| 1 | Representative Gardiner offered the following: |
| 2 |
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| 3 | Amendment to Senate Amendment (697284) (with title |
| 4 | amendment) |
| 5 | Remove lines 7-318 and insert: |
| 6 | Section 1. Subsection (7) of section 409.8132, Florida |
| 7 | Statutes, is amended to read: |
| 8 | 409.8132 Medikids program component.-- |
| 9 | (7) ENROLLMENT.--Enrollment in the Medikids program |
| 10 | component may occur at any time throughout the year. A child may |
| 11 | not receive services under the Medikids program until the child |
| 12 | is enrolled in a managed care plan or MediPass. Once determined |
| 13 | eligible, an applicant may receive choice counseling and select |
| 14 | a managed care plan or MediPass. The agency may initiate |
| 15 | mandatory assignment for a Medikids applicant who has not chosen |
| 16 | a managed care plan or MediPass provider after the applicant's |
| 17 | voluntary choice period ends; however, the agency shall ensure |
| 18 | that family members are assigned to the same managed care plan |
| 19 | or the same MediPass provider to the greatest extent possible, |
| 20 | including situations in which some family members are enrolled |
| 21 | in Medicaid and other family members are enrolled in a Title |
| 22 | XXI-funded component of the Florida Kidcare program. An |
| 23 | applicant may select MediPass under the Medikids program |
| 24 | component only in counties that have fewer than two managed care |
| 25 | plans available to serve Medicaid recipients and only if the |
| 26 | federal Health Care Financing Administration determines that |
| 27 | MediPass constitutes "health insurance coverage" as defined in |
| 28 | Title XXI of the Social Security Act. |
| 29 | Section 2. Subsection (2) of section 409.8134, Florida |
| 30 | Statutes, is amended to read: |
| 31 | 409.8134 Program expenditure ceiling.-- |
| 32 | (2) The Florida Kidcare program may conduct enrollment at |
| 33 | any time throughout the year for the purpose of enrolling |
| 34 | children eligible for all program components listed in s. |
| 35 | 409.813 except Medicaid. The four Florida Kidcare administrators |
| 36 | shall work together to ensure that the year-round enrollment |
| 37 | period is announced statewide. Eligible children shall be |
| 38 | enrolled on a first-come, first-served basis using the date the |
| 39 | enrollment application is received. Enrollment shall immediately |
| 40 | cease when the expenditure ceiling is reached. Year-round |
| 41 | enrollment shall only be held if the Social Services Estimating |
| 42 | Conference determines that sufficient federal and state funds |
| 43 | will be available to finance the increased enrollment through |
| 44 | federal fiscal year 2007. Any individual who is not enrolled |
| 45 | must reapply by submitting a new application. The application |
| 46 | for the Florida Kidcare program shall be valid for a period of |
| 47 | 120 days after the date it was received. At the end of the 120- |
| 48 | day period, if the applicant has not been enrolled in the |
| 49 | program, the application shall be invalid and the applicant |
| 50 | shall be notified of the action. The applicant may reactivate |
| 51 | resubmit the application after notification of the action taken |
| 52 | by the program. Except for the Medicaid program, whenever the |
| 53 | Social Services Estimating Conference determines that there are |
| 54 | presently, or will be by the end of the current fiscal year, |
| 55 | insufficient funds to finance the current or projected |
| 56 | enrollment in the Florida Kidcare program, all additional |
| 57 | enrollment must cease and additional enrollment may not resume |
| 58 | until sufficient funds are available to finance such enrollment. |
| 59 | Section 3. Paragraphs (c) and (f) of subsection (4) and |
| 60 | subsections (5), (7), and (8) of section 409.814, Florida |
| 61 | Statutes, are amended to read: |
| 62 | 409.814 Eligibility.--A child who has not reached 19 years |
| 63 | of age whose family income is equal to or below 200 percent of |
| 64 | the federal poverty level is eligible for the Florida Kidcare |
| 65 | program as provided in this section. For enrollment in the |
| 66 | Children's Medical Services Network, a complete application |
| 67 | includes the medical or behavioral health screening. If, |
| 68 | subsequently, an individual is determined to be ineligible for |
| 69 | coverage, he or she must immediately be disenrolled from the |
| 70 | respective Florida Kidcare program component. |
| 71 | (4) The following children are not eligible to receive |
| 72 | premium assistance for health benefits coverage under the |
| 73 | Florida Kidcare program, except under Medicaid if the child |
| 74 | would have been eligible for Medicaid under s. 409.903 or s. |
| 75 | 409.904 as of June 1, 1997: |
| 76 | (c) A child who is seeking premium assistance for the |
| 77 | Florida Kidcare program through employer-sponsored group |
| 78 | coverage, if the child has been covered by the same employer's |
| 79 | group coverage during the 90 days 6 months prior to the family's |
| 80 | submitting an application for determination of eligibility under |
| 81 | the program. |
| 82 | (f) A child who has had his or her coverage in an |
| 83 | employer-sponsored or private health benefit plan voluntarily |
| 84 | canceled in the last 90 days 6 months, except those children who |
| 85 | were on the waiting list prior to March 12, 2004, or whose |
| 86 | coverage was voluntarily canceled for good cause, including, but |
