Florida Senate - 2013 (PROPOSED COMMITTEE BILL) SPB 7038
FOR CONSIDERATION By the Committee on Appropriations
576-02536-13 20137038__
1 A bill to be entitled
2 An act relating to health care; amending s.
3 409.811, F.S.; revising and providing definitions;
4 amending s. 409.813, F.S.; revising the components of
5 the Florida Kidcare program; prohibiting a cause of
6 action from arising against the Florida Healthy Kids
7 Corporation for failure to make health services
8 available; amending s. 409.8132, F.S.; revising the
9 eligibility of the Medikids program component;
10 revising the enrollment requirements of the Medikids
11 program component; amending s. 409.8134, F.S.;
12 conforming provisions to changes made by the act;
13 amending s. 409.814, F.S.; revising eligibility
14 requirements for the Florida Kidcare program; amending
15 s. 409.815, F.S.; revising the minimum health benefits
16 coverage under the Florida Kidcare Act; deleting
17 obsolete provisions; amending ss. 409.816 and
18 409.8177, F.S.; conforming provisions to changes made
19 by the act; repealing s. 409.817, F.S., relating to
20 the approval of health benefits coverage and financial
21 assistance; repealing s. 409.8175, F.S., relating to
22 delivery of services in rural counties; amending s.
23 409.818, F.S.; revising the duties of the Department
24 of Children and Families and the Agency for Health
25 Care Administration with regard to the Florida Kidcare
26 Act; deleting the duties of the Department of Health
27 and the Office of Insurance Regulation with regard to
28 the Florida Kidcare Act; amending s. 409.820, F.S.;
29 requiring the Department of Health, in consultation
30 with the agency and the Florida Healthy Kids
31 Corporation, to develop a minimum set of pediatric and
32 adolescent quality assurance and access standards for
33 all program components; amending s. 624.91, F.S.;
34 revising the legislative intent of the Florida Healthy
35 Kids Corporation Act to include the Healthy Florida
36 program; revising the medical loss ratio requirements
37 for the contracts for the Florida Healthy Kids
38 Corporation; modifying the membership of the Florida
39 Healthy Kids Corporation’s board of directors;
40 creating an executive steering committee; requiring
41 additional corporate compliance requirements for the
42 Florida Healthy Kids Corporation; revising
43 participation guidelines for non-subsidized enrollees
44 in the Healthy Kids program; repealing s. 624.915,
45 F.S., relating to the operating fund of the Florida
46 Healthy Kids Corporation; creating s. 624.917, F.S.;
47 creating the Healthy Florida program; providing
48 definitions; providing eligibility and enrollment
49 requirements; authorizing the Florida Healthy Kids
50 Corporation to contract with certain insurers;
51 requiring the corporation to establish a benefits
52 package and a process for payment of services;
53 authorizing the corporation to collect premiums and
54 copayments; requiring the corporation to oversee the
55 Healthy Florida program and to establish a grievance
56 process and integrity process; providing applicability
57 of certain state laws for administration of the
58 Healthy Florida program; requiring the corporation to
59 collect certain data and to submit enrollment reports
60 and interim independent evaluations to the
61 Legislature; providing for expiration of the program;
62 providing an implementation and interpretation clause;
63 providing an effective date.
64
65 Be It Enacted by the Legislature of the State of Florida:
66
67 Section 1. Section 409.811, Florida Statutes, is amended to
68 read:
69 409.811 Definitions relating to Florida Kidcare Act.—As
70 used in ss. 409.810-409.821, the term:
71 (1) “Actuarially equivalent” means that:
72 (a) The aggregate value of the benefits included in health
73 benefits coverage is equal to the value of the benefits in the
74 benchmark benefit plan; and
75 (b) The benefits included in health benefits coverage are
76 substantially similar to the benefits included in the benchmark
77 benefit plan, except that preventive health services must be the
78 same as in the benchmark benefit plan.
79 (2) “Agency” means the Agency for Health Care
80 Administration.
81 (3) “Applicant” means a parent or guardian of a child or a
82 child whose disability of nonage has been removed under chapter
83 743, who applies for determination of eligibility for health
84 benefits coverage under ss. 409.810-409.821.
85 (4) “Child benchmark benefit plan” means the form and level
86 of health benefits coverage established in s. 409.815.
87 (5) “Child” means any person under 19 years of age.
88 (6) “Child with special health care needs” means a child
89 whose serious or chronic physical or developmental condition
90 requires extensive preventive and maintenance care beyond that
91 required by typically healthy children. Health care utilization
92 by such a child exceeds the statistically expected usage of the
93 normal child adjusted for chronological age, and such a child
94 often needs complex care requiring multiple providers,
95 rehabilitation services, and specialized equipment in a number
96 of different settings.
97 (7) “Children’s Medical Services Network” or “network”
98 means a statewide managed care service system as defined in s.
99 391.021(1).
100 (8) “CHIP” means the children’s health insurance program as
101 authorized under Title XXI of the Social Security Act, and its
102 regulations, ss. 409.810-820, and as administered in this state
103 by the agency, the department and the Florida Healthy Kids
104 Corporation, as appropriate to their responsibilities.
105 (9) “Combined eligibility notice” means an eligibility
106 notice that informs an applicant or enrollee or multiple family
107 members of a household, when feasible, of eligibility for each
108 of the insurance affordability programs and enrollment into a
109 program or exchange plan. A combined eligibility form must be
110 issued by the last agency or department to make an eligibility,
111 renewal or denial determination. The form must meet all of the
112 federal and state law and regulatory requirements no later than
113 January 1, 2014.
114 (8) “Community rate” means a method used to develop
115 premiums for a health insurance plan that spreads financial risk
116 across a large population and allows adjustments only for age,
117 gender, family composition, and geographic area.
118 (10)(9) “Department” means the Department of Health.
119 (11)(10) “Enrollee” means a child who has been determined
120 eligible for and is receiving coverage under ss. 409.810
121 409.821.
122 (11) “Family” means the group or the individuals whose
123 income is considered in determining eligibility for the Florida
124 Kidcare program. The family includes a child with a parent or
125 caretaker relative who resides in the same house or living unit
126 or, in the case of a child whose disability of nonage has been
127 removed under chapter 743, the child. The family may also
128 include other individuals whose income and resources are
129 considered in whole or in part in determining eligibility of the
130 child.
131 (12) “Family income” means cash received at periodic
132 intervals from any source, such as wages, benefits,
133 contributions, or rental property. Income also may include any
134 money that would have been counted as income under the Aid to
135 Families with Dependent Children (AFDC) state plan in effect
136 prior to August 22, 1996.
137 (12)(13) “Florida Kidcare program,” “Kidcare program,” or
138 “program” means the health benefits program administered through
139 ss. 409.810-409.821.
140 (13)(14) “Guarantee issue” means that health benefits
141 coverage must be offered to an individual regardless of the
142 individual’s health status, preexisting condition, or claims
143 history.
144 (14)(15) “Health benefits coverage” means protection that
145 provides payment of benefits for covered health care services or
146 that otherwise provides, either directly or through arrangements
147 with other persons, covered health care services on a prepaid
148 per capita basis or on a prepaid aggregate fixed-sum basis.
149 (15)(16) “Health insurance plan” means health benefits
150 coverage under the following:
151 (a) A health plan offered by any certified health
152 maintenance organization or authorized health insurer, except a
153 plan that is limited to the following: a limited benefit,
154 specified disease, or specified accident; hospital indemnity;
155 accident only; limited benefit convalescent care; Medicare
156 supplement; credit disability; dental; vision; long-term care;
157 disability income; coverage issued as a supplement to another
158 health plan; workers’ compensation liability or other insurance;
159 or motor vehicle medical payment only; or
160 (b) An employee welfare benefit plan that includes health
161 benefits established under the Employee Retirement Income
162 Security Act of 1974, as amended.
163 (16) “Household income” means the group or the individual
164 whose income is considered in determining eligibility for the
165 Florida Kidcare program. The term “household” has the same
166 meaning as provided in section 36B(d)(2) of the Internal Revenue
167 Code of 1986.
168 (17) “Medicaid” means the medical assistance program
169 authorized by Title XIX of the Social Security Act, and
170 regulations thereunder, and ss. 409.901-409.920, as administered
171 in this state by the agency.
