are insufficient to cover enrollments. |
| 320 | 12. Develop and implement a plan to publicize the Florida |
| 321 | Kidcare program Healthy Kids Corporation, the eligibility |
| 322 | requirements of the program, and the procedures for enrollment |
| 323 | in the program and to maintain public awareness of the |
| 324 | corporation and the program. Health care and dental health plans |
| 325 | participating in the program may develop and distribute |
| 326 | marketing and other promotional materials and participate in |
| 327 | activities, such as health fairs and public events, as approved |
| 328 | by the corporation. Health care and dental health plans may also |
| 329 | contact their current and former enrollees to encourage |
| 330 | continued participation in the program and assist the enrollee |
| 331 | in transferring from a Title XIX-funded plan to a Title XXI- |
| 332 | funded plan. |
| 333 | 13. Establish an assignment process for Florida Healthy |
| 334 | Kids program enrollees to ensure that family members are |
| 335 | assigned to the same managed care plan to the greatest extent |
| 336 | possible, including situations in which some family members are |
| 337 | enrolled in a Medicaid managed care plan and other family |
| 338 | members are enrolled in a Florida Healthy Kids plan. The Agency |
| 339 | for Health Care Administration shall consult with the |
| 340 | corporation to implement this subparagraph. |
| 341 | 14.13. Secure staff necessary to properly administer the |
| 342 | corporation. Staff costs shall be funded from state and local |
| 343 | matching funds and such other private or public funds as become |
| 344 | available. The board of directors shall determine the number of |
| 345 | staff members necessary to administer the corporation. |
| 346 | 15.14. Provide a report annually to the Governor, Chief |
| 347 | Financial Officer, Commissioner of Education, Senate President, |
| 348 | Speaker of the House of Representatives, and Minority Leaders of |
| 349 | the Senate and the House of Representatives. |
| 350 | 16. Provide a report by October 31, 2008, to the Governor, |
| 351 | the Senate, and the House of Representatives, which includes an |
| 352 | actuarial analysis of the projected impact on premiums from the |
| 353 | addition of habilitative and behavior analysis services in |
| 354 | accordance with s. 409.815. |
| 355 | 17. Provide information on a quarterly basis to the |
| 356 | Governor, the Senate, and the House of Representatives that |
| 357 | assesses the cost and utilization of services for the Florida |
| 358 | Healthy Kids health benefits plans provided through the Florida |
| 359 | Healthy Kids Corporation. The information must be specific to |
| 360 | each eligibility component of the plan and, at a minimum, |
| 361 | include: |
| 362 | a. The monthly enrollment and expenditures for enrollees. |
| 363 | b. The cost and utilization of specific services. |
| 364 | c. An analysis of the impact on premiums prior to and |
| 365 | following implementation of the Window of Opportunity Act. |
| 366 | d. An analysis of trends regarding transfer of enrollees |
| 367 | from the Florida Healthy Kids plans to the Children's Medical |
| 368 | Services Network plan. |
| 369 | e. Any recommendations resulting from the analysis |
| 370 | conducted under this subparagraph. |
| 371 | 18.15. Establish benefit packages which conform to the |
| 372 | provisions of the Florida Kidcare program, as created in ss. |
| 373 | 409.810-409.820. |
| 374 | Section 13. Section 624.916, Florida Statutes, is created |
| 375 | to read: |
| 376 | 624.916 Developmental disabilities compact.-- |
| 377 | (1) The Office of Insurance Regulation shall convene a |
| 378 | workgroup by August 31, 2008, for the purpose of negotiating a |
| 379 | compact that includes a binding agreement among the participants |
| 380 | relating to insurance and access to services for persons with |
| 381 | developmental disabilities as defined in s. 393.063, with the |
| 382 | addition of autism spectrum disorder as defined in s. |
| 383 | 391.026(2)(r)1. The workgroup shall consist of the following: |
| 384 | (a) Representatives of all health insurers licensed under |
| 385 | this chapter. |
| 386 | (b) Representatives of all health maintenance |
| 387 | organizations licensed under part I of chapter 641. |
| 388 | (c) Representatives of employers with self-insured health |
| 389 | benefit plans. |
| 390 | (d) Two designees of the Governor, one of whom must be a |
| 391 | consumer advocate. |
| 392 | (e) A designee of the President of the Senate. |
| 393 | (f) A designee of the Speaker of the House of |