| 87 | not limited to, the following circumstances: |
| 88 | 1. The cost of participation in an employer-sponsored or |
| 89 | private health benefit plan is greater than 5 percent of the |
| 90 | family's income; |
| 91 | 2. The parent lost a job that provided an employer- |
| 92 | sponsored health benefit plan for children; |
| 93 | 3. The parent with health benefits coverage for the child |
| 94 | is deceased; |
| 95 | 4. The employer of the parent canceled health benefits |
| 96 | coverage for children; |
| 97 | 5. The child's health benefits coverage ended because the |
| 98 | child reached the maximum lifetime coverage amount; |
| 99 | 6. The child has exhausted coverage under a COBRA |
| 100 | continuation provision; or |
| 101 | 7. A situation involving domestic violence led to the loss |
| 102 | of coverage. |
| 103 | (5) A child whose family income is above 200 percent of |
| 104 | the federal poverty level or a child who is excluded under the |
| 105 | provisions of subsection (4) may participate in the Medikids |
| 106 | program as provided in s. 409.8132 or, if the child is |
| 107 | ineligible for Medikids by reason of age, in the Florida Healthy |
| 108 | Kids program as provided in s. 624.91, subject to the following |
| 109 | provisions: |
| 110 | (a) The family is not eligible for premium assistance |
| 111 | payments and must pay the full cost of the premium, including |
| 112 | any administrative costs. |
| 113 | (b) The agency is authorized to place limits on enrollment |
| 114 | in Medikids by these children in order to avoid adverse |
| 115 | selection. The number of children participating in Medikids |
| 116 | whose family income exceeds 200 percent of the federal poverty |
| 117 | level must not exceed 10 percent of total enrollees in the |
| 118 | Medikids program. |
| 119 | (b)(c) The board of directors of the Florida Healthy Kids |
| 120 | Corporation is authorized to place limits on enrollment of these |
| 121 | children in order to avoid adverse selection. In addition, the |
| 122 | board is authorized to offer a reduced benefit package to these |
| 123 | children in order to limit program costs for such families. The |
| 124 | number of children participating in the Florida Healthy Kids |
| 125 | program whose family income exceeds 200 percent of the federal |
| 126 | poverty level must not exceed 10 percent of total enrollees in |
| 127 | the Florida Healthy Kids program. |
| 128 | (7) When determining or reviewing a child's eligibility |
| 129 | under the Florida Kidcare program, the applicant shall be |
| 130 | provided with reasonable notice of changes in eligibility which |
| 131 | may affect enrollment in one or more of the program components. |
| 132 | When a transition from one program component to another is |
| 133 | authorized, there shall be cooperation between the program |
| 134 | components, and the affected family, the child's health |
| 135 | insurance plan, and the child's health care providers to promote |
| 136 | which promotes continuity of health care coverage. If a child is |
| 137 | determined ineligible for Medicaid or Medikids, the agency, in |
| 138 | coordination with the department, shall notify that child's |
| 139 | Medicaid managed care plan or MediPass provider of such |
| 140 | determination before the child's eligibility is scheduled to be |
| 141 | terminated so that the Medicaid managed care plan or MediPass |
| 142 | provider can assist the child's family in applying for Florida |
| 143 | Kidcare program coverage. Any authorized transfers must be |
| 144 | managed within the program's overall appropriated or authorized |
| 145 | levels of funding. Each component of the program shall establish |
| 146 | a reserve to ensure that transfers between components will be |
| 147 | accomplished within current year appropriations. These reserves |
| 148 | shall be reviewed by each convening of the Social Services |
| 149 | Estimating Conference to determine the adequacy of such reserves |
| 150 | to meet actual experience. |
| 151 | (8) In determining the eligibility of a child for the |
| 152 | Florida Kidcare program, an assets test is not required. The |
| 153 | information required under this section from each applicant |
| 154 | shall be obtained electronically to the extent possible. If such |
| 155 | information cannot be obtained electronically, the Each |
| 156 | applicant shall provide written documentation during the |
| 157 | application process and the redetermination process, including, |
| 158 | but not limited to, the following: |
| 159 | (a) Proof of family income, which must include a copy of |
| 160 | the applicant's most recent federal income tax return. In the |
| 161 | absence of a federal income tax return, an applicant may submit |
| 162 | wages and earnings statements (pay stubs), W-2 forms, or other |
| 163 | appropriate documents. |
| 164 | (b) A statement from all family members that: |
| 165 | 1. Their employer does not sponsor a health benefit plan |
| 166 | for employees; or |
| 167 | 2. The potential enrollee is not covered by the employer- |
| 168 | sponsored health benefit plan because the potential enrollee is |
| 169 | not eligible for coverage, or, if the potential enrollee is |
| 170 | eligible but not covered, a statement of the cost to enroll the |
| 171 | potential enrollee in the employer-sponsored health benefit |
| 172 | plan. |
| 173 |
|
| 174 | An individual who applies for coverage under the Florida Kidcare |
| 175 | program and who pays the full cost of the premium is exempt from |
| 176 | the requirements of this subsection. |