172 (18) “Medically necessary” means the use of any medical
173 treatment, service, equipment, or supply necessary to palliate
174 the effects of a terminal condition, or to prevent, diagnose,
175 correct, cure, alleviate, or preclude deterioration of a
176 condition that threatens life, causes pain or suffering, or
177 results in illness or infirmity and which is:
178 (a) Consistent with the symptom, diagnosis, and treatment
179 of the enrollee’s condition;
180 (b) Provided in accordance with generally accepted
181 standards of medical practice;
182 (c) Not primarily intended for the convenience of the
183 enrollee, the enrollee’s family, or the health care provider;
184 (d) The most appropriate level of supply or service for the
185 diagnosis and treatment of the enrollee’s condition; and
186 (e) Approved by the appropriate medical body or health care
187 specialty involved as effective, appropriate, and essential for
188 the care and treatment of the enrollee’s condition.
189 (19) “Medikids” means a component of the Florida Kidcare
190 program of medical assistance authorized by Title XXI of the
191 Social Security Act, and regulations thereunder, and s.
192 409.8132, as administered in the state by the agency.
193 (20) “Modified Adjusted Gross Income (MAGI)” means the
194 individual or household’s annual adjusted gross income as
195 defined in 26 U.S.C. s. 36 of the Internal Revenue Code of 1986
196 which is used to determine eligibility under the Florida Kidcare
197 program.
198 (21) “Patient Protection and Affordable Care Act” or “Act”
199 means the federal law enacted as Public Law 111-148, as further
200 amended by the federal Health Care and Education Reconciliation
201 Act of 2010, Public Law 111-152, and any amendments,
202 regulations, or guidance thereunder, issued under those acts.
203 (22)(20) “Preexisting condition exclusion” means, with
204 respect to coverage, a limitation or exclusion of benefits
205 relating to a condition based on the fact that the condition was
206 present before the date of enrollment for such coverage, whether
207 or not any medical advice, diagnosis, care, or treatment was
208 recommended or received before such date.
209 (23)(21) “Premium” means the entire cost of a health
210 insurance plan, including the administration fee or the risk
211 assumption charge.
212 (24)(22) “Premium assistance payment” means the monthly
213 consideration paid by the agency per enrollee in the Florida
214 Kidcare program towards health insurance premiums.
215 (25)(23) “Qualified alien” means an alien as defined in 8
216 U.S.C. s. 1641 (b) and (c) s. 431 of the Personal Responsibility
217 and Work Opportunity Reconciliation Act of 1996, as amended,
218 Pub. L. No. 104-193.
219 (26)(24) “Resident” means a United States citizen, or
220 qualified alien, who is domiciled in this state.
221 (27)(25) “Rural county” means a county having a population
222 density of less than 100 persons per square mile, or a county
223 defined by the most recent United States Census as rural, in
224 which there is no prepaid health plan participating in the
225 Medicaid program as of July 1, 1998.
226 (26) “Substantially similar” means that, with respect to
227 additional services as defined in s. 2103(c)(2) of Title XXI of
228 the Social Security Act, these services must have an actuarial
229 value equal to at least 75 percent of the actuarial value of the
230 coverage for that service in the benchmark benefit plan and,
231 with respect to the basic services as defined in s. 2103(c)(1)
232 of Title XXI of the Social Security Act, these services must be
233 the same as the services in the benchmark benefit plan.
234 Section 2. Section 409.813, Florida Statutes, is amended to
235 read:
236 409.813 Health benefits coverage; program components;
237 entitlement and nonentitlement.—
238 (1) The Florida Kidcare program includes health benefits
239 coverage provided to children through the following program
240 components, which shall be marketed as the Florida Kidcare
241 program:
242 (a) Medicaid;
243 (b) Medikids as created in s. 409.8132;
244 (c) The Florida Healthy Kids Corporation as created in s.
245 624.91; and
246 (d) Employer-sponsored group health insurance plans
247 approved under ss. 409.810-409.821; and
248 (d)(e) The Children’s Medical Services network established
249 in chapter 391.
250 (2) Except for Title XIX-funded Florida Kidcare program
251 coverage under the Medicaid program, coverage under the Florida
252 Kidcare program is not an entitlement. No cause of action shall
253 arise against the state, the department, the Department of
254 Children and Family Services, or the agency, or the Florida
255 Healthy Kids Corporation for failure to make health services
256 available to any person under ss. 409.810-409.821.
257 Section 3. Subsections (6) and (7) of section 409.8132,
258 Florida Statutes, are amended to read:
259 409.8132 Medikids program component.—
260 (6) ELIGIBILITY.—
261 (a) A child who has attained the age of 1 year but who is
262 under the age of 5 years is eligible to enroll in the Medikids
263 program component of the Florida Kidcare program, if the child
264 is a member of a family that has a family income which exceeds
265 the Medicaid applicable income level as specified in s. 409.903,
266 but which is equal to or below 200 percent of the current
267 federal poverty level. In determining the eligibility of such a
268 child, an assets test is not required. A child who is eligible
269 for Medikids may elect to enroll in Florida Healthy Kids
270 coverage or employer-sponsored group coverage. However, a child
271 who is eligible for Medikids may participate in the Florida
272 Healthy Kids program only if the child has a sibling
273 participating in the Florida Healthy Kids program and the
274 child’s county of residence permits such enrollment.
275 (b) The provisions of s. 409.814 apply to the Medikids
276 program.
277 (7) ENROLLMENT.—Enrollment in the Medikids program
278 component may occur at any time throughout the year. A child may
279 not receive services under the Medikids program until the child
280 is enrolled in a managed care plan or MediPass. Once determined
281 eligible, an applicant may receive choice counseling and select
282 a managed care plan or MediPass. The agency may initiate
283 mandatory assignment for a Medikids applicant who has not chosen
284 a managed care plan or MediPass provider after the applicant’s
285 voluntary choice period ends. An applicant may select MediPass
286 under the Medikids program component only in counties that have
287 fewer than two managed care plans available to serve Medicaid
288 recipients and only if the federal Health Care Financing
289 Administration determines that MediPass constitutes “health
290 insurance coverage” as defined in Title XXI of the Social
291 Security Act.
292 Section 4. Subsection (2) of section 409.8134, Florida
293 Statutes, is amended to read:
294 409.8134 Program expenditure ceiling; enrollment.—
295 (2) The Florida Kidcare program may conduct enrollment
296 continuously throughout the year.—
297 (a) Children eligible for coverage under the Title XXI
298 funded Florida Kidcare program shall be enrolled on a first
299 come, first-served basis using the date the enrollment
300 application is received. Enrollment shall immediately cease when
301 the expenditure ceiling is reached. Year-round enrollment shall
302 only be held if the Social Services Estimating Conference
303 determines that sufficient federal and state funds will be
304 available to finance the increased enrollment.
305 (b) The application for the Florida Kidcare program is
306 valid for a period of 120 days after the date it was received.
307 At the end of the 120-day period, if the applicant has not been
308 enrolled in the program, the application is invalid and the
309 applicant shall be notified of the action. The applicant may
310 reactivate the application after notification of the action
311 taken by the program.
312 (c) Except for the Medicaid program, whenever the Social
313 Services Estimating Conference determines that there are
314 presently, or will be by the end of the current fiscal year,
315 insufficient funds to finance the current or projected
316 enrollment in the Florida Kidcare program, all additional
317 enrollment must cease and additional enrollment may not resume
318 until sufficient funds are available to finance such enrollment.
319 Section 5. Section 409.814, Florida Statutes, is amended to
320 read:
321 409.814 Eligibility.—A child who has not reached 19 years
322 of age whose household family income is equal to or below 200
323 percent of the federal poverty level is eligible for the Florida
324 Kidcare program as provided in this section. If an enrolled
325 individual is determined to be ineligible for coverage, he or
326 she must be immediately disenrolled from the respective Florida
327 Kidcare program component and referred to another insurance
328 affordability program, if appropriate, through a combined
329 eligibility notice.
330 (1) A child who is eligible for Medicaid coverage under s.
331 409.903 or s. 409.904 must be offered the opportunity to enroll
332 enrolled in Medicaid and is not eligible to receive health
333 benefits under any other health benefits coverage authorized
334 under the Florida Kidcare program. A child who is eligible for
335 Medicaid and opts to enroll in CHIP may disenroll from CHIP at
336 any time and transition to Medicaid. This transition must occur
337 without any break in coverage.
