HB 795

A bill to be entitled
2An act relating to the Florida Kidcare program; amending
3s. 409.8132, F.S.; providing that certain children under
4the age of 1 may participate in the Medikids program;
5conforming cross-references; amending s. 409.814, F.S.;
6requiring that children who are eligible for Kidcare be
7offered the opportunity to be made presumptively eligible;
8providing that children who are eligible for a state-
9sponsored health benefit plan and the subsidized Kidcare
10program may enroll in the program; providing that an
11eligible child who is a lawful immigrant may enroll in the
12Florida Kidcare program regardless of the child's date of
13entry; conforming provisions to changes made by the act;
14amending s. 409.815, F.S.; authorizing Kidcare coverage
15for temporomandibular joint disease; amending s. 409.816,
16F.S.; conforming a cross-reference; amending s. 409.818,
17F.S.; conforming provisions to changes made by the act;
18allowing a redetermination of a child's eligibility for
19Medicaid to be linked to a child's eligibility for other
20programs; amending s. 409.904, F.S.; providing that
21Medicaid-eligible children are deemed eligible for 12
22months of coverage regardless of any change in
23circumstances; requiring that such children be offered the
24opportunity to be made presumptively eligible; providing
25that a pregnant woman in a family of certain income level
26is eligible for Medicaid for the duration of her pregnancy
27and for the postpartum period; amending s. 624.91, F.S.,
28relating to the Florida Healthy Kids Corporation;
29conforming provisions to changes made by the act; deleting
30an obsolete provision; expanding the membership of the
31board of directors of the Florida Healthy Kids
32Corporation; directing the Agency for Health Care
33Administration to implement the federal Family Opportunity
34Act; providing an effective date.
36Be It Enacted by the Legislature of the State of Florida:
38     Section 1.  Subsection (6) of section 409.8132, Florida
39Statutes, is amended to read:
40     409.8132  Medikids program component.-
41     (6)  ELIGIBILITY.-
42     (a)  A child who has attained the age of 1 year but who is
43under the age of 5 years is eligible to enroll in the Medikids
44program component of the Florida Kidcare program, if the child
45is a member of a family that has a family income that which
46exceeds the Medicaid applicable income level as specified in s.
47409.903, but that which is equal to or below 200 percent of the
48current federal poverty level. In determining the eligibility of
49such a child, an assets test is not required. A child who is
50eligible for Medikids may elect to enroll in Florida Healthy
51Kids coverage or employer-sponsored group coverage. However, a
52child who is eligible for Medikids may participate in the
53Florida Healthy Kids program only if the child has a sibling
54participating in the Florida Healthy Kids program and the
55child's county of residence permits such enrollment.
56     (b)  A child who is under the age of 1 year who has a
57family income above 200 percent of the current federal poverty
58level may participate in the Medikids program as provided in s.
60     (c)(b)  The provisions of s. 409.814(3)-(8) apply
61409.814(3), (4), (5), and (6) shall be applicable to the
62Medikids program.
63     Section 2.  Section 409.814, Florida Statutes, is amended
64to read:
65     409.814  Eligibility.-A child who has not reached 19 years
66of age whose family income is equal to or below 200 percent of
67the federal poverty level is eligible for the Florida Kidcare
68program as provided in this section. A child who is eligible
69under this section must be offered the opportunity to be made
70presumptively eligible. For enrollment in the Children's Medical
71Services Network, a complete application includes the medical or
72behavioral health screening. If, subsequently, an enrolled
73individual is determined to be ineligible for coverage, he or
74she must be immediately be disenrolled from the respective
75Florida Kidcare program component.
76     (1)  A child who is eligible for Medicaid coverage under s.
77409.903 or s. 409.904 must be enrolled in Medicaid and is not
78eligible to receive health benefits under any other health
79benefits coverage authorized under the Florida Kidcare program.
80     (2)  A child who is not eligible for Medicaid, but who is
81eligible for the Florida Kidcare program, may obtain health
82benefits coverage under any of the other components listed in s.
83409.813 if such coverage is approved and available in the county
84in which the child resides.
85     (3)  A Title XXI-funded child who is eligible for the
86Florida Kidcare program and who is a child with special health
87care needs, as determined through a medical or behavioral
88screening instrument, is eligible for health benefits coverage
89from and shall be assigned to and may opt out of the Children's
90Medical Services Network.
91     (4)  A child who is eligible for a state-sponsored health
92benefit plan through a family member or guardian employed by the
93state and who meets the eligibility requirements for the
94subsidized Florida Kidcare program may enroll in the subsidized
95Florida Kidcare program.