| 177 | Section 4. Paragraph (b) of subsection (1) of section |
| 178 | 409.818, Florida Statutes, is amended to read: |
| 179 | 409.818 Administration.--In order to implement ss. |
| 180 | 409.810-409.820, the following agencies shall have the following |
| 181 | duties: |
| 182 | (1) The Department of Children and Family Services shall: |
| 183 | (b) Establish and maintain the eligibility determination |
| 184 | process under the program except as specified in subsection (5). |
| 185 | The department shall directly, or through the services of a |
| 186 | contracted third-party administrator, establish and maintain a |
| 187 | process for determining eligibility of children for coverage |
| 188 | under the program. The eligibility determination process must be |
| 189 | used solely for determining eligibility of applicants for health |
| 190 | benefits coverage under the program. The eligibility |
| 191 | determination process must include an initial determination of |
| 192 | eligibility for any coverage offered under the program, as well |
| 193 | as a redetermination or reverification of eligibility each |
| 194 | subsequent 12 6 months. Effective January 1, 1999, a child who |
| 195 | has not attained the age of 5 and who has been determined |
| 196 | eligible for the Medicaid program is eligible for coverage for |
| 197 | 12 months without a redetermination or reverification of |
| 198 | eligibility. In conducting an eligibility determination, the |
| 199 | department shall determine if the child has special health care |
| 200 | needs. The department, in consultation with the Agency for |
| 201 | Health Care Administration and the Florida Healthy Kids |
| 202 | Corporation, shall develop procedures for redetermining |
| 203 | eligibility which enable a family to easily update any change in |
| 204 | circumstances which could affect eligibility. The department may |
| 205 | accept changes in a family's status as reported to the |
| 206 | department by the Florida Healthy Kids Corporation without |
| 207 | requiring a new application from the family. Redetermination of |
| 208 | a child's eligibility for Medicaid may not be linked to a |
| 209 | child's eligibility determination for other programs. |
| 210 | Section 5. Subsection (26) is added to section 409.906, |
| 211 | Florida Statutes, to read: |
| 212 | 409.906 Optional Medicaid services.--Subject to specific |
| 213 | appropriations, the agency may make payments for services which |
| 214 | are optional to the state under Title XIX of the Social Security |
| 215 | Act and are furnished by Medicaid providers to recipients who |
| 216 | are determined to be eligible on the dates on which the services |
| 217 | were provided. Any optional service that is provided shall be |
| 218 | provided only when medically necessary and in accordance with |
| 219 | state and federal law. Optional services rendered by providers |
| 220 | in mobile units to Medicaid recipients may be restricted or |
| 221 | prohibited by the agency. Nothing in this section shall be |
| 222 | construed to prevent or limit the agency from adjusting fees, |
| 223 | reimbursement rates, lengths of stay, number of visits, or |
| 224 | number of services, or making any other adjustments necessary to |
| 225 | comply with the availability of moneys and any limitations or |
| 226 | directions provided for in the General Appropriations Act or |
| 227 | chapter 216. If necessary to safeguard the state's systems of |
| 228 | providing services to elderly and disabled persons and subject |
| 229 | to the notice and review provisions of s. 216.177, the Governor |
| 230 | may direct the Agency for Health Care Administration to amend |
| 231 | the Medicaid state plan to delete the optional Medicaid service |
| 232 | known as "Intermediate Care Facilities for the Developmentally |
| 233 | Disabled." Optional services may include: |
| 234 | (26) HOME AND COMMUNITY-BASED SERVICES for AUTISM SPECTRUM |
| 235 | DISORDER AND OTHER DEVELOPMENTAL DISABILITIES.--The agency is |
| 236 | authorized to seek federal approval through a Medicaid waiver or |
| 237 | a state plan amendment for the provision of occupational |
| 238 | therapy, speech therapy, physical therapy, behavior analysis, |
| 239 | and behavior assistant services to individuals who are 5 years |
| 240 | of age and under and have a diagnosed developmental disability |
| 241 | as defined in s. 624.916. These services shall be provided for |
| 242 | producing and maintaining improvements in communication, human |
| 243 | behavior, and skill acquisition, including the the reduction of |
| 244 | problematic behavior. Coverage for such services shall be |
| 245 | limited to $36,000 annually and may not exceed $200,000 in total |
| 246 | lifetime benefits. The agency shall submit an annual report |
| 247 | beginning on January 1, 2009, to the President of the Senate, |
| 248 | the Speaker of the House of Representatives, and the relevant |
| 249 | committees of the Senate and the House of Representatives |
| 250 | regarding progress on obtaining federal approval and |
| 251 | recommendations for the implementation of these home and |
| 252 | community-based services. The agency may not implement this |
| 253 | subsection without prior legislative approval. |
| 254 | Section 6. Paragraph (b) of subsection (5) of section |
| 255 | 624.91, Florida Statutes, are amended to read: |
| 256 | 624.91 The Florida Healthy Kids Corporation Act.-- |
| 257 | (5) CORPORATION AUTHORIZATION, DUTIES, POWERS.-- |
| 258 | (b) The Florida Healthy Kids Corporation shall: |