338 (2) A child who is not eligible for Medicaid, but who is
339 eligible for the Florida Kidcare program, may obtain health
340 benefits coverage under any of the other components listed in s.
341 409.813 if such coverage is approved and available in the county
342 in which the child resides.
343 (3) A Title XXI-funded child who is eligible for the
344 Florida Kidcare program who is a child with special health care
345 needs, as determined through a medical or behavioral screening
346 instrument, is eligible for health benefits coverage from and
347 shall be assigned to and may opt out of the Children’s Medical
348 Services Network.
349 (4) The following children are not eligible to receive
350 Title XXI-funded premium assistance for health benefits coverage
351 under the Florida Kidcare program, except under Medicaid if the
352 child would have been eligible for Medicaid under s. 409.903 or
353 s. 409.904 as of June 1, 1997:
354 (a) A child who is covered under a family member’s group
355 health benefit plan or under other private or employer health
356 insurance coverage, if the cost of the child’s participation is
357 not greater than 5 percent of the household’s family’s income.
358 If a child is otherwise eligible for a subsidy under the Florida
359 Kidcare program and the cost of the child’s participation in the
360 family member’s health insurance benefit plan is greater than 5
361 percent of the household’s family’s income, the child may enroll
362 in the appropriate subsidized Kidcare program.
363 (b) A child who is seeking premium assistance for the
364 Florida Kidcare program through employer-sponsored group
365 coverage, if the child has been covered by the same employer’s
366 group coverage during the 60 days before the family submitted an
367 application for determination of eligibility under the program.
368 (b)(c) A child who is an alien, but who does not meet the
369 definition of qualified alien, in the United States.
370 (c)(d) A child who is an inmate of a public institution or
371 a patient in an institution for mental diseases.
372 (d)(e) A child who is otherwise eligible for premium
373 assistance for the Florida Kidcare program and has had his or
374 her coverage in an employer-sponsored or private health benefit
375 plan voluntarily canceled in the last 60 days, except those
376 children whose coverage was voluntarily canceled for good cause,
377 including, but not limited to, the following circumstances:
378 1. The cost of participation in an employer-sponsored
379 health benefit plan is greater than 5 percent of the household’s
380 modified adjusted gross family’s income;
381 2. The parent lost a job that provided an employer
382 sponsored health benefit plan for children;
383 3. The parent who had health benefits coverage for the
384 child is deceased;
385 4. The child has a medical condition that, without medical
386 care, would cause serious disability, loss of function, or
387 death;
388 5. The employer of the parent canceled health benefits
389 coverage for children;
390 6. The child’s health benefits coverage ended because the
391 child reached the maximum lifetime coverage amount;
392 7. The child has exhausted coverage under a COBRA
393 continuation provision;
394 8. The health benefits coverage does not cover the child’s
395 health care needs; or
396 9. Domestic violence led to loss of coverage.
397 (5) A child who is otherwise eligible for the Florida
398 Kidcare program and who has a preexisting condition that
399 prevents coverage under another insurance plan as described in
400 paragraph (4)(a) which would have disqualified the child for the
401 Florida Kidcare program if the child were able to enroll in the
402 plan is eligible for Florida Kidcare coverage when enrollment is
403 possible.
404 (5)(6) A child whose household’s modified adjusted gross
405 family income is above 200 percent of the federal poverty level
406 or a child who is excluded under the provisions of subsection
407 (4) may participate in the Florida Kidcare program as provided
408 in s. 409.8132 or, if the child is ineligible for Medikids by
409 reason of age, in the Florida Healthy Kids program, subject to
410 the following:
411 (a) The family is not eligible for premium assistance
412 payments and must pay the full cost of the premium, including
413 any administrative costs.
414 (b) The board of directors of the Florida Healthy Kids
415 Corporation may offer a reduced benefit package to these
416 children in order to limit program costs for such families.
417 (c) By August 15, 2013, the Florida Healthy Kids
418 Corporation shall notify all current full-pay enrollees of the
419 availability of the exchange and how to access other insurance
420 affordability options. New applications for full-pay coverage
421 may not be accepted after September 30, 2013.
422 (6)(7) Once a child is enrolled in the Florida Kidcare
423 program, the child is eligible for coverage for 12 months
424 without a redetermination or reverification of eligibility, if
425 the family continues to pay the applicable premium. Eligibility
426 for program components funded through Title XXI of the Social
427 Security Act terminates when a child attains the age of 19. A
428 child who has not attained the age of 5 and who has been
429 determined eligible for the Medicaid program is eligible for
430 coverage for 12 months without a redetermination or
431 reverification of eligibility.
432 (7)(8) When determining or reviewing a child’s eligibility
433 under the Florida Kidcare program, the applicant shall be
434 provided with reasonable notice of changes in eligibility which
435 may affect enrollment in one or more of the program components.
436 If a transition from one program component to another is
437 authorized, there shall be cooperation between the program
438 components and the affected family which promotes continuity of
439 health care coverage. Any authorized transfers must be managed
440 within the program’s overall appropriated or authorized levels
441 of funding. Each component of the program shall establish a
442 reserve to ensure that transfers between components will be
443 accomplished within current year appropriations. These reserves
444 shall be reviewed by each convening of the Social Services
445 Estimating Conference to determine the adequacy of such reserves
446 to meet actual experience.
447 (8)(9) In determining the eligibility of a child, an assets
448 test is not required. Each applicant shall provide documentation
449 during the application process and the redetermination process,
450 including, but not limited to, the following:
451 (a) Proof of household family income, which must be
452 verified electronically to determine financial eligibility for
453 the Florida Kidcare program. Written documentation, which may
454 include wages and earnings statements or pay stubs, W-2 forms,
455 or a copy of the applicant’s most recent federal income tax
456 return, is required only if the electronic verification is not
457 available or does not substantiate the applicant’s income. This
458 paragraph expires December 31, 2013.
459 (b) A statement from all applicable, employed household
460 family members that:
461 1. Their employers do not sponsor health benefit plans for
462 employees;
463 2. The potential enrollee is not covered by an employer
464 sponsored health benefit plan; or
465 3. The potential enrollee is covered by an employer
466 sponsored health benefit plan and the cost of the employer
467 sponsored health benefit plan is more than 5 percent of the
468 household’s modified adjusted gross family’s income.
469 (c) To enroll in the Children’s Medical Services Network, a
470 completed application, including a clinical screening.
471 (d) Effective January 1, 2014, eligibility will be
472 determined through electronic matching using the federal hub and
473 other resources. Written documentation from the applicant may be
474 accepted if the electronic verification does not substantiate
475 the applicant’s income or if there has been a change in
476 circumstances.
477 (9)(10) Subject to paragraph (4)(a), the Florida Kidcare
478 program shall withhold benefits from an enrollee if the program
479 obtains evidence that the enrollee is no longer eligible,
480 submitted incorrect or fraudulent information in order to
481 establish eligibility, or failed to provide verification of
482 eligibility. The applicant or enrollee shall be notified that
483 because of such evidence program benefits will be withheld
484 unless the applicant or enrollee contacts a designated
485 representative of the program by a specified date, which must be
486 within 10 working days after the date of notice, to discuss and
487 resolve the matter. The program shall make every effort to
488 resolve the matter within a timeframe that will not cause
489 benefits to be withheld from an eligible enrollee.
490 (10)(11) The following individuals may be subject to
491 prosecution in accordance with s. 414.39:
492 (a) An applicant obtaining or attempting to obtain benefits
493 for a potential enrollee under the Florida Kidcare program when
494 the applicant knows or should have known the potential enrollee
495 does not qualify for the Florida Kidcare program.
496 (b) An individual who assists an applicant in obtaining or
497 attempting to obtain benefits for a potential enrollee under the
498 Florida Kidcare program when the individual knows or should have
499 known the potential enrollee does not qualify for the Florida
500 Kidcare program.
501 Section 6. Paragraphs (g), (k), (q), and (w) of subsection
502 (2) of section 409.815, Florida Statutes, are amended to read:
503 409.815 Health benefits coverage; limitations.—
504 (2) BENCHMARK BENEFITS.—In order for health benefits
505 coverage to qualify for premium assistance payments for an
506 eligible child under ss. 409.810-409.821, the health benefits
507 coverage, except for coverage under Medicaid and Medikids, must
508 include the following minimum benefits, as medically necessary.
509 (g) Behavioral health services.—
510 1. Mental health benefits include:
511 a. Inpatient services, limited to 30 inpatient days per
512 contract year for psychiatric admissions, or residential
513 services in facilities licensed under s. 394.875(6) or s.
514 395.003 in lieu of inpatient psychiatric admissions; however, a
515 minimum of 10 of the 30 days shall be available only for
516 inpatient psychiatric services if authorized by a physician; and
517 b. Outpatient services, including outpatient visits for
518 psychological or psychiatric evaluation, diagnosis, and
519 treatment by a licensed mental health professional, limited to
520 40 outpatient visits each contract year.
521 2. Substance abuse services include:
522 a. Inpatient services, limited to 7 inpatient days per
523 contract year for medical detoxification only and 30 days of
524 residential services; and
525 b. Outpatient services, including evaluation, diagnosis,
526 and treatment by a licensed practitioner, limited to 40
527 outpatient visits per contract year.
528
529 Effective October 1, 2009, Covered services include inpatient
530 and outpatient services for mental and nervous disorders as
531 defined in the most recent edition of the Diagnostic and
532 Statistical Manual of Mental Disorders published by the American
533 Psychiatric Association. Such benefits include psychological or
534 psychiatric evaluation, diagnosis, and treatment by a licensed
535 mental health professional and inpatient, outpatient, and
536 residential treatment of substance abuse disorders. Any benefit
537 limitations, including duration of services, number of visits,
538 or number of days for hospitalization or residential services,
539 shall not be any less favorable than those for physical
540 illnesses generally. The program may also implement appropriate
541 financial incentives, peer review, utilization requirements, and
542 other methods used for the management of benefits provided for
543 other medical conditions in order to reduce service costs and
544 utilization without compromising quality of care.
545 (k) Hospice services.—Covered services include reasonable
546 and necessary services for palliation or management of an
547 enrollee’s terminal illness, with the following exceptions:
548 1. Once a family elects to receive hospice care for an
549 enrollee, other services that treat the terminal condition will
550 not be covered; and
551 2. Services required for conditions totally unrelated to
552 the terminal condition are covered to the extent that the
553 services are included in this section.
554 (q) Dental services.—Effective October 1, 2009, Dental
555 services shall be covered as required under federal law and may
556 also include those dental benefits provided to children by the
557 Florida Medicaid program under s. 409.906(6).
558 (w) Reimbursement of federally qualified health centers and
559 rural health clinics.—Effective October 1, 2009, Payments for
560 services provided to enrollees by federally qualified health
561 centers and rural health clinics under this section shall be
562 reimbursed using the Medicaid Prospective Payment System as
563 provided for under s. 2107(e)(1)(D) of the Social Security Act.
564 If such services are paid for by health insurers or health care
565 providers under contract with the Florida Healthy Kids
566 Corporation, such entities are responsible for this payment. The
567 agency may seek any available federal grants to assist with this
568 transition.
569 Section 7. Section 409.816, Florida Statutes, is amended to
570 read:
571 409.816 Limitations on premiums and cost-sharing.—The
572 following limitations on premiums and cost-sharing are
573 established for the program.
574 (1) Enrollees who receive coverage under the Medicaid
575 program may not be required to pay:
576 (a) Enrollment fees, premiums, or similar charges; or
577 (b) Copayments, deductibles, coinsurance, or similar
578 charges.
579 (2) Enrollees in households that have families with a
580 modified adjusted gross family income equal to or below 150
581 percent of the federal poverty level, who are not receiving
582 coverage under the Medicaid program, may not be required to pay:
583 (a) Enrollment fees, premiums, or similar charges that
584 exceed the maximum monthly charge permitted under s. 1916(b)(1)
585 of the Social Security Act; or
586 (b) Copayments, deductibles, coinsurance, or similar
587 charges that exceed a nominal amount, as determined consistent
588 with regulations referred to in s. 1916(a)(3) of the Social
589 Security Act. However, such charges may not be imposed for
590 preventive services, including well-baby and well-child care,
591 age-appropriate immunizations, and routine hearing and vision
592 screenings.
593 (3) Enrollees in households that have families with a
594 modified adjusted gross family income above 150 percent of the
595 federal poverty level who are not receiving coverage under the
596 Medicaid program or who are not eligible under s. 409.814(5) s.
597 409.814(6) may be required to pay enrollment fees, premiums,
598 copayments, deductibles, coinsurance, or similar charges on a
599 sliding scale related to income, except that the total annual
600 aggregate cost-sharing with respect to all children in a
601 household family may not exceed 5 percent of the household’s
602 modified adjusted family’s income. However, copayments,
603 deductibles, coinsurance, or similar charges may not be imposed
604 for preventive services, including well-baby and well-child
605 care, age-appropriate immunizations, and routine hearing and
606 vision screenings.
607 Section 8. Section 409.817, Florida Statutes, is repealed.
608 Section 9. Section 409.8175, Florida Statutes, is repealed.
609 Section 10. Paragraph (c) of subsection (1) of section
610 409.8177, Florida Statutes, is amended to read:
611 409.8177 Program evaluation.—
612 (1) The agency, in consultation with the Department of
613 Health, the Department of Children and Family Services, and the
614 Florida Healthy Kids Corporation, shall contract for an
615 evaluation of the Florida Kidcare program and shall by January 1
616 of each year submit to the Governor, the President of the
617 Senate, and the Speaker of the House of Representatives a report
618 of the program. In addition to the items specified under s. 2108
619 of Title XXI of the Social Security Act, the report shall
620 include an assessment of crowd-out and access to health care, as
621 well as the following:
622 (c) The characteristics of the children and families
623 assisted under the program, including ages of the children,
624 household family income, and access to or coverage by other
625 health insurance prior to the program and after disenrollment
626 from the program.
627 Section 11. Section 409.818, Florida Statutes, is amended
628 to read:
629 409.818 Administration.—In order to implement ss. 409.810
630 409.821, the following agencies shall have the following duties:
631 (1) The Department of Children and Family Services shall:
632 (a) Maintain Develop a simplified eligibility determination
633 and renewal process application mail-in form to be used for
634 determining the eligibility of children for coverage under the
635 Florida Kidcare program, in consultation with the agency, the
636 Department of Health, and the Florida Healthy Kids Corporation.
637 The simplified eligibility process application form must include
638 an item that provides an opportunity for the applicant to
639 indicate whether coverage is being sought for a child with
640 special health care needs. Families applying for children’s
641 Medicaid coverage must also be able to use the simplified
642 application process form without having to pay a premium.
643 (b) Establish and maintain the eligibility determination
644 process under the program except as specified in subsection (3),
645 which includes the following: (5).
646 1. The department shall directly, or through the services
647 of a contracted third-party administrator, establish and
648 maintain a process for determining eligibility of children for
649 coverage under the program. The eligibility determination
650 process must be used solely for determining eligibility of
651 applicants for health benefits coverage under the program. The
652 eligibility determination process must include an initial
653 determination of eligibility for any coverage offered under the
654 program, as well as a redetermination or reverification of
655 eligibility each subsequent 6 months. Effective January 1, 1999,
656 A child who has not attained the age of 5 and who has been
657 determined eligible for the Medicaid program is eligible for
658 coverage for 12 months without a redetermination or
659 reverification of eligibility. In conducting an eligibility
660 determination, the department shall determine if the child has
661 special health care needs.
662 2. The department, in consultation with the Agency for
663 Health Care Administration and the Florida Healthy Kids
664 Corporation, shall develop procedures for redetermining
665 eligibility which enable applicants and enrollees a family to
666 easily update any change in circumstances which could affect
667 eligibility.
668 3. The department may accept changes in a family’s status
669 as reported to the department by the Florida Healthy Kids
670 Corporation or the exchange without requiring a new application
671 from the family. Redetermination of a child’s eligibility for
672 Medicaid may not be linked to a child’s eligibility
673 determination for other programs.
674 4. The department, in consultation with the agency and the
675 Florida Healthy Kids Corporation, shall develop a combined
676 eligibility notice to inform applicants and enrollees of their
677 application or renewal status, as appropriate. The content must
678 be coordinated to meet all federal and state requirements under
679 the Act.
680 (c) Inform program applicants about eligibility
681 determinations and provide information about eligibility of
682 applicants to the Florida Kidcare program and to insurers and
683 their agents, through a centralized coordinating office.
684 (d) Adopt rules necessary for conducting program
685 eligibility functions.
686 (2) The Department of Health shall:
687 (a) Design an eligibility intake process for the program,
688 in coordination with the Department of Children and Family
689 Services, the agency, and the Florida Healthy Kids Corporation.
690 The eligibility intake process may include local intake points
691 that are determined by the Department of Health in coordination
692 with the Department of Children and Family Services.
693 (b) Chair a state-level Florida Kidcare coordinating
694 council to review and make recommendations concerning the
695 implementation and operation of the program. The coordinating
696 council shall include representatives from the department, the
697 Department of Children and Family Services, the agency, the
698 Florida Healthy Kids Corporation, the Office of Insurance
699 Regulation of the Financial Services Commission, local
700 government, health insurers, health maintenance organizations,
701 health care providers, families participating in the program,
702 and organizations representing low-income families.
703 (c) In consultation with the Florida Healthy Kids
704 Corporation and the Department of Children and Family Services,
705 establish a toll-free telephone line to assist families with
706 questions about the program.
707 (d) Adopt rules necessary to implement outreach activities.
708 (2)(3) The Agency for Health Care Administration, under the
709 authority granted in s. 409.914(1), shall:
710 (a) Calculate the premium assistance payment necessary to
711 comply with the premium and cost-sharing limitations specified
712 in s. 409.816 and the Act. The premium assistance payment for
713 each enrollee in a health insurance plan participating in the
714 Florida Healthy Kids Corporation shall equal the premium
715 approved by the Florida Healthy Kids Corporation and the Office
716 of Insurance Regulation of the Financial Services Commission
717 pursuant to ss. 627.410 and 641.31, less any enrollee’s share of
718 the premium established within the limitations specified in s.
719 409.816. The premium assistance payment for each enrollee in an
720 employer-sponsored health insurance plan approved under ss.
721 409.810-409.821 shall equal the premium for the plan adjusted
722 for any benchmark benefit plan actuarial equivalent benefit
723 rider approved by the Office of Insurance Regulation pursuant to
724 ss. 627.410 and 641.31, less any enrollee’s share of the premium
725 established within the limitations specified in s. 409.816. In
726 calculating the premium assistance payment levels for children
727 with family coverage, the agency shall set the premium
728 assistance payment levels for each child proportionately to the
729 total cost of family coverage.
730 (b) Make premium assistance payments to health insurance
731 plans on a periodic basis. The agency may use its Medicaid
732 fiscal agent or a contracted third-party administrator in making
733 these payments. The agency may require health insurance plans
734 that participate in the Medikids program or employer-sponsored
735 group health insurance to collect premium payments from an
736 enrollee’s family. Participating health insurance plans shall
737 report premium payments collected on behalf of enrollees in the
738 program to the agency in accordance with a schedule established
739 by the agency.
740 (c) Monitor compliance with quality assurance and access
741 standards developed under s. 409.820 and in accordance with s.
742 2103(f) of the Social Security Act, 42 U.S.C. s. 1397cc(f).
743 (d) Establish a mechanism for investigating and resolving
744 complaints and grievances from program applicants, enrollees,
745 and health benefits coverage providers, and maintain a record of
746 complaints and confirmed problems. In the case of a child who is
747 enrolled in a managed care organization health maintenance
748 organization, the agency must use the provisions of s. 641.511
749 to address grievance reporting and resolution requirements.
750 (e) Approve health benefits coverage for participation in
751 the program, following certification by the Office of Insurance
752 Regulation under subsection (4).
753 (e)(f) Adopt rules necessary for calculating premium
754 assistance payment levels, making premium assistance payments,
755 monitoring access and quality assurance standards and,
756 investigating and resolving complaints and grievances,
757 administering the Medikids program, and approving health
758 benefits coverage.
759 (f) Contract with the Florida Healthy Kids Corporation for
760 the administration of the Florida Kidcare Program and the
761 Healthy Florida Program and to facilitate the release of any
762 federal and state funds.
763
764 The agency is designated the lead state agency for Title XXI of
765 the Social Security Act for purposes of receipt of federal
766 funds, for reporting purposes, and for ensuring compliance with
767 federal and state regulations and rules.
768 (4) The Office of Insurance Regulation shall certify that
769 health benefits coverage plans that seek to provide services
770 under the Florida Kidcare program, except those offered through
771 the Florida Healthy Kids Corporation or the Children’s Medical
772 Services Network, meet, exceed, or are actuarially equivalent to
773 the benchmark benefit plan and that health insurance plans will
774 be offered at an approved rate. In determining actuarial
775 equivalence of benefits coverage, the Office of Insurance
776 Regulation and health insurance plans must comply with the
777 requirements of s. 2103 of Title XXI of the Social Security Act.
778 The department shall adopt rules necessary for certifying health
779 benefits coverage plans.
780 (3)(5) The Florida Healthy Kids Corporation shall retain
781 its functions as authorized in s. 624.91, including eligibility
782 determination for participation in the Healthy Kids program.
783 (4)(6) The agency, the Department of Health, the Department
784 of Children and Family Services, and the Florida Healthy Kids
785 Corporation, and the Office of Insurance Regulation, after
786 consultation with and approval of the Speaker of the House of
787 Representatives and the President of the Senate, are authorized
788 to make program modifications that are necessary to overcome any
789 objections of the United States Department of Health and Human
790 Services to obtain approval of the state’s child health
791 insurance plan under Title XXI of the Social Security Act.
792 Section 12. Section 409.820, Florida Statutes, is amended
793 to read:
794 409.820 Quality assurance and access standards.—Except for
795 Medicaid, the Department of Health, in consultation with the
796 agency and the Florida Healthy Kids Corporation, shall develop a
797 minimum set of pediatric and adolescent quality assurance and
798 access standards for all program components. The standards must
799 include a process for granting exceptions to specific
800 requirements for quality assurance and access. Compliance with
801 the standards shall be a condition of program participation by
802 health benefits coverage providers. These standards shall comply
803 with the provisions of this chapter and chapter 641 and Title
804 XXI of the Social Security Act.
805 Section 13. Section 624.91, Florida Statutes, is amended to
806 read:
807 624.91 The Florida Healthy Kids Corporation Act.—
808 (1) SHORT TITLE.—This section may be cited as the “William
809 G. ‘Doc’ Myers Healthy Kids Corporation Act.”
810 (2) LEGISLATIVE INTENT.—
811 (a) The Legislature finds that increased access to health
812 care services could improve children’s health and reduce the
813 incidence and costs of childhood illness and disabilities among
814 children in this state. Many children do not have comprehensive,
815 affordable health care services available. It is the intent of
816 the Legislature that the Florida Healthy Kids Corporation
817 provide comprehensive health insurance coverage to such
818 children. The corporation is encouraged to cooperate with any
819 existing health service programs funded by the public or the
820 private sector.
821 (b) It is the intent of the Legislature that the Florida
822 Healthy Kids Corporation serve as one of several providers of
823 services to children eligible for medical assistance under Title
824 XXI of the Social Security Act. Although the corporation may
825 serve other children, the Legislature intends the primary
826 recipients of services provided through the corporation be
827 school-age children with a family income below 200 percent of
828 the federal poverty level, who do not qualify for Medicaid. It
829 is also the intent of the Legislature that state and local
830 government Florida Healthy Kids funds be used to continue
831 coverage, subject to specific appropriations in the General
832 Appropriations Act, to children not eligible for federal
833 matching funds under Title XXI.
834 (c) It is further the intent of the Legislature that the
835 Florida Healthy Kids Corporation administer and manage services
836 for Healthy Florida, a health care program for uninsured adults
837 using a unique network of providers and contracts. Enrollees in
838 Healthy Florida will receive comprehensive health care services
839 from private, licensed health insurers who meet standards
840 established by the corporation. It is further the intent of the
841 Legislature that these enrollees participate in their own health
842 care decisionmaking and contribute financially toward their
843 medical costs. The Legislature intends to provide an alternative
844 benefit package that includes a full range of services which
845 meet the needs of residents of this state. As a new program, the
846 Legislature will also ensure that a comprehensive evaluation is
847 conducted to measure the overall impact of the program and
848 identify whether to renew the program after an initial 3-year
849 term.
850 (3) ELIGIBILITY FOR STATE-FUNDED ASSISTANCE.—Only the
851 following individuals are eligible for state-funded assistance
852 in paying premiums for Healthy Florida or Florida Healthy Kids
853 premiums:
854 (a) Residents of this state who are eligible for the
855 Florida Kidcare program pursuant to s. 409.814 or the Healthy
856 Florida pursuant to s. 624.917.
857 (b) Notwithstanding s. 409.814, legal aliens who are
858 enrolled in the Florida Healthy Kids program as of January 31,
859 2004, who do not qualify for Title XXI federal funds because
860 they are not qualified aliens as defined in s. 409.811.
861 (4) NONENTITLEMENT.—Nothing in this section shall be
862 construed as providing an individual with an entitlement to
863 health care services. No cause of action shall arise against the
864 state, the Florida Healthy Kids Corporation, or a unit of local
865 government for failure to make health services available under
866 this section.
867 (5) CORPORATION AUTHORIZATION, DUTIES, POWERS.—
868 (a) There is created the Florida Healthy Kids Corporation,
869 a not-for-profit corporation.
870 (b) The Florida Healthy Kids Corporation shall:
871 1. Arrange for the collection of any family, individual, or
872 local contributions, or employer payment or premium, in an
873 amount to be determined by the board of directors, to provide
874 for payment of premiums for comprehensive insurance coverage and
875 for the actual or estimated administrative expenses.
876 2. Arrange for the collection of any voluntary
877 contributions to provide for payment of Florida Kidcare or
878 Healthy Florida program premiums for enrollees children who are
879 not eligible for medical assistance under Title XIX or Title XXI
880 of the Social Security Act.
881 3. Subject to the provisions of s. 409.8134, accept
882 voluntary supplemental local match contributions that comply
883 with the requirements of Title XXI of the Social Security Act
884 for the purpose of providing additional Florida Kidcare coverage
885 in contributing counties under Title XXI.
886 4. Establish the administrative and accounting procedures
887 for the operation of the corporation.
888 5. Establish, with consultation from appropriate
889 professional organizations, standards for preventive health
890 services and providers and comprehensive insurance benefits
891 appropriate to children, provided that such standards for rural
892 areas shall not limit primary care providers to board-certified
893 pediatricians.
894 6. Determine eligibility for children seeking to
895 participate in the Title XXI-funded components of the Florida
896 Kidcare program consistent with the requirements specified in s.
897 409.814, as well as the non-Title-XXI-eligible children as
898 provided in subsection (3).
899 7. Establish procedures under which providers of local
900 match to, applicants to and participants in the program may have
901 grievances reviewed by an impartial body and reported to the
902 board of directors of the corporation.
903 8. Establish participation criteria and, if appropriate,
904 contract with an authorized insurer, health maintenance
905 organization, or third-party administrator to provide
906 administrative services to the corporation.
907 9. Establish enrollment criteria that include penalties or
908 waiting periods of 30 days for reinstatement of coverage upon
909 voluntary cancellation for nonpayment of family and individual
910 premiums under the programs.
911 10.a. Contract with authorized insurers or any provider of
912 health care services, meeting standards established by the
913 corporation, for the provision of comprehensive insurance
914 coverage to participants. Such standards shall include criteria
915 under which the corporation may contract with more than one
916 provider of health care services in program sites.
917 b. Health plans shall be selected through a competitive bid
918 process.
919 c. The Florida Healthy Kids Corporation shall purchase
920 goods and services in the most cost-effective manner consistent
921 with the delivery of quality medical care. The maximum
922 administrative cost for a Florida Healthy Kids Corporation
923 contract shall be 15 percent. For all health care contracts, the
924 minimum medical loss ratio is for a Florida Healthy Kids
925 Corporation contract shall be 85 percent. The calculations must
926 use uniform financial data collected from all plans in a format
927 established by the corporation and shall be computed for each
928 insurer on a statewide basis. Funds shall be classified in a
929 manner consistent with 45 C.F.R. part 158 For dental contracts,
930 the remaining compensation to be paid to the authorized insurer
931 or provider under a Florida Healthy Kids Corporation contract
932 shall be no less than an amount which is 85 percent of premium;
933 to the extent any contract provision does not provide for this
934 minimum compensation, this section shall prevail.
935 d. The health plan selection criteria and scoring system,
936 and the scoring results, shall be available upon request for
937 inspection after the bids have been awarded.
938 11. Establish disenrollment criteria in the event local
939 matching funds are insufficient to cover enrollments.
940 12. Develop and implement a plan to publicize the Florida
941 Kidcare program and Healthy Florida, the eligibility
942 requirements of the programs program, and the procedures for
943 enrollment in the program and to maintain public awareness of
944 the corporation and the programs program.
945 13. Secure staff necessary to properly administer the
946 corporation. Staff costs shall be funded from state and local
947 matching funds and such other private or public funds as become
948 available. The board of directors shall determine the number of
949 staff members necessary to administer the corporation.
950 14. In consultation with the partner agencies, provide a
951 report on the Florida Kidcare program annually to the Governor,
952 the Chief Financial Officer, the Commissioner of Education, the
953 President of the Senate, the Speaker of the House of
954 Representatives, and the Minority Leaders of the Senate and the
955 House of Representatives.
956 15. Provide information on a quarterly basis to the
957 Legislature and the Governor which compares the costs and
958 utilization of the full-pay enrolled population and the Title
959 XXI-subsidized enrolled population in the Florida Kidcare
960 program. The information, at a minimum, must include:
961 a. The monthly enrollment and expenditure for full-pay
962 enrollees in the Medikids and Florida Healthy Kids programs
963 compared to the Title XXI-subsidized enrolled population; and
964 b. The costs and utilization by service of the full-pay
965 enrollees in the Medikids and Florida Healthy Kids programs and
966 the Title XXI-subsidized enrolled population. This subparagraph
967 is repealed effective December 31, 2013.
968
969 By February 1, 2010, the Florida Healthy Kids Corporation shall
970 provide a study to the Legislature and the Governor on premium
971 impacts to the subsidized portion of the program from the
972 inclusion of the full-pay program, which shall include
973 recommendations on how to eliminate or mitigate possible impacts
974 to the subsidized premiums.
975 16. By August 15, 2013, the corporation shall notify all
976 current full-pay enrollees of the availability of the exchange,
977 as defined in the federal Patient Protection and Affordable Care
978 Act, and how to access other insurance affordability options.
979 New applications for full-pay coverage may not be accepted after
980 September 30, 2013.
981 17.16. Establish benefit packages that conform to the
982 provisions of the Florida Kidcare program, as created in ss.
983 409.810-409.821.
984 (c) Coverage under the corporation’s program is secondary
985 to any other available private coverage held by, or applicable
986 to, the participant child or family member. Insurers under
987 contract with the corporation are the payors of last resort and
988 must coordinate benefits with any other third-party payor that
989 may be liable for the participant’s medical care.
990 (d) The Florida Healthy Kids Corporation shall be a private
991 corporation not for profit, registered, incorporated, and
992 organized pursuant to chapter 617, and shall have all powers
993 necessary to carry out the purposes of this act, including, but
994 not limited to, the power to receive and accept grants, loans,
995 or advances of funds from any public or private agency and to
996 receive and accept from any source contributions of money,
997 property, labor, or any other thing of value, to be held, used,
998 and applied for the purposes of this act. The corporation and
999 any committees it forms shall act in compliance with part III of
1000 chapter 112, and chapters 119 and 286.
1001 (6) BOARD OF DIRECTORS AND MANAGEMENT SUPERVISION.—
1002 (a) The Florida Healthy Kids Corporation shall operate
1003 subject to the supervision and approval of a board of directors
1004 chaired by an appointee designated by the Governor Chief
1005 Financial Officer or her or his designee, and composed of 12
1006 other members. The Senate shall confirm the designated chair and
1007 other board appointees selected for 3-year terms of office as
1008 follows:
1009 1. The Secretary of Health Care Administration, or his or
1010 her designee.
1011 2. One member appointed by the Commissioner of Education
1012 from the Office of School Health Programs of the Florida
1013 Department of Education.
1014 3. One member appointed by the Chief Financial Officer from
1015 among three members nominated by the Florida Pediatric Society.
1016 4. One member, appointed by the Governor, who represents
1017 the Children’s Medical Services Program.
1018 5. One member appointed by the Chief Financial Officer from
1019 among three members nominated by the Florida Hospital
1020 Association.
1021 6. One member, appointed by the Governor, who is an expert
1022 on child health policy.
1023 7. One member, appointed by the Chief Financial Officer,
1024 from among three members nominated by the Florida Academy of
1025 Family Physicians.
1026 8. One member, appointed by the Governor, who represents
1027 the state Medicaid program.
1028 9. One member, appointed by the Chief Financial Officer,
1029 from among three members nominated by the Florida Association of
1030 Counties.
1031 10. The State Health Officer or her or his designee.
1032 11. The Secretary of Children and Family Services, or his
1033 or her designee.
1034 12. One member, appointed by the Governor, from among three
1035 members nominated by the Florida Dental Association.
1036 (b) A member of the board of directors serves at the
1037 pleasure of the Governor may be removed by the official who
1038 appointed that member. The board shall appoint an executive
1039 director, who is responsible for other staff authorized by the
1040 board.
1041 (c) Board members are entitled to receive, from funds of
1042 the corporation, reimbursement for per diem and travel expenses
1043 as provided by s. 112.061.
1044 (d) There shall be no liability on the part of, and no
1045 cause of action shall arise against, any member of the board of
1046 directors, or its employees or agents, for any action they take
1047 in the performance of their powers and duties under this act.
1048 (e) Board members who are serving on or before the date of
1049 enactment of this act or similar legislation may remain until
1050 July 1, 2013.
1051 (f) An executive steering committee is created to provide
1052 management direction and support and to make recommendations to
1053 the board on the programs. The steering committee is composed of
1054 the Secretary of Health Care Administration, the Secretary of
1055 Children and Families, and the State Surgeon General. Committee
1056 members may not delegate their membership or attendance.
1057 (7) LICENSING NOT REQUIRED; FISCAL OPERATION.—
1058 (a) The corporation shall not be deemed an insurer. The
1059 officers, directors, and employees of the corporation shall not
1060 be deemed to be agents of an insurer. Neither the corporation
1061 nor any officer, director, or employee of the corporation is
1062 subject to the licensing requirements of the insurance code or
1063 the rules of the Department of Financial Services or Office of
1064 Insurance Regulation. However, any marketing representative
1065 utilized and compensated by the corporation must be appointed as
1066 a representative of the insurers or health services providers
1067 with which the corporation contracts.
1068 (b) The board has complete fiscal control over the
1069 corporation and is responsible for all corporate operations.
1070 (c) The Department of Financial Services shall supervise
1071 any liquidation or dissolution of the corporation and shall
1072 have, with respect to such liquidation or dissolution, all power
1073 granted to it pursuant to the insurance code.
1074 Section 14. Section 624.915, Florida Statutes, is repealed.
1075 Section 15. Section 624.917, Florida Statutes, is created
1076 to read:
1077 624.917 Healthy Florida program.—
1078 (1) PROGRAM CREATION.—There is created Healthy Florida, a
1079 health care program for lower income, uninsured adults who meet
1080 the eligibility guidelines established under s. 624.91. The
1081 Florida Healthy Kids Corporation shall administer the program
1082 under its existing corporate governance and structure.
1083 (2) DEFINITIONS.—As used in this section, the term:
1084 (a) “Actuarially equivalent” means:
1085 1. The aggregate value of the benefits included in health
1086 benefits coverage is equal to the value of the benefits in the
1087 child benchmark benefit plan as defined in s. 409.811; and
1088 2. The benefits included in health benefits coverage are
1089 substantially similar to the benefits included in the child
1090 benchmark benefit plan, except that preventive health services
1091 do not include dental services.
1092 (b) “Agency” means the Agency for Health Care
1093 Administration.
1094 (c) “Applicant” means the individual who applies for
1095 determination of eligibility for health benefits coverage under
1096 s. 624.91(8).
1097 (d) “Child benchmark benefit plan” means the form and level
1098 of health benefits coverage established in s. 409.815.
1099 (e) “Child” means any person under 19 years of age.
1100 (f) “Corporation” means Florida Healthy Kids Corporation.
1101 (g) “Enrollee” means an individual who has been determined
1102 eligible for and is receiving coverage under s. 624.91(8).
1103 (h) “Florida Kidcare program” or “Kidcare program,” means
1104 the health benefits program administered through ss. 409.810
1105 409.821.
1106 (i) “Health benefits coverage” means protection that
1107 provides payment of benefits for covered health care services or
1108 that otherwise provides, either directly or through arrangements
1109 with other persons, covered health care services on a prepaid
1110 per capita basis or on a prepaid aggregate fixed-sum basis.
1111 (j) “Healthy Florida” means the program created by this
1112 section which is administered by the Florida Healthy Kids
1113 Corporation.
1114 (k) “Healthy Kids” means the Florida Kidcare program
1115 component created under s. 624.91 for children ages 5 through
1116 18.
1117 (l) “Household income” means the group or the individual
1118 whose income is considered in determining eligibility for the
1119 Healthy Florida program. The household has the same meaning as
1120 it is defined under section 36B(d)(2) of the Internal Revenue
1121 Code of 1986.
1122 (m) “Medicaid” means the medical assistance program
1123 authorized by Title XIX of the Social Security Act, and
1124 regulations thereunder, and ss. 409.901-409.920, as administered
1125 in this state by the agency.
1126 (n) “Medically necessary” means the use of any medical
1127 treatment, service, equipment, or supply necessary to palliate
1128 the effects of a terminal condition, or to prevent, diagnose,
1129 correct, cure, alleviate, or preclude deterioration of a
1130 condition that threatens life, causes pain or suffering, or
1131 results in illness or infirmity and which is:
1132 1. Consistent with the symptom, diagnosis, and treatment of
1133 the enrollee’s condition;
1134 2. Provided in accordance with generally accepted standards
1135 of medical practice;
1136 3. Not primarily intended for the convenience of the
1137 enrollee, the enrollee’s family, or the health care provider;
1138 4. The most appropriate level of supply or service for the
1139 diagnosis and treatment of the enrollee’s condition; and
1140 5. Approved by the appropriate medical body or health care
1141 specialty involved as effective, appropriate, and essential for
1142 the care and treatment of the enrollee’s condition.
1143 (o) “Modified Adjusted Gross Income (MAGI)” means the
1144 individual or household’s annual adjusted gross income as
1145 defined in 26 U.S.C. s. 36 of the Internal Revenue Code of 1986
1146 which is used to determine eligibility under the Florida Kidcare
1147 program.
1148 (p) “Patient Protection and Affordable Care Act” or “Act”
1149 means the federal law enacted as Pub. L. No. 111-148, as further
1150 amended by the federal Health Care and Education Reconciliation
1151 Act of 2010, Public Law 111-152, and any amendments, regulations
1152 or guidance thereunder, issued under those acts.
1153 (q) “Premium” means the entire cost of a health insurance
1154 plan, including the administration fee or the risk assumption
1155 charge.
1156 (r) “Premium assistance payment” means the monthly
1157 consideration paid by the agency per enrollee in the Florida
1158 Kidcare program towards health insurance premiums.
1159 (s) “Qualified alien” means an alien as defined in 8 U.S.C.
1160 s. 1641(b) and (c).
1161 (t) “Resident” means a United States citizen or qualified
1162 alien who is domiciled in this state.
1163 (3) ELIGIBILITY.—To be eligible and remain eligible for the
1164 Healthy Florida program, an individual must be a resident of
1165 this state and meet the following additional criteria:
1166 (a) Be identified as “newly eligible” as defined in
1167 subclause (VIII) of section 1902(a)(10)(A)(i) of the Social
1168 Security Act (section 2001 of the Patient Protection and
1169 Affordable Care Act) and as may be further defined by federal
1170 regulation.
1171 (b) Maintain eligibility with the corporation and meet all
1172 renewal requirements as established by the corporation.
1173 (c) Renew eligibility on at least an annual basis.
1174 (4) ENROLLMENT.—The corporation may begin the enrollment of
1175 applicants in the Healthy Florida program on October 1, 2013.
1176 Enrollment may occur directly, through the services of a third
1177 party administrator, referrals from the Department of Children
1178 and Families and the exchange as defined by the federal Patient
1179 Protection and Affordable Care Act. As an enrollee disenrolls,
1180 the corporation must also provide the enrollee with information
1181 about other insurance affordability programs and electronically
1182 refer the enrollee to the exchange or other programs, as
1183 appropriate. The earliest coverage effective date under the
1184 program shall be January 1, 2014.
1185 (5) DELIVERY OF SERVICES.—The corporation shall contract
1186 with authorized insurers licensed under chapter 627 and managed
1187 care organizations under chapter 624 which meet standards
1188 established by the corporation to provide comprehensive health
1189 care services to enrollees who qualify for services under this
1190 section. The corporation may contract for such services on a
1191 statewide or regional basis.
1192 (a) The corporation must establish access and network
1193 standards for such contracts and ensure that contracted
1194 providers have sufficient providers to meet enrollee needs.
1195 Quality standards must be developed by the corporation, specific
1196 to the adult population, which take into consideration
1197 recommendations from the National Committee on Quality
1198 Assurance, stakeholders, and other existing performance
1199 indicators from both public and commercial populations.
1200 (b) Enrollees must be provided a choice. The corporation
1201 has the authority to select a plan if no selection has been
1202 received before the coverage start date. Once enrolled,
1203 enrollees have an initial 90-day free look period before a lock
1204 in period of not more than 12 months is applied. Exceptions to
1205 the lock-in period must be offered to enrollees for good cause
1206 reasons and qualifying events.
1207 (c) The corporation may consider contracts that provide
1208 family plans that would allow members from multiple state and
1209 federal funded programs to remain together under the same plan.
1210 (d) All contracts must meet the medical loss ratio
1211 requirements under s. 624.91.
1212 (6) BENEFITS.—The corporation shall establish a benefits
1213 package that is actuarially equivalent to the benchmark benefit
1214 plan offered under s. 409.815(2), excluding dental, and meets
1215 the alternative benefits package requirements under section 1937
1216 of the Social Security Act. Benefits must be offered as an
1217 integrated, single package.
1218 (a) In addition to benchmark benefits, health reimbursement
1219 accounts (HRAs) or a comparable health savings account for each
1220 enrollee must be established through the corporation or the
1221 contracts managed by the corporation. Enrollees must be rewarded
1222 for healthy behaviors, wellness program adherence, and other
1223 activities established by the corporation which demonstrate
1224 compliance with preventive care or disease management
1225 guidelines. Funds deposited into these accounts may be used to
1226 pay cost-sharing obligations or to purchase over the counter
1227 health related items, to the extent allowed under federal law or
1228 regulation.
1229 (b) Enhanced services may be offered if the cost of such
1230 additional services provides savings to the overall plan.
1231 (c) The corporation shall establish a process for the
1232 payment of wrap-around services not covered by the benchmark
1233 plan through a separate subcapitation process to its contracted
1234 providers if it is determined that such services are required by
1235 federal law. Such services would be covered when deemed
1236 medically necessary on an individual basis. The subcapitation
1237 pool is subject to a separate reconciliation process under the
1238 medical loss ratio provisions in s. 624.91.
1239 (d) A prior authorization process and other utilization
1240 controls may be established by the plan for any benefit if
1241 approved by the corporation.
1242 (7) COST SHARING.—The corporation may collect premiums and
1243 copayments from enrollees in accordance with federal law.
1244 Amounts to be collected for the Healthy Florida program must be
1245 established annually in the General Appropriations Act.
1246 (a) Payment of a monthly premium may be required before the
1247 establishment of an enrollee’s coverage start date and to retain
1248 monthly coverage.
1249 (b) Enrollees may be required to make copayments as a
1250 condition of receiving a health care service.
1251 (c) Providers are responsible for the collection of point
1252 of service cost sharing obligations. The enrollee’s cost sharing
1253 contribution will be considered part of the provider’s total
1254 reimbursement. Failure to collect any enrollee cost sharing will
1255 reduce the provider’s share of the reimbursement.
1256 (8) PROGRAM MANAGEMENT.—The corporation is responsible for
1257 the oversight of the Healthy Florida program. The agency shall
1258 seek a state plan amendment or other appropriate federal
1259 approval to implement the Healthy Florida program. The agency
1260 shall consult with the corporation in the amendment’s
1261 development with a submission deadline to the federal Department
1262 of Health and Human Services of June 14, 2013. The Agency will
1263 contract with the corporation for the administration of the
1264 program and for the timely release of federal and state funds.
1265 The Agency retains its authorities as provided under ss. 409.902
1266 and 409.963.
1267 (a) The corporation shall establish a process by which
1268 grievances can be resolved and Healthy Florida recipients can be
1269 informed of their rights under the Medicaid Fair Hearing
1270 Process, as appropriate, or any alternative resolution process
1271 adopted by the corporation.
1272 (b) The corporation shall establish a program integrity
1273 process to ensure compliance with program guidelines. At a
1274 minimum, the corporation shall withhold benefits from an
1275 applicant or enrollee if the corporation obtains evidence that
1276 the applicant or enrollee is no longer eligible, submitted
1277 incorrect or fraudulent information in order to establish
1278 eligibility, or failed to provide verification of eligibility.
1279 The applicant or enrollee shall be notified that because of such
1280 evidence program benefits will be withheld unless the applicant
1281 or enrollee contacts a designated representative of the
1282 corporation by a specified date, which must be within 10 working
1283 days after the date of notice, to discuss and resolve the
1284 matter. The corporation shall make every effort to resolve the
1285 matter within a timeframe that will not cause benefits to be
1286 withheld from an eligible enrollee. The following individuals
1287 may be subject to specific prosecution in accordance with s.
1288 414.39:
1289 1. An applicant obtaining or attempting to obtain benefits
1290 for a potential enrollee under the Healthy Florida program when
1291 the applicant knows or should have known the potential enrollee
1292 does not qualify for the Healthy Florida program.
1293 2. An individual who assists an applicant in obtaining or
1294 attempting to obtain benefits for a potential enrollee under the
1295 Healthy Florida program when the individual knows or should have
1296 known the potential enrollee does not qualify for the Healthy
1297 Florida program.
1298 (9) APPLICABILITY OF LAWS RELATING TO MEDICAID.—The
1299 provisions of ss. 409.902, 409.9128, and 409.920 apply to the
1300 administration of the program.
1301 (10) PROGRAM EVALUATION.—The corporation must collect both
1302 eligibility and enrollment data from program applicants and
1303 enrollees as well as encounter and utilization data from all
1304 contracted entities during the program term. Monthly enrollment
1305 reports must be submitted to the Senate President, the Speaker
1306 of the House of Representative and the Minority Leaders of the
1307 Florida Senate and House of Representatives. An interim
1308 independent evaluation of the program shall be submitted to the
1309 presiding officers no later than July 1, 2015, with annual
1310 evaluations due thereafter every July 1. The evaluations should
1311 address at a minimum application and enrollment trends and
1312 issues, utilization and cost data, and customer satisfaction.
1313 (11) PROGRAM EXPIRATION.—The Healthy Florida program shall
1314 expire at the end of the state fiscal year in which any of these
1315 conditions occur, whichever occurs first:
1316 (a) The federal match contribution falls below 90 percent.
1317 (b) The federal match contribution falls below the
1318 “Increased FMAP for Medical Assistance for Newly Eligible
1319 Mandatory Individuals” as specified in the federal Patient
1320 Protection and Affordable Care Act (Public Law 111-148), as
1321 amended by the federal Health Care and Education Reconciliation
1322 Act of 2010 (Public Law 111-152).
1323 (c) The federal match for the Healthy Florida program and
1324 the Medicaid program are blended under federal law or regulation
1325 in such a way that causes the overall federal contribution to
1326 diminish when compared to separate, non-blended federal
1327 contributions.
1328 Section 16. The corporation may make changes to comply with
1329 the objections of the federal Department of Health and Human
1330 Services to gain approval of the Healthy Florida program in
1331 compliance with the federal Patient Protection and Affordable
1332 Care Act upon giving notice to the Senate and the House of
1333 Representatives of the proposed changes. If there is a conflict
1334 between a provision in this section and the federal Patient
1335 Protection and Affordable Care Act (Public Law 111-148), as
1336 amended by the federal Health Care and Education Reconciliation
1337 Act of 2010 (Public Law 111-152), the provision must be
1338 interpreted and applied so as to comply with the requirement of
1339 the federal law.
1340 Section 17. This act shall take effect upon becoming a law.