96     (5)  A child who is an immigrant lawfully residing in the
97United States and who meets the eligibility requirements for the
98Florida Kidcare program may enroll in the program regardless of
99the child's date of entry.
100     (6)(4)  The following children are not eligible to receive
101Title XXI-funded premium assistance for health benefits coverage
102under the Florida Kidcare program, except under Medicaid if the
103child would have been eligible for Medicaid under s. 409.903 or
104s. 409.904 as of June 1, 1997:
105     (a)  A child who is eligible for coverage under a state
106health benefit plan on the basis of a family member's employment
107with a public agency in the state.
108     (a)(b)  A child who is covered under a family member's
109group health benefit plan or under other private or employer
110health insurance coverage, if the cost of the child's
111participation is not greater than 5 percent of the family's
112income. If a child is otherwise eligible for a subsidy under the
113Florida Kidcare program and the cost of the child's
114participation in the family member's health insurance benefit
115plan is greater than 5 percent of the family's income, the child
116may enroll in the appropriate subsidized Kidcare program.
117     (b)(c)  A child who is seeking premium assistance for the
118Florida Kidcare program through employer-sponsored group
119coverage, if the child has been covered by the same employer's
120group coverage during the 60 days before the family submitted
121prior to the family's submitting an application for
122determination of eligibility under the program.
123     (d)  A child who is an alien, but who does not meet the
124definition of qualified alien, in the United States.
125     (c)(e)  A child who is an inmate of a public institution or
126a patient in an institution for mental diseases.
127     (d)(f)  A child who is otherwise eligible for premium
128assistance for the Florida Kidcare program and has had his or
129her coverage in an employer-sponsored or private health benefit
130plan voluntarily canceled in the last 60 days, except those
131children whose coverage was voluntarily canceled for good cause,
132including, but not limited to, the following circumstances:
133     1.  The cost of participation in an employer-sponsored
134health benefit plan is greater than 5 percent of the family's
136     2.  The parent lost a job that provided an employer-
137sponsored health benefit plan for children;
138     3.  The parent who had health benefits coverage for the
139child is deceased;
140     4.  The child has a medical condition that, without medical
141care, would cause serious disability, loss of function, or
143     5.  The employer of the parent canceled health benefits
144coverage for children;
145     6.  The child's health benefits coverage ended because the
146child reached the maximum lifetime coverage amount;
147     7.  The child has exhausted coverage under a COBRA
148continuation provision;
149     8.  The health benefits coverage does not cover the child's
150health care needs; or
151     9.  Domestic violence led to loss of coverage.
152     (7)(5)  A child who is otherwise eligible for the Florida
153Kidcare program and who has a preexisting condition that
154prevents coverage under another insurance plan as described in
155paragraph (6)(a) (4)(b) which would have disqualified the child
156for the Florida Kidcare program if the child were able to enroll
157in the plan is shall be eligible for Florida Kidcare coverage
158when enrollment is possible.
159     (8)(6)  A child whose family income is above 200 percent of
160the federal poverty level or a child who is excluded under the
161provisions of subsection (6) (4) may participate in the Florida
162Kidcare program as provided in s. 409.8132 or, if the child is
163ineligible for Medikids by reason of age, in the Florida Healthy
164Kids program, subject to the following provisions:
165     (a)  The family is not eligible for premium assistance
166payments and must pay the full cost of the premium, including
167any administrative costs.
168     (b)  The board of directors of the Florida Healthy Kids
169Corporation may offer a reduced benefit package to these
170children in order to limit program costs for such families.
171     (9)(7)  Once a child is enrolled in the Florida Kidcare
172program, the child is eligible for coverage under the program
173for 12 months without a redetermination or reverification of
174eligibility, if the family continues to pay the applicable
175premium. Eligibility for program components funded through Title
176XXI of the Social Security Act terminates shall terminate when a
177child attains the age of 19. A child who has not attained the
178age of 5 and who has been determined eligible for the Medicaid
179program is eligible for coverage for 12 months without a
180redetermination or reverification of eligibility.
181     (10)(8)  When determining or reviewing a child's
182eligibility under the Florida Kidcare program, the applicant
183shall be provided with reasonable notice of changes in
184eligibility which may affect enrollment in one or more of the
185program components. If When a transition from one program
186component to another is authorized, there shall be cooperation
187between the program components and the affected family which
188promotes continuity of health care coverage. Any authorized
189transfers must be managed within the program's overall
190appropriated or authorized levels of funding. Each component of
191the program shall establish a reserve to ensure that transfers
192between components will be accomplished within current year
193appropriations. These reserves shall be reviewed by each
194convening of the Social Services Estimating Conference to
195determine the adequacy of such reserves to meet actual
197     (11)(9)  In determining the eligibility of a child, an
198assets test is not required. Each applicant shall provide
199documentation during the application process and the
200redetermination process, including, but not limited to, the
202     (a)  Each applicant's Proof of family income, which must
203shall be verified electronically to determine financial
204eligibility for the Florida Kidcare program. Written
205documentation, which may include wages and earnings statements
206or pay stubs, W-2 forms, or a copy of the applicant's most
207recent federal income tax return, is shall be required only if
208the electronic verification is not available or does not
209substantiate the applicant's income.