| 259 | 1. Arrange for the collection of any family, local |
| 260 | contributions, or employer payment or premium, in an amount to |
| 261 | be determined by the board of directors, to provide for payment |
| 262 | of premiums for comprehensive insurance coverage and for the |
| 263 | actual or estimated administrative expenses. |
| 264 | 2. Arrange for the collection of any voluntary |
| 265 | contributions to provide for payment of premiums for children |
| 266 | who are not eligible for medical assistance under Title XXI of |
| 267 | the Social Security Act. |
| 268 | 3. Subject to the provisions of s. 409.8134, accept |
| 269 | voluntary supplemental local match contributions that comply |
| 270 | with the requirements of Title XXI of the Social Security Act |
| 271 | for the purpose of providing additional coverage in contributing |
| 272 | counties under Title XXI. |
| 273 | 4. Establish the administrative and accounting procedures |
| 274 | for the operation of the corporation. |
| 275 | 5. Establish, with consultation from appropriate |
| 276 | professional organizations, standards for preventive health |
| 277 | services and providers and comprehensive insurance benefits |
| 278 | appropriate to children, provided that such standards for rural |
| 279 | areas shall not limit primary care providers to board-certified |
| 280 | pediatricians. |
| 281 | 6. Determine eligibility for children seeking to |
| 282 | participate in the Title XXI-funded components of the Florida |
| 283 | Kidcare program consistent with the requirements specified in s. |
| 284 | 409.814, as well as the non-Title-XXI-eligible children as |
| 285 | provided in subsection (3). |
| 286 | 7. Establish procedures under which providers of local |
| 287 | match to, applicants to and participants in the program may have |
| 288 | grievances reviewed by an impartial body and reported to the |
| 289 | board of directors of the corporation. |
| 290 | 8. Establish participation criteria and, if appropriate, |
| 291 | contract with an authorized insurer, health maintenance |
| 292 | organization, or third-party administrator to provide |
| 293 | administrative services to the corporation. |
| 294 | 9. Establish enrollment criteria which shall include |
| 295 | penalties or waiting periods of not fewer than 60 days for |
| 296 | reinstatement of coverage upon voluntary cancellation for |
| 297 | nonpayment of family premiums. |
| 298 | 10. Contract with authorized insurers or any provider of |
| 299 | health care services, meeting standards established by the |
| 300 | corporation, for the provision of comprehensive insurance |
| 301 | coverage to participants. Such standards shall include criteria |
| 302 | under which the corporation may contract with more than one |
| 303 | provider of health care services in program sites. Health plans |
| 304 | shall be selected through a competitive bid process. The Florida |
| 305 | Healthy Kids Corporation shall purchase goods and services in |
| 306 | the most cost-effective manner consistent with the delivery of |
| 307 | quality medical care. The maximum administrative cost for a |
| 308 | Florida Healthy Kids Corporation contract shall be 15 percent. |
| 309 | For health care contracts, the minimum medical loss ratio for a |
| 310 | Florida Healthy Kids Corporation contract shall be 85 percent. |
| 311 | For dental contracts, the remaining compensation to be paid to |
| 312 | the authorized insurer or provider under a Florida Healthy Kids |
| 313 | Corporation contract shall be no less than an amount which is 85 |
| 314 | percent of premium; to the extent any contract provision does |
| 315 | not provide for this minimum compensation, this section shall |
| 316 | prevail. The health plan selection criteria and scoring system, |
| 317 | and the scoring results, shall be available upon request for |
| 318 | inspection after the bids have been awarded. |
| 319 | 11. Establish disenrollment criteria in the event local |
| 320 | matching funds are insufficient to cover enrollments. |
| 321 | 12. Develop and implement a plan to publicize the Florida |
| 322 | Kidcare program Healthy Kids Corporation, the eligibility |
| 323 | requirements of the program, and the procedures for enrollment |
| 324 | in the program and to maintain public awareness of the |
| 325 | corporation and the program. Health care and dental health plans |
| 326 | participating in the program may develop and distribute |
| 327 | marketing and other promotional materials and participate in |
| 328 | activities, such as health fairs and public events, as approved |
| 329 | by the corporation. Health care and dental health plans may also |
| 330 | contact their current and former enrollees to encourage |
| 331 | continued participation in the program and assist the enrollee |
| 332 | in transferring from a Title XIX-funded plan to a Title XXI- |
| 333 | funded plan. |
| 334 | 13. Establish an assignment process for Florida Healthy |
| 335 | Kids program enrollees to ensure that family members are |
| 336 | assigned to the same managed care plan to the greatest extent |
| 337 | possible, including situations in which some family members are |
| 338 | enrolled in a Medicaid managed care plan and other family |
| 339 | members are enrolled in a Florida Healthy Kids plan. The Agency |
| 340 | for Health Care Administration shall consult with the |
| 341 | corporation to implement this subparagraph. |
| 342 | 14.13. Secure staff necessary to properly administer the |
| 343 | corporation. Staff costs shall be funded from state and local |