| 394 | Representatives. |
| 395 | (2) The Office of Insurance Regulation shall convene a |
| 396 | consumer advisory workgroup for the purpose of providing a forum |
| 397 | for comment on the compact negotiated in subsection (1). The |
| 398 | office shall convene the workgroup prior to finalization of the |
| 399 | compact. |
| 400 | (3) The agreement shall include the following components: |
| 401 | (a) A requirement that each signatory to the agreement |
| 402 | increase coverage for behavior analysis and behavior assistant |
| 403 | services as defined in s. 409.815(2)(r) and speech therapy, |
| 404 | physical therapy, and occupational therapy when necessary due to |
| 405 | the presence of a developmental disability as defined in s. |
| 406 | 393.063 or autism spectrum disorder as defined in s. |
| 407 | 391.026(2)(r)1. |
| 408 | (b) Procedures for clear and specific notice to |
| 409 | policyholders identifying the amount, scope, and conditions |
| 410 | under which coverage is provided for behavior analysis and |
| 411 | behavior assistant services as defined in s. 409.815(2)(r) and |
| 412 | speech therapy, physical therapy, and occupational therapy when |
| 413 | necessary due to the presence of a developmental disability as |
| 414 | defined in s. 393.063 or autism spectrum disorder as defined in |
| 415 | s. 391.026(2)(r)1. |
| 416 | (c) Penalties for documented cases of denial of claims for |
| 417 | medically necessary services due to the presence of a |
| 418 | developmental disability as defined in s. 393.063 or autism |
| 419 | spectrum disorder as defined in s. 391.026(2)(r)1. |
| 420 | (d) Proposals for new product lines that may be offered in |
| 421 | conjunction with traditional health insurance and provide a more |
| 422 | appropriate means of spreading risk, financing costs, and |
| 423 | accessing favorable prices. |
| 424 | (4) Upon completion of the negotiations for the compact, |
| 425 | the office shall report the results to the Governor, the |
| 426 | President of the Senate, and the Speaker of the House of |
| 427 | Representatives. |
| 428 | (5) Beginning February 15, 2009, and continuing annually |
| 429 | thereafter, the Office of Insurance Regulation shall provide a |
| 430 | report to the Governor, the President of the Senate, and the |
| 431 | Speaker of the House of Representatives regarding the |
| 432 | implementation of the agreement negotiated under this section. |
| 433 | The report shall include: |
| 434 | (a) The signatories to the agreement. |
| 435 | (b) An analysis of the coverage provided under the |
| 436 | agreement in comparison to the coverage required under ss. |
| 437 | 627.6686 and 641.31098. |
| 438 | (c) An analysis of the compliance with the agreement by |
| 439 | the signatories, including documented cases of claims denied in |
| 440 | violation of the agreement. |
| 441 | (6) The Office of Insurance Regulation shall continue to |
| 442 | monitor participation, compliance, and effectiveness of the |
| 443 | agreement and report its findings at least annually. |
| 444 | Section 14. Section 627.6686, Florida Statutes, is created |
| 445 | to read: |
| 446 | 627.6686 Coverage for individuals with developmental |
| 447 | disabilities required; exception.-- |
| 448 | (1) As used in this section, the term: |
| 449 | (a) "Autism spectrum disorder" means any of the following |
| 450 | disorders as defined with most recent edition of the Diagnostic |
| 451 | and Statistical Manual of Mental Disorders of the American |
| 452 | Psychiatric Association: |
| 453 | 1. Autistic disorder; |
| 454 | 2. Asperger syndrome; or |
| 455 | 3. Pervasive developmental disorder not otherwise |
| 456 | specified. |
| 457 | (b) "Developmental disability" has the same meaning as |
| 458 | provided in s. 393.063. |
| 459 | (c) "Eligible individual" means an individual under 18 |
| 460 | years of age or an individual 18 years of age or older who is in |
| 461 | high school who has been diagnosed as having a developmental |
| 462 | disability at 8 years of age or younger. |
| 463 | (d) "Health insurance plan" means a group health insurance |
| 464 | policy or group health benefit plan offered by an insurer which |
| 465 | includes the state group insurance program provided under s. |
| 466 | 110.123. The term does not include any health insurance plan |
| 467 | offered in the individual market, any health insurance plan that |
| 468 | is individually underwritten, or any health insurance plan |
| 469 | provided to a small employer. |
| 470 | (e) "Insurer" means an insurer providing health insurance |
| 471 | coverage, which is licensed to engage in the business of |