210     (b)  Each applicant shall provide A statement from all
211applicable, employed family members that:
212     1.  Their employers do not sponsor health benefit plans for
214     2.  the potential enrollee is not covered by an employer-
215sponsored health benefit plan; or
216     3.  The potential enrollee is covered by an employer-
217sponsored health benefit plan and the cost of the employer-
218sponsored health benefit plan is more than 5 percent of the
219family's income.
220     (12)(10)  Subject to paragraph (6)(a) (4)(b), the Florida
221Kidcare program shall withhold benefits from an enrollee if the
222program obtains evidence that the enrollee is no longer
223eligible, submitted incorrect or fraudulent information in order
224to establish eligibility, or failed to provide verification of
225eligibility. The applicant or enrollee shall be notified that
226because of such evidence program benefits will be withheld
227unless the applicant or enrollee contacts a designated
228representative of the program by a specified date, which must be
229within 10 working days after the date of notice, to discuss and
230resolve the matter. The program shall make every effort to
231resolve the matter within a timeframe that will not cause
232benefits to be withheld from an eligible enrollee.
233     (13)(11)  The following individuals may be subject to
234prosecution in accordance with s. 414.39:
235     (a)  An applicant obtaining or attempting to obtain
236benefits for a potential enrollee under the Florida Kidcare
237program if when the applicant knows or should have known that
238the potential enrollee does not qualify for the Florida Kidcare
240     (b)  An individual who assists an applicant in obtaining or
241attempting to obtain benefits for a potential enrollee under the
242Florida Kidcare program if when the individual knows or should
243have known that the potential enrollee does not qualify for the
244Florida Kidcare program.
245     Section 3.  Paragraph (f) of subsection (2) of section
246409.815, Florida Statutes, is amended to read:
247     409.815  Health benefits coverage; limitations.-
248     (2)  BENCHMARK BENEFITS.-In order for health benefits
249coverage to qualify for premium assistance payments for an
250eligible child under ss. 409.810-409.821, the health benefits
251coverage, except for coverage under Medicaid and Medikids, must
252include the following minimum benefits, as medically necessary.
253     (f)  Outpatient services.-Covered services include
254preventive, diagnostic, therapeutic, palliative care, and other
255services authorized by the enrollee's health benefits coverage
256provider and provided to an enrollee in the outpatient portion
257of a health facility licensed under chapter 395, except for the
258following limitations:
259     1.  Services must be authorized by the enrollee's health
260benefits coverage provider; and
261     2.  Treatment for temporomandibular joint disease (TMJ) is
262specifically excluded.
263     Section 4.  Subsection (3) of section 409.816, Florida
264Statutes, is amended to read:
265     409.816  Limitations on premiums and cost-sharing.-The
266following limitations on premiums and cost-sharing are
267established for the program.
268     (3)  Enrollees in families with a family income above 150
269percent of the federal poverty level who are not receiving
270coverage under the Medicaid program or who are not eligible
271under s. 409.814(8) 409.814(6) may be required to pay enrollment
272fees, premiums, copayments, deductibles, coinsurance, or similar
273charges on a sliding scale related to income, except that the
274total annual aggregate cost-sharing with respect to all children
275in a family may not exceed 5 percent of the family's income.
276However, copayments, deductibles, coinsurance, or similar
277charges may not be imposed for preventive services, including
278well-baby and well-child care, age-appropriate immunizations,
279and routine hearing and vision screenings.
280     Section 5.  Paragraph (b) of subsection (1) of section
281409.818, Florida Statutes, is amended to read:
282     409.818  Administration.-In order to implement ss. 409.810-
283409.821, the following agencies shall have the following duties:
284     (1)  The Department of Children and Family Services shall:
285     (b)  Establish and maintain the eligibility determination
286process under the program except as specified in subsection (5).