| 344 | matching funds and such other private or public funds as become |
| 345 | available. The board of directors shall determine the number of |
| 346 | staff members necessary to administer the corporation. |
| 347 | 15.14. Provide a report annually to the Governor, Chief |
| 348 | Financial Officer, Commissioner of Education, Senate President, |
| 349 | Speaker of the House of Representatives, and Minority Leaders of |
| 350 | the Senate and the House of Representatives. |
| 351 | 16.15. Establish benefit packages which conform to the |
| 352 | provisions of the Florida Kidcare program, as created in ss. |
| 353 | 409.810-409.820. |
| 354 | Section 7. Section 624.916, Florida Statutes, is created |
| 355 | to read: |
| 356 | 624.916 Developmental disabilities compact.-- |
| 357 | (1) This section may be cited as the "Window of |
| 358 | Opportunity Act." |
| 359 | (2) The Office of Insurance Regulation shall convene a |
| 360 | workgroup by August 31, 2008, for the purpose of negotiating a |
| 361 | compact that includes a binding agreement among the participants |
| 362 | relating to insurance and access to services for persons with |
| 363 | developmental disabilities. The workgroup shall consist of the |
| 364 | following: |
| 365 | (a) Representatives of all health insurers licensed under |
| 366 | this chapter. |
| 367 | (b) Representatives of all health maintenance |
| 368 | organizations licensed under part I of chapter 641. |
| 369 | (c) Representatives of employers with self-insured health |
| 370 | benefit plans. |
| 371 | (d) Two designees of the Governor, one of whom must be a |
| 372 | consumer advocate. |
| 373 | (e) A designee of the President of the Senate. |
| 374 | (f) A designee of the Speaker of the House of |
| 375 | Representatives. |
| 376 | (3) The Office of Insurance Regulation shall convene a |
| 377 | consumer advisory workgroup for the purpose of providing a forum |
| 378 | for comment on the compact negotiated in subsection (2). The |
| 379 | office shall convene the workgroup prior to finalization of the |
| 380 | compact. |
| 381 | (4) The agreement shall include the following components: |
| 382 | (a) A requirement that each signatory to the agreement |
| 383 | increase coverage for behavior analysis and behavior assistant |
| 384 | services and speech therapy, physical therapy, and occupational |
| 385 | therapy due to the presence of a developmental disability for |
| 386 | producing and maintaining improvements in communication, human |
| 387 | behavior, and skill acquisition, including the the reduction of |
| 388 | problematic behavior. |
| 389 | (b) Procedures for clear and specific notice to |
| 390 | policyholders identifying the amount, scope, and conditions |
| 391 | under which coverage is provided for behavior analysis and |
| 392 | behavior assistant services and speech therapy, physical |
| 393 | therapy, and occupational therapy when medically necessary due |
| 394 | to the presence of a developmental disability. |
| 395 | (c) Penalties for documented cases of denial of claims for |
| 396 | medically necessary services due to the presence of a |
| 397 | developmental disability. |
| 398 | (d) Proposals for new product lines that may be offered in |
| 399 | conjunction with traditional health insurance and provide a more |
| 400 | appropriate means of spreading risk, financing costs, and |
| 401 | accessing favorable prices. |
| 402 | (5) Upon completion of the negotiations for the compact, |
| 403 | the office shall report the results to the Governor, the |
| 404 | President of the Senate, and the Speaker of the House of |
| 405 | Representatives. |
| 406 | (6) Beginning February 15, 2009, and continuing annually |
| 407 | thereafter, the Office of Insurance Regulation shall provide a |
| 408 | report to the Governor, the President of the Senate, and the |
| 409 | Speaker of the House of Representatives regarding the |
| 410 | implementation of the agreement negotiated under this section. |
| 411 | The report shall include: |
| 412 | (a) The signatories to the agreement. |
| 413 | (b) An analysis of the coverage provided under the |
| 414 | agreement in comparison to the coverage required under ss. |
| 415 | 627.6686 and 641.31098. |
| 416 | (c) An analysis of the compliance with the agreement by |
| 417 | the signatories, including documented cases of claims denied in |
| 418 | violation of the agreement. |
| 419 | (7) The Office of Insurance Regulation shall continue to |
| 420 | monitor participation, compliance, and effectiveness of the |
| 421 | agreement and report its findings at least annually. |
| 422 | (8) As used in this section, the term "developmental |
| 423 | disabilities" includes: |
| 424 | (a) The term as defined in s. 393.063; |
| 425 | (b) Down syndrome, a genetic disorder caused by the |
| 426 | presence of extra chromosomal material on chromosome 21. Causes |
| 427 | of the syndrome may include Trisomy 21, Mosaicism, Robertsonian |
| 428 | Translocation, and other duplications of a portion of chromosome |
| 429 | 21; and |
| 430 | (c) Autism spectrum disorder means any of the following |
| 431 | disorders as defined in the most recent edition of the |
| 432 | Diagnostic and Statistical Manual of Mental Disorders of the |
| 433 | American Psychiatric Association: |
| 434 | 1. Autistic disorder. |
| 435 | 2. Asperger's syndrome. |
| 436 | 3. Pervasive developmental disorder not otherwise |
| 437 | specified. |
| 438 | Section 8. Section 627.6686, Florida Statutes, is created |
| 439 | to read: |
| 440 | 627.6686 Coverage for individuals with developmental |
| 441 | disabilities required; exception.-- |
