Florida Senate - 2013 SB 1816
By the Committee on Appropriations
576-02875-13 20131816__
1 A bill to be entitled
2 An act relating to health care; amending s. 409.811,
3 F.S.; revising and providing definitions; amending s.
4 409.813, F.S.; revising the components of the Florida
5 Kidcare program; prohibiting a cause of action from
6 arising against the Florida Healthy Kids Corporation
7 for failure to make health services available;
8 amending s. 409.8132, F.S.; revising the eligibility
9 of the Medikids program component; revising the
10 enrollment requirements of the Medikids program
11 component; amending s. 409.8134, F.S.; conforming
12 provisions to changes made by the act; amending s.
13 409.814, F.S.; revising eligibility requirements for
14 the Florida Kidcare program; amending s. 409.815,
15 F.S.; revising the minimum health benefits coverage
16 under the Florida Kidcare Act; deleting obsolete
17 provisions; amending ss. 409.816 and 409.8177, F.S.;
18 conforming provisions to changes made by the act;
19 repealing s. 409.817, F.S., relating to the approval
20 of health benefits coverage and financial assistance;
21 repealing s. 409.8175, F.S., relating to delivery of
22 services in rural counties; amending s. 409.818, F.S.;
23 revising the duties of the Department of Children and
24 Families and the Agency for Health Care Administration
25 with regard to the Florida Kidcare Act; deleting the
26 duties of the Department of Health and the Office of
27 Insurance Regulation with regard to the Florida
28 Kidcare Act; amending s. 409.820, F.S.; requiring the
29 Department of Health, in consultation with the agency
30 and the Florida Healthy Kids Corporation, to develop a
31 minimum set of pediatric and adolescent quality
32 assurance and access standards for all program
33 components; amending s. 624.91, F.S.; revising the
34 legislative intent of the Florida Healthy Kids
35 Corporation Act to include the Healthy Florida
36 program; revising participation guidelines for
37 nonsubsidized enrollees in the Healthy Kids program;
38 revising the medical loss ratio requirements for the
39 contracts for the Florida Healthy Kids Corporation;
40 modifying the membership of the Florida Healthy Kids
41 Corporation’s board of directors; creating an
42 executive steering committee; requiring additional
43 corporate compliance requirements for the Florida
44 Healthy Kids Corporation; repealing s. 624.915, F.S.,
45 relating to the operating fund of the Florida Healthy
46 Kids Corporation; creating s. 624.917, F.S.; creating
47 the Healthy Florida program; providing definitions;
48 providing eligibility and enrollment requirements;
49 authorizing the Florida Healthy Kids Corporation to
50 contract with certain insurers; requiring the
51 corporation to establish a benefits package and a
52 process for payment of services; authorizing the
53 corporation to collect premiums and copayments;
54 requiring the corporation to oversee the Healthy
55 Florida program and to establish a grievance process
56 and integrity process; providing applicability of
57 certain state laws for administration of the Healthy
58 Florida program; requiring the corporation to collect
59 certain data and to submit enrollment reports and
60 interim independent evaluations to the Legislature;
61 providing for expiration of the program; providing an
62 implementation and interpretation clause; providing an
63 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 younger than under 19 years of
88 age.
89 (6) “Child with special health care needs” means a child
90 whose serious or chronic physical or developmental condition
91 requires extensive preventive and maintenance care beyond that
92 required by typically healthy children. Health care utilization
93 by such a child exceeds the statistically expected usage of the
94 normal child adjusted for chronological age, and such a child
95 often needs complex care requiring multiple providers,
96 rehabilitation services, and specialized equipment in a number
97 of different settings.
98 (7) “Children’s Medical Services Network” or “network”
99 means a statewide managed care service system as defined in s.
100 391.021(1).
101 (8) “CHIP” means the Children’s Health Insurance Program as
102 authorized under Title XXI of the Social Security Act, and its
103 regulations, ss. 409.810-409.820, and as administered in this
104 state by the agency, the department, and the Florida Healthy
105 Kids Corporation, as appropriate to their respective
106 responsibilities.
107 (9) “Combined eligibility notice” means an eligibility
108 notice that informs an applicant, an enrollee, or multiple
109 family members of a household, when feasible, of eligibility for
110 each of the insurance affordability programs and enrollment into
111 a program or exchange plan. A combined eligibility form must be
112 issued by the last agency or department to make an eligibility,
113 renewal or denial determination. The form must meet all of the
114 federal and state law and regulatory requirements no later than
115 January 1, 2014.
116 (8) “Community rate” means a method used to develop
117 premiums for a health insurance plan that spreads financial risk
118 across a large population and allows adjustments only for age,
119 gender, family composition, and geographic area.
120 (10)(9) “Department” means the Department of Health.
121 (11)(10) “Enrollee” means a child who has been determined
122 eligible for and is receiving coverage under ss. 409.810
123 409.821.