287The department shall directly, or through the services of a
288contracted third-party administrator, establish and maintain a
289process for determining eligibility of children for coverage
290under the program. The eligibility determination process must be
291used solely for determining eligibility of applicants for health
292benefits coverage under the program. The eligibility
293determination process must include an initial determination of
294eligibility for any coverage offered under the program, as well
295as a redetermination or reverification of eligibility each
296subsequent 6 months. Effective January 1, 1999, a child who has
297not attained the age of 5 and who has been determined eligible
298for the Medicaid program is eligible for coverage for 12 months
299without a redetermination or reverification of eligibility. In
300conducting an eligibility determination, the department shall
301determine if the child has special health care needs. The
302department, in consultation with the Agency for Health Care
303Administration and the Florida Healthy Kids Corporation, shall
304develop procedures for redetermining eligibility which enable a
305family to easily update any change in circumstances which could
306affect eligibility. The department may accept changes in a
307family's status as reported to the department by the Florida
308Healthy Kids Corporation without requiring a new application
309from the family. Redetermination of a child's eligibility for
310Medicaid may not be linked to a child's eligibility
311determination for other programs.
312     Section 6.  Subsections (6) and (7) of section 409.904,
313Florida Statutes, are amended to read:
314     409.904  Optional payments for eligible persons.-The agency
315may make payments for medical assistance and related services on
316behalf of the following persons who are determined to be
317eligible subject to the income, assets, and categorical
318eligibility tests set forth in federal and state law. Payment on
319behalf of these Medicaid eligible persons is subject to the
320availability of moneys and any limitations established by the
321General Appropriations Act or chapter 216.
322     (6)  A child who has not attained the age of 19 who has
323been determined eligible for the Medicaid program is deemed to
324be eligible for a total of 6 months, regardless of changes in
325circumstances other than attainment of the maximum age.
326Effective January 1, 1999, a child who has not attained the age
327of 5 and who has been determined eligible for the Medicaid
328program is deemed to be eligible for a total of 12 months
329regardless of changes in circumstances other than attainment of
330the maximum age. Subject to federal regulations, a child who is
331eligible under this subsection must be offered the opportunity
332to be made presumptively eligible.
333     (7)  A pregnant woman for the duration of her pregnancy and
334for the postpartum period as defined in federal law and rule or
335a child under 1 year of age who lives in a family that has an
336income above 185 percent of the most recently published federal
337poverty level, but that which is at or below 200 percent of such
338poverty level. In determining the eligibility of such child, an
339assets test is not required. An individual A child who is
340eligible for Medicaid under this subsection must be offered the
341opportunity, subject to federal rules, to be made presumptively
343     Section 7.  Paragraph (b) of subsection (5) and paragraph
344(a) of subsection (6) of section 624.91, Florida Statutes, are
345amended to read:
346     624.91  The Florida Healthy Kids Corporation Act.-
348     (b)  The Florida Healthy Kids Corporation shall:
349     1.  Arrange for the collection of any family, local
350contributions, or employer payment or premium, in an amount to
351be determined by the board of directors, to provide for payment
352of premiums for comprehensive insurance coverage and for the
353actual or estimated administrative expenses.
354     2.  Arrange for the collection of any voluntary
355contributions to provide for payment of Florida Kidcare program
356premiums for children who are not eligible for medical
357assistance under Title XIX or Title XXI of the Social Security
359     3.  Subject to the provisions of s. 409.8134, accept
360voluntary supplemental local match contributions that comply
361with the requirements of Title XXI of the Social Security Act
362for the purpose of providing additional Florida Kidcare coverage
363in contributing counties under Title XXI.
364     4.  Establish the administrative and accounting procedures
365for the operation of the corporation.
366     5.  Establish, with consultation from appropriate
367professional organizations, standards for preventive health
368services and providers and comprehensive insurance benefits
369appropriate to children if, provided that such standards for
370rural areas do shall not limit primary care providers to board-
371certified pediatricians.
372     6.  Determine eligibility for children seeking to
373participate in the Title XXI-funded components of the Florida
374Kidcare program consistent with the requirements specified in s.
375409.814, as well as the non-Title-XXI-eligible children as
376provided in subsection (3).
377     7.  Establish procedures under which providers of local
378match to, applicants to, and participants in the program may
379have grievances reviewed by an impartial body and reported to
380the board of directors of the corporation.
381     8.  Establish participation criteria and, if appropriate,
382contract with an authorized insurer, health maintenance
383organization, or third-party administrator to provide
384administrative services to the corporation.
385     9.  Establish enrollment criteria that include penalties or
38630-day waiting periods of 30 days for reinstatement of coverage
387upon voluntary cancellation for nonpayment of family premiums.