| 442 | (1) This section and section 641.31098, may be cited as the |
| 443 | "Steven A. Geller Developmental Disabilities Coverage Act." |
| 444 | (2) As used in this section, the term: |
| 445 | (a) "Applied behavior analysis" means the design, |
| 446 | implementation, and evaluation of environmental modifications, |
| 447 | using behavioral stimuli and consequences, to produce socially |
| 448 | significant improvement in human behavior, including, but not |
| 449 | limited to, the use of direct observation, measurement, and |
| 450 | functional analysis of the relations between environment and |
| 451 | behavior. |
| 452 | (b) "Developmental disabilities" means the term as defined |
| 453 | in s. 624.916. |
| 454 | (c) "Eligible individual" means an individual under 18 |
| 455 | years of age or an individual 18 years of age or older who is in |
| 456 | high school who has been diagnosed as having a developmental |
| 457 | disability at 8 years of age or younger. |
| 458 | (d) "Health insurance plan" means a group health insurance |
| 459 | policy or group health benefit plan offered by an insurer which |
| 460 | includes the state group insurance program provided under s. |
| 461 | 110.123. The term does not include any health insurance plan |
| 462 | offered in the individual market, any health insurance plan that |
| 463 | is individually underwritten, or any health insurance plan |
| 464 | provided to a small employer. |
| 465 | (e) "Insurer" means an insurer providing health insurance |
| 466 | coverage, which is licensed to engage in the business of |
| 467 | insurance in this state and is subject to insurance regulation. |
| 468 | (3) A health insurance plan issued or renewed on or after |
| 469 | April 1, 2009, shall provide coverage to an eligible individual |
| 470 | for: |
| 471 | (a) Well-baby and well-child screening for diagnosing the |
| 472 | presence of a developmental disability . |
| 473 | (b) Treatment of a developmental disability through speech |
| 474 | therapy, occupational therapy, physical therapy, and applied |
| 475 | behavior analysis to produce and maintain improvements in |
| 476 | communication, human behavior, and skill acquisition, including |
| 477 | the the reduction of problematic behavior. Applied behavior |
| 478 | analysis services shall be provided by an individual certified |
| 479 | pursuant to s. 393.17 or an individual licensed under chapter |
| 480 | 490 or chapter 491. |
| 481 | (4) The coverage required pursuant to subsection (3) is |
| 482 | subject to the following requirements: |
| 483 | (a) Coverage shall be limited to treatment that is |
| 484 | prescribed by the insured's treating physician in accordance |
| 485 | with a treatment plan. |
| 486 | (b) Coverage for the services described in subsection (3) |
| 487 | shall be limited to $36,000 annually and may not exceed $200,000 |
| 488 | in total lifetime benefits. |
| 489 | (c) Coverage may not be denied on the basis that provided |
| 490 | services are habilitative in nature. |
| 491 | (d) Coverage may be subject to other general exclusions |
| 492 | and limitations of the insurer's policy or plan, including, but |
| 493 | not limited to, coordination of benefits, participating provider |
| 494 | requirements, restrictions on services provided by family or |
| 495 | household members, and utilization review of health care |
| 496 | services, including the review of medical necessity, case |
| 497 | management, and other managed care provisions. |
| 498 | (5) The coverage required pursuant to subsection (3) may |
| 499 | not be subject to dollar limits, deductibles, or coinsurance |
| 500 | provisions that are less favorable to an insured than the dollar |
| 501 | limits, deductibles, or coinsurance provisions that apply to |
| 502 | physical illnesses that are generally covered under the health |
| 503 | insurance plan, except as otherwise provided in subsection (4). |
| 504 | (6) An insurer may not deny or refuse to issue coverage |
| 505 | for medically necessary services, refuse to contract with, or |
| 506 | refuse to renew or reissue or otherwise terminate or restrict |
| 507 | coverage for an individual because the individual is diagnosed |
| 508 | as having a developmental disability. |
| 509 | (7) The treatment plan required pursuant to subsection (4) |
| 510 | shall include all elements necessary for the health insurance |
| 511 | plan to appropriately pay claims. These elements include, but |
| 512 | are not limited to, a diagnosis, the proposed treatment by type, |
| 513 | the frequency and duration of treatment, the anticipated |
| 514 | outcomes stated as goals, the frequency with which the treatment |
| 515 | plan will be updated, and the signature of the treating |
| 516 | physician. |
| 517 | (8) Beginning January 1, 2011, the maximum benefit under |
| 518 | paragraph (4)(b) shall be adjusted annually on January 1 of each |
| 519 | calendar year to reflect any change from the previous year in |
| 520 | the medical component of the then current Consumer Price Index |
| 521 | for all urban consumers, published by the Bureau of Labor |
| 522 | Statistics of the United States Department of Labor. |
| 523 | (9) This section may not be construed as limiting benefits |
| 524 | and coverage otherwise available to an insured under a health |
| 525 | insurance plan. |
| 526 | (10) The Office of Insurance Regulation may not enforce |
| 527 | this section against an insurer that is a signatory no later |
| 528 | than April 1, 2009, to the developmental disabilities compact |