| 472 | insurance in this state and is subject to insurance regulation. |
| 473 | (2) A health insurance plan issued or renewed on or after |
| 474 | July 1, 2009, shall provide coverage to an eligible individual |
| 475 | for: |
| 476 | (a) Well-baby and well-child screening for diagnosing the |
| 477 | presence of a developmental disability. |
| 478 | (b) Treatment of a developmental disability through speech |
| 479 | therapy, occupational therapy, physical therapy, and behavior |
| 480 | analysis services. Behavior analysis services shall be provided |
| 481 | by an individual certified pursuant to s. 393.17 or an |
| 482 | individual licensed under chapter 490 or chapter 491. |
| 483 | (3) The coverage required pursuant to subsection (2) is |
| 484 | subject to the following requirements: |
| 485 | (a) Coverage shall be limited to treatment that is |
| 486 | prescribed by the insured's treating physician in accordance |
| 487 | with a treatment plan. |
| 488 | (b) Coverage for the services described in subsection (2) |
| 489 | shall be limited to $36,000 annually and may not exceed $108,000 |
| 490 | in total lifetime benefits. |
| 491 | (c) Coverage may not be denied on the basis that provided |
| 492 | services are habilitative in nature. |
| 493 | (d) Coverage may be subject to other general exclusions |
| 494 | and limitations of the insurer's policy or plan, including, but |
| 495 | not limited to, coordination of benefits, participating provider |
| 496 | requirements, restrictions on services provided by family or |
| 497 | household members, and utilization review of health care |
| 498 | services, including the review of medical necessity, case |
| 499 | management, and other managed care provisions. |
| 500 | (4) The coverage required pursuant to subsection (2) may |
| 501 | not be subject to dollar limits, deductibles, or coinsurance |
| 502 | provisions that are less favorable to an insured than the dollar |
| 503 | limits, deductibles, or coinsurance provisions that apply to |
| 504 | physical illnesses that are generally covered under the health |
| 505 | insurance plan, except as otherwise provided in subsection (3). |
| 506 | (5) An insurer may not deny or refuse to issue coverage |
| 507 | for medically necessary services, refuse to contract with, or |
| 508 | refuse to renew or reissue or otherwise terminate or restrict |
| 509 | coverage for an individual because the individual is diagnosed |
| 510 | as having a developmental disability. |
| 511 | (6) The treatment plan required pursuant to subsection (3) |
| 512 | shall include all elements necessary for the health insurance |
| 513 | plan to appropriately pay claims. These elements include, but |
| 514 | are not limited to, a diagnosis, the proposed treatment by type, |
| 515 | the frequency and duration of treatment, the anticipated |
| 516 | outcomes stated as goals, the frequency with which the treatment |
| 517 | plan will be updated, and the signature of the treating |
| 518 | physician. |
| 519 | (7) Beginning January 1, 2011, the maximum benefit under |
| 520 | paragraph (3)(b) shall be adjusted annually on January 1 of each |
| 521 | calendar year to reflect any change from the previous year in |
| 522 | the medical component of the then current Consumer Price Index |
| 523 | for all urban consumers, published by the Bureau of Labor |
| 524 | Statistics of the United States Department of Labor. |
| 525 | (8) This section may not be construed as limiting benefits |
| 526 | and coverage otherwise available to an insured under a health |
| 527 | insurance plan. |
| 528 | (9) The Office of Insurance Regulation may not enforce |
| 529 | this section against an insurer that is a signatory to the |
| 530 | developmental disabilities compact established under s. 624.916. |
| 531 | Section 15. Section 641.31098, Florida Statutes, is |
| 532 | created to read: |
| 533 | 641.31098 Coverage for individuals with developmental |
| 534 | disabilities.-- |
| 535 | (1) As used in this section, the term: |
| 536 | (a) "Autism spectrum disorder" means any of the following |
| 537 | disorders as defined with most recent edition of the Diagnostic |
| 538 | and Statistical Manual of Mental Disorders of the American |
| 539 | Psychiatric Association: |
| 540 | 1. Autistic disorder; |
| 541 | 2. Asperger syndrome; or |
| 542 | 3. Pervasive developmental disorder not otherwise |
| 543 | specified. |
| 544 | (b) "Developmental disability" has the same meaning as |
| 545 | provided in s. 393.063 . |
| 546 | (c) "Eligible individual" means an individual under 18 |
| 547 | years of age or an individual 18 years of age or older who is in |