388     10.  Contract with authorized insurers or providers any
389provider of health care services, who meet meeting standards
390established by the corporation, for the provision of
391comprehensive insurance coverage to participants. Such standards
392must shall include criteria under which the corporation may
393contract with more than one provider of health care services in
394program sites. Health plans shall be selected through a
395competitive bid process. The Florida Healthy Kids Corporation
396shall purchase goods and services in the most cost-effective
397manner consistent with the delivery of quality medical care. The
398maximum administrative cost for a Florida Healthy Kids
399Corporation contract is shall be 15 percent. For health care
400contracts, the minimum medical loss ratio for a Florida Healthy
401Kids Corporation contract is shall be 85 percent. For dental
402contracts, the remaining compensation to be paid to the
403authorized insurer or provider must be at least under a Florida
404Healthy Kids Corporation contract shall be no less than an
405amount which is 85 percent of the premium; to the extent any
406contract provision does not provide for this minimum
407compensation, this section prevails shall prevail. The health
408plan selection criteria and scoring system, and the scoring
409results, must shall be available upon request for inspection
410after the bids have been awarded.
411     11.  Establish disenrollment criteria if in the event local
412matching funds are insufficient to cover enrollments.
413     12.  Develop and implement a plan to publicize the Florida
414Kidcare program, the eligibility requirements of the program,
415and the procedures for enrollment in the program and to maintain
416public awareness of the corporation and the program.
417     13.  Secure staff necessary to properly administer the
418corporation. Staff costs shall be funded from state and local
419matching funds and such other private or public funds as become
420available. The board of directors shall determine the number of
421staff members necessary to administer the corporation.
422     14.  In consultation with the partner agencies, provide a
423report on the Florida Kidcare program annually to the Governor,
424the Chief Financial Officer, the Commissioner of Education, the
425President of the Senate, the Speaker of the House of
426Representatives, and the Minority Leaders of the Senate and the
427House of Representatives.
428     15.  Provide information on a quarterly basis to the
429Legislature and the Governor which compares the costs and
430utilization of the full-pay enrolled population and the Title
431XXI-subsidized enrolled population in the Florida Kidcare
432program. The information, At a minimum, the information must
434     a.  The monthly enrollment and expenditure for full-pay
435enrollees in the Medikids and Florida Healthy Kids programs
436compared to the Title XXI-subsidized enrolled population; and
437     b.  The costs and utilization by service of the full-pay
438enrollees in the Medikids and Florida Healthy Kids programs and
439the Title XXI-subsidized enrolled population.
441By February 1, 2010, the Florida Healthy Kids Corporation shall
442provide a study to the Legislature and the Governor on premium
443impacts to the subsidized portion of the program from the
444inclusion of the full-pay program, which shall include
445recommendations on how to eliminate or mitigate possible impacts
446to the subsidized premiums.
447     16.  Establish benefit packages that conform to the
448provisions of the Florida Kidcare program, as created in ss.
450     (6)  BOARD OF DIRECTORS.-
451     (a)  The Florida Healthy Kids Corporation is shall operate
452subject to the supervision and approval of a board of directors
453chaired by the Chief Financial Officer or her or his designee,
454and composed of 12 11 other members selected for 3-year terms of
455office as follows:
456     1.  The Secretary of Health Care Administration, or his or
457her designee.
458     2.  One member, appointed by the Commissioner of Education,
459from the Office of School Health Programs of the Florida
460Department of Education.
461     3.  One member, appointed by the Chief Financial Officer,
462from among three members nominated by the Florida Pediatric
464     4.  One member, appointed by the Governor, who represents
465the Children's Medical Services Program.
466     5.  One member, appointed by the Chief Financial Officer
467from among three members nominated by the Florida Hospital
469     6.  One member, appointed by the Governor, who is an expert
470on child health policy.
471     7.  One member, appointed by the Chief Financial Officer,
472from among three members nominated by the Florida Academy of
473Family Physicians.
474     8.  One member, appointed by the Governor, who represents
475the state Medicaid program.
476     9.  One member, appointed by the Chief Financial Officer,
477from among three members nominated by the Florida Association of
479     10.  The State Health Officer, or her or his designee.
480     11.  The Secretary of Children and Family Services, or his
481or her designee.
482     12.  One member, appointed by the Governor, from among
483three members nominated by the Florida Dental Association.
484     Section 8.  Subject to appropriation, the Agency for Health
485Care Administration shall implement the federal Family
486Opportunity Act, ss. 6062-6071 of the Deficit Reduction Act of
4872005, to allow families whose income is up to 300 percent of the
488federal poverty level to buy Medicaid coverage for their
489disabled children.
490     Section 9.  This act shall take effect October 1, 2011.

CODING: Words stricken are deletions; words underlined are additions.