| 529 | established under s. 624.916. The Office of Insurance Regulation |
| 530 | shall enforce this section against an insurer that is a |
| 531 | signatory to the compact established under s. 624.916 if the |
| 532 | insurer has not complied with the terms of the compact for all |
| 533 | health insurance plans by April 1, 2010. |
| 534 | Section 9. Section 641.31098, Florida Statutes, is created |
| 535 | to read: |
| 536 | 641.31098 Coverage for individuals with developmental |
| 537 | disabilities.-- |
| 538 | (1) This section and section 627.6686, may be cited as the |
| 539 | "Steven A. Geller Developmental Disabilities Coverage Act." |
| 540 | (2) As used in this section, the term: |
| 541 | (a) "Applied behavior analysis" means the design, |
| 542 | implementation, and evaluation of environmental modifications, |
| 543 | using behavioral stimuli and consequences, to produce socially |
| 544 | significant improvement in human behavior, including, but not |
| 545 | limited to, the use of direct observation, measurement, and |
| 546 | functional analysis of the relations between environment and |
| 547 | behavior. |
| 548 | (b) "Developmental disabilities" means the term as defined |
| 549 | in s. 624.916. |
| 550 | (c) "Eligible individual" means an individual under 18 |
| 551 | years of age or an individual 18 years of age or older who is in |
| 552 | high school who has been diagnosed as having a developmental |
| 553 | disability at 8 years of age or younger. |
| 554 | (d) "Health maintenance contract" means a group health |
| 555 | maintenance contract offered by a health maintenance |
| 556 | organization. This term does not include a health maintenance |
| 557 | contract offered in the individual market, a health maintenance |
| 558 | contract that is individually underwritten, or a health |
| 559 | maintenance contract provided to a small employer. |
| 560 | (3) A health maintenance contract issued or renewed on or |
| 561 | after April 1, 2009, shall provide coverage to an eligible |
| 562 | individual for: |
| 563 | (a) Well-baby and well-child screening for diagnosing the |
| 564 | presence of a developmental disability . |
| 565 | (b) Treatment of a developmental disability through |
| 566 | speech therapy, occupational therapy, physical therapy, and |
| 567 | applied behavior analysis services to produce and maintain |
| 568 | improvements in communication, human behavior, and skill |
| 569 | acquisition, including the the reduction of problematic |
| 570 | behavior. Applied behavior analysis services shall be provided |
| 571 | by an individual certified pursuant to s. 393.17 or an |
| 572 | individual licensed under chapter 490 or chapter 491. |
| 573 | (4) The coverage required pursuant to subsection (3) is |
| 574 | subject to the following requirements: |
| 575 | (a) Coverage shall be limited to treatment that is |
| 576 | prescribed by the subscriber's treating physician in accordance |
| 577 | with a treatment plan. |
| 578 | (b) Coverage for the services described in subsection (3) |
| 579 | shall be limited to $36,000 annually and may not exceed $200,000 |
| 580 | in total benefits. |
| 581 | (c) Coverage may not be denied on the basis that provided |
| 582 | services are habilitative in nature. |
| 583 | (d) Coverage may be subject to general exclusions and |
| 584 | limitations of the subscriber's contract, including, but not |
| 585 | limited to, coordination of benefits, participating provider |
| 586 | requirements, and utilization review of health care services, |
| 587 | including the review of medical necessity, case management, and |
| 588 | other managed care provisions. |
| 589 | (5) The coverage required pursuant to subsection (3) may |
| 590 | not be subject to dollar limits, deductibles, or coinsurance |
| 591 | provisions that are less favorable to a subscriber than the |
| 592 | dollar limits, deductibles, or coinsurance provisions that apply |
| 593 | to physical illnesses that are generally covered under the |
| 594 | subscriber's contract, except as otherwise provided in |
| 595 | subsection (4). |
| 596 | (6) A health maintenance organization may not deny or |
| 597 | refuse to issue coverage for medically necessary services, |
| 598 | refuse to contract with, or refuse to renew or reissue or |
| 599 | otherwise terminate or restrict coverage for an individual |
| 600 | solely because the individual is diagnosed as having a |
| 601 | developmental disability. |
| 602 | (7) The treatment plan required pursuant to subsection (4) |
| 603 | shall include, but is not limited to, a diagnosis, the proposed |
| 604 | treatment by type, the frequency and duration of treatment, the |
| 605 | anticipated outcomes stated as goals, the frequency with which |
| 606 | the treatment plan will be updated, and the signature of the |
| 607 | treating physician. |
| 608 | (8) Beginning January 1, 2011, the maximum benefit under |
| 609 | paragraph (4)(b) shall be adjusted annually on January 1 of each |
| 610 | calendar year to reflect any change from the previous year in |
| 611 | the medical component of the then current Consumer Price Index |
| 612 | for all urban consumers, published by the Bureau of Labor |
| 613 | Statistics of the United States Department of Labor. |
| 614 | (9) The Office of Insurance Regulation may not enforce |
| 615 | this section against a health maintenance organization that is a |
| 616 | signatory no later than April 1, 2009, to the developmental |
| 617 | disabilities compact established under s. 624.916. The Office of |
| 618 | Insurance Regulation shall enforce this section against a health |