| 548 | high school who has been diagnosed as having a developmental |
| 549 | disability at 8 years of age or younger. |
| 550 | (d) "Health maintenance contract" means a group health |
| 551 | maintenance contract offered by a health maintenance |
| 552 | organization. This term does not include a health maintenance |
| 553 | contract offered in the individual market, a health maintenance |
| 554 | contract that is individually underwritten, or a health |
| 555 | maintenance contract provided to a small employer. |
| 556 | (2) A health maintenance contract issued or renewed on or |
| 557 | after July 1, 2009, shall provide coverage to an eligible |
| 558 | individual for: |
| 559 | (a) Well-baby and well-child screening for diagnosing the |
| 560 | presence of a developmental disability. |
| 561 | (b) Treatment of a developmental disability through speech |
| 562 | therapy, occupational therapy, physical therapy, and behavior |
| 563 | analysis services. Behavior analysis services shall be provided |
| 564 | by an individual certified pursuant to s. 393.17 or an |
| 565 | individual licensed under chapter 490 or chapter 491. |
| 566 | (3) The coverage required pursuant to subsection (2) is |
| 567 | subject to the following requirements: |
| 568 | (a) Coverage shall be limited to treatment that is |
| 569 | prescribed by the subscriber's treating physician in accordance |
| 570 | with a treatment plan. |
| 571 | (b) Coverage for the services described in subsection (2) |
| 572 | shall be limited to $36,000 annually and may not exceed $108,000 |
| 573 | in total benefits. |
| 574 | (c) Coverage may not be denied on the basis that provided |
| 575 | services are habilitative in nature. |
| 576 | (d) Coverage may be subject to general exclusions and |
| 577 | limitations of the subscriber's contract, including, but not |
| 578 | limited to, coordination of benefits, participating provider |
| 579 | requirements, and utilization review of health care services, |
| 580 | including the review of medical necessity, case management, and |
| 581 | other managed care provisions. |
| 582 | (4) The coverage required pursuant to subsection (2) may |
| 583 | not be subject to dollar limits, deductibles, or coinsurance |
| 584 | provisions that are less favorable to a subscriber than the |
| 585 | dollar limits, deductibles, or coinsurance provisions that apply |
| 586 | to physical illnesses that are generally covered under the |
| 587 | subscriber's contract, except as otherwise provided in |
| 588 | subsection (3). |
| 589 | (5) A health maintenance organization may not deny or |
| 590 | refuse to issue coverage for medically necessary services, |
| 591 | refuse to contract with, or refuse to renew or reissue or |
| 592 | otherwise terminate or restrict coverage for an individual |
| 593 | solely because the individual is diagnosed as having a |
| 594 | developmental disability. |
| 595 | (6) The treatment plan required pursuant to subsection (3) |
| 596 | shall include, but is not limited to, a diagnosis, the proposed |
| 597 | treatment by type, the frequency and duration of treatment, the |
| 598 | anticipated outcomes stated as goals, the frequency with which |
| 599 | the treatment plan will be updated, and the signature of the |
| 600 | treating physician. |
| 601 | (7) Beginning January 1, 2011, the maximum benefit under |
| 602 | paragraph (3)(b) shall be adjusted annually on January 1 of each |
| 603 | calendar year to reflect any change from the previous year in |
| 604 | the medical component of the then current Consumer Price Index |
| 605 | for all urban consumers, published by the Bureau of Labor |
| 606 | Statistics of the United States Department of Labor. |
| 607 | (8) The Office of Insurance Regulation may not enforce |
| 608 | this section against a health maintenance organization that is a |
| 609 | signatory no later than July 1, 2009, to the developmental |
| 610 | disabilities compact established under s. 624.916. The Office of |
| 611 | Insurance Regulation shall enforce this section against a health |
| 612 | maintenance organization that is a signatory to the compact |
| 613 | established under s. 624.916 if the health maintenance |
| 614 | organization has not complied with the terms of the compact for |
| 615 | all health maintenance contracts by July 1, 2010. |
| 616 |
|
| 617 | ----------------------------------------------------- |
| 618 | T I T L E A M E N D M E N T |
| 619 | Remove line 1541 |
| 620 | premium; amending s. 409.811, F.S.; providing a definition of |
| 621 | the term "autism spectrum disorder"; amending s. 409.815, F.S.; |
| 622 | revising provisions |