124 (11) “Family” means the group or the individuals whose
125 income is considered in determining eligibility for the Florida
126 Kidcare program. The family includes a child with a parent or
127 caretaker relative who resides in the same house or living unit
128 or, in the case of a child whose disability of nonage has been
129 removed under chapter 743, the child. The family may also
130 include other individuals whose income and resources are
131 considered in whole or in part in determining eligibility of the
132 child.
133 (12) “Family income” means cash received at periodic
134 intervals from any source, such as wages, benefits,
135 contributions, or rental property. Income also may include any
136 money that would have been counted as income under the Aid to
137 Families with Dependent Children (AFDC) state plan in effect
138 prior to August 22, 1996.
139 (12)(13) “Florida Kidcare program,” “Kidcare program,” or
140 “program” means the health benefits program administered through
141 ss. 409.810-409.821.
142 (13)(14) “Guarantee issue” means that health benefits
143 coverage must be offered to an individual regardless of the
144 individual’s health status, preexisting condition, or claims
145 history.
146 (14)(15) “Health benefits coverage” means protection that
147 provides payment of benefits for covered health care services or
148 that otherwise provides, either directly or through arrangements
149 with other persons, covered health care services on a prepaid
150 per capita basis or on a prepaid aggregate fixed-sum basis.
151 (15)(16) “Health insurance plan” means health benefits
152 coverage under the following:
153 (a) A health plan offered by any certified health
154 maintenance organization or authorized health insurer, except a
155 plan that is limited to the following: a limited benefit,
156 specified disease, or specified accident; hospital indemnity;
157 accident only; limited benefit convalescent care; Medicare
158 supplement; credit disability; dental; vision; long-term care;
159 disability income; coverage issued as a supplement to another
160 health plan; workers’ compensation liability or other insurance;
161 or motor vehicle medical payment only; or
162 (b) An employee welfare benefit plan that includes health
163 benefits established under the Employee Retirement Income
164 Security Act of 1974, as amended.
165 (16) “Household income” means the group or the individual
166 whose income is considered in determining eligibility for the
167 Florida Kidcare program. The term “household” has the same
168 meaning as provided in s. 36B(d)(2) of the Internal Revenue Code
169 of 1986.
170 (17) “Medicaid” means the medical assistance program
171 authorized by Title XIX of the Social Security Act, and
172 regulations thereunder, and ss. 409.901-409.920, as administered
173 in this state by the agency.
174 (18) “Medically necessary” means the use of any medical
175 treatment, service, equipment, or supply necessary to palliate
176 the effects of a terminal condition, or to prevent, diagnose,
177 correct, cure, alleviate, or preclude deterioration of a
178 condition that threatens life, causes pain or suffering, or
179 results in illness or infirmity and which is:
180 (a) Consistent with the symptom, diagnosis, and treatment
181 of the enrollee’s condition;
182 (b) Provided in accordance with generally accepted
183 standards of medical practice;
184 (c) Not primarily intended for the convenience of the
185 enrollee, the enrollee’s family, or the health care provider;
186 (d) The most appropriate level of supply or service for the
187 diagnosis and treatment of the enrollee’s condition; and
188 (e) Approved by the appropriate medical body or health care
189 specialty involved as effective, appropriate, and essential for
190 the care and treatment of the enrollee’s condition.
191 (19) “Medikids” means a component of the Florida Kidcare
192 program of medical assistance authorized by Title XXI of the
193 Social Security Act, and regulations thereunder, and s.
194 409.8132, as administered in the state by the agency.
195 (20) “Modified adjusted gross income” means the
196 individual’s or household’s annual adjusted gross income as
197 defined in s. 36B(d)(2) of the Internal Revenue Code of 1986
198 which is used to determine eligibility under the Florida Kidcare
199 program.
200 (21) “Patient Protection and Affordable Care Act” or “Act”
201 means the federal law enacted as Pub. L. No. 111-148, as further
202 amended by the federal Health Care and Education Reconciliation
203 Act of 2010, Pub. L. No. 111-152, and any amendments,
204 regulations, or guidance issued under those acts.
205 (22)(20) “Preexisting condition exclusion” means, with
206 respect to coverage, a limitation or exclusion of benefits
207 relating to a condition based on the fact that the condition was
208 present before the date of enrollment for such coverage, whether
209 or not any medical advice, diagnosis, care, or treatment was
210 recommended or received before such date.
211 (23)(21) “Premium” means the entire cost of a health
212 insurance plan, including the administration fee or the risk
213 assumption charge.
214 (24)(22) “Premium assistance payment” means the monthly
215 consideration paid by the agency per enrollee in the Florida
216 Kidcare program towards health insurance premiums.
217 (25)(23) “Qualified alien” means an alien as defined in 8
218 U.S.C. s. 1641 (b) and (c) s. 431 of the Personal Responsibility
219 and Work Opportunity Reconciliation Act of 1996, as amended,
220 Pub. L. No. 104-193.
221 (26)(24) “Resident” means a United States citizen, or
222 qualified alien, who is domiciled in this state.
223 (27)(25) “Rural county” means a county having a population
224 density of less than 100 persons per square mile, or a county
225 defined by the most recent United States Census as rural, in
226 which there is no prepaid health plan participating in the
227 Medicaid program as of July 1, 1998.
228 (26) “Substantially similar” means that, with respect to
229 additional services as defined in s. 2103(c)(2) of Title XXI of
230 the Social Security Act, these services must have an actuarial
231 value equal to at least 75 percent of the actuarial value of the
232 coverage for that service in the benchmark benefit plan and,
233 with respect to the basic services as defined in s. 2103(c)(1)
234 of Title XXI of the Social Security Act, these services must be
235 the same as the services in the benchmark benefit plan.
236 Section 2. Section 409.813, Florida Statutes, is amended to
237 read:
238 409.813 Health benefits coverage; program components;
239 entitlement and nonentitlement.—
240 (1) The Florida Kidcare program includes health benefits
241 coverage provided to children through the following program
242 components, which shall be marketed as the Florida Kidcare
243 program:
244 (a) Medicaid;
245 (b) Medikids as created in s. 409.8132;
246 (c) The Florida Healthy Kids Corporation as created in s.
247 624.91; and
248 (d) Employer-sponsored group health insurance plans
249 approved under ss. 409.810-409.821; and
250 (d)(e) The Children’s Medical Services network established
251 in chapter 391.
252 (2) Except for Title XIX-funded Florida Kidcare program
253 coverage under the Medicaid program, coverage under the Florida
254 Kidcare program is not an entitlement. No cause of action shall
255 arise against the state, the department, the Department of
256 Children and Families Family Services, or the agency, or the
257 Florida Healthy Kids Corporation for failure to make health
258 services available to any person under ss. 409.810-409.821.
259 Section 3. Subsections (6) and (7) of section 409.8132,
260 Florida Statutes, are amended to read:
261 409.8132 Medikids program component.—
262 (6) ELIGIBILITY.—
263 (a) A child who has attained the age of 1 year but who is
264 under the age of 5 years is eligible to enroll in the Medikids
265 program component of the Florida Kidcare program, if the child
266 is a member of a family that has a family income which exceeds
267 the Medicaid applicable income level as specified in s. 409.903,
268 but which is equal to or below 200 percent of the current
269 federal poverty level. In determining the eligibility of such a
270 child, an assets test is not required. A child who is eligible
271 for Medikids may elect to enroll in Florida Healthy Kids
272 coverage or employer-sponsored group coverage. However, a child
273 who is eligible for Medikids may participate in the Florida
274 Healthy Kids program only if the child has a sibling
275 participating in the Florida Healthy Kids program and the
276 child’s county of residence permits such enrollment.
277 (b) The provisions of s. 409.814 apply to the Medikids
278 program.
279 (7) ENROLLMENT.—Enrollment in the Medikids program
280 component may occur at any time throughout the year. A child may
281 not receive services under the Medikids program until the child
282 is enrolled in a managed care plan or MediPass. Once determined
283 eligible, an applicant may receive choice counseling and select
284 a managed care plan or MediPass. The agency may initiate
285 mandatory assignment for a Medikids applicant who has not chosen
286 a managed care plan or MediPass provider after the applicant’s
287 voluntary choice period ends. An applicant may select MediPass
288 under the Medikids program component only in counties that have
289 fewer than two managed care plans available to serve Medicaid
290 recipients and only if the federal Health Care Financing
291 Administration determines that MediPass constitutes “health
292 insurance coverage” as defined in Title XXI of the Social
293 Security Act.
294 Section 4. Subsection (2) of section 409.8134, Florida
295 Statutes, is amended to read:
296 409.8134 Program expenditure ceiling; enrollment.—
297 (2) The Florida Kidcare program may conduct enrollment
298 continuously throughout the year.
299 (a) Children eligible for coverage under the Title XXI
300 funded Florida Kidcare program shall be enrolled on a first
301 come, first-served basis using the date the enrollment
302 application is received. Enrollment shall immediately cease when
303 the expenditure ceiling is reached. Year-round enrollment shall
304 only be held if the Social Services Estimating Conference
305 determines that sufficient federal and state funds will be
306 available to finance the increased enrollment.
307 (b) The application for the Florida Kidcare program is
308 valid for a period of 120 days after the date it was received.
309 At the end of the 120-day period, if the applicant has not been
310 enrolled in the program, the application is invalid and the
311 applicant shall be notified of the action. The applicant may
312 reactivate the application after notification of the action
313 taken by the program.
314 (c) Except for the Medicaid program, whenever the Social
315 Services Estimating Conference determines that there are
316 presently, or will be by the end of the current fiscal year,
317 insufficient funds to finance the current or projected
318 enrollment in the Florida Kidcare program, all additional
319 enrollment must cease and additional enrollment may not resume
320 until sufficient funds are available to finance such enrollment.
321 Section 5. Section 409.814, Florida Statutes, is amended to
322 read:
323 409.814 Eligibility.—A child who has not reached 19 years
324 of age whose household family income is equal to or below 200
325 percent of the federal poverty level is eligible for the Florida
326 Kidcare program