| 619 | maintenance organization that is a signatory to the compact |
| 620 | established under s. 624.916 if the health maintenance |
| 621 | organization has not complied with the terms of the compact for |
| 622 | all health maintenance contracts by April 1, 2010. |
| 623 | Section 5. This act shall take effect July 1, 2008. |
| 624 |
|
| 625 |
|
| 626 |
|
| 627 | ----------------------------------------------------- |
| 628 | T I T L E A M E N D M E N T |
| 629 | Remove lines 325-374 and insert: |
| 630 | amending s. 409.8132, F.S.; revising provisions relating to |
| 631 | enrollment in the Medikids program component of Florida Kidcare; |
| 632 | providing for the Agency for Health Care Administration to |
| 633 | assign family members to the same managed care plan or Medicaid |
| 634 | provider, under certain circumstances; amending s. 409.8134, |
| 635 | F.S.; providing limitations on year-round enrollment for premium |
| 636 | assistance; amending s. 409.814, F.S.; revising conditions for |
| 637 | eligibility for premium assistance for the Florida Kidcare |
| 638 | Program; providing limitations on enrollment in the Medikids |
| 639 | program after January 1, 2009; providing for enrollment of new |
| 640 | applicants in the Florida Healthy Kids program; revising duties |
| 641 | of the board of directors of the Florida Healthy Kids |
| 642 | Corporation regarding enrollment limitations; providing for |
| 643 | notification to certain managed care plans or MediPass providers |
| 644 | prior to termination of a child's eligibility for Florida |
| 645 | Kidcare; providing for certain information relating to |
| 646 | eligibility to be obtained electronically; providing an |
| 647 | exemption from certain requirements for individuals who pay the |
| 648 | full cost of the Florida Kidcare premium; amending s. 409.815, |
| 649 | F.S.; revising provisions relating to health benefits coverage |
| 650 | for specified services to include habilitative and behavior |
| 651 | analysis services; providing definitions; limiting the lifetime |
| 652 | maximum of health benefits coverage for certain services; |
| 653 | amending s. 409.818, F.S.; revising timeframe for |
| 654 | redetermination or reverification of eligibility for Florida |
| 655 | Kidcare; amending s. 409.906, F.S.; creating the "Window of |
| 656 | Opportunity Act"; authorizing the Agency for Health Care |
| 657 | Administration to seek federal approval through a state plan |
| 658 | amendment to provide home and community-based services for |
| 659 | autism spectrum disorder and other development disabilities; |
| 660 | specifying eligibility criteria; specifying limitations on |
| 661 | provision of benefits; requiring reports to the Legislature; |
| 662 | requiring legislative approval for implementation of certain |
| 663 | provisions; amending s. 409.91, F.S.; revising duties of the |
| 664 | Florida Healthy Kids Corporation; creating s. 624.916, F.S.; |
| 665 | creating the "Window of Opportunity Act"; directing the Office |
| 666 | of Insurance Regulation to establish a workgroup to develop and |
| 667 | execute a compact relating to coverage for insured persons with |
| 668 | development disabilities; providing for membership of the |
| 669 | workgroup; requiring the workgroup to convene within a specified |
| 670 | period of time; directing the office to establish a consumer |
| 671 | advisory workgroup and providing purpose thereof; requiring the |
| 672 | compact to contain specified components; requiring reports to |
| 673 | the Governor and the Legislature; creating s. 627.6686, F.S.; |
| 674 | creating the Steven A. Geller Autism Coverage Act"; providing |
| 675 | health insurance coverage for individuals with autism spectrum |
| 676 | disorder; providing definitions; providing coverage for certain |
| 677 | screening to diagnose and treat autism spectrum disorder; |
| 678 | providing limitations on coverage; providing for eligibility |
| 679 | standards for benefits and coverage; prohibiting insurers from |
| 680 | denying coverage under certain circumstances; specifying |
| 681 | required elements of a treatment plan; providing, beginning |
| 682 | January 1, 2011, that the maximum benefit shall be adjusted |
| 683 | annually; clarifying that the section may not be construed as |
| 684 | limiting benefits and coverage otherwise available to an insured |
| 685 | under a health insurance plan; prohibiting the Office of |
| 686 | Insurance Regulation from enforcing certain provisions against |
| 687 | insurers that are signatories to the developmental disabilities |
| 688 | compact by a specified date; creating s. 641.31098, F.S.; |
| 689 | providing coverage under a health maintenance contract for |
| 690 | individuals with autism spectrum disorder; providing |
| 691 | definitions; providing coverage for certain screening to |
| 692 | diagnose and treat autism spectrum disorder; providing |
| 693 | limitations on coverage; providing for eligibility standards for |
| 694 | benefits and coverage; prohibiting health maintenance |
| 695 | organizations from denying coverage under certain circumstances; |
| 696 | specifying required elements of a treatment plan; providing, |
| 697 | beginning January 1, 2011, that the maximum benefit shall be |
| 698 | adjusted annually; prohibiting the Office of Insurance |
| 699 | Regulation from enforcing certain provisions against health |
| 700 | maintenance organizations that are signatories to the |
| 701 | developmental disabilities compact by a specified date; |
| 702 | providing an effective date. |
| 703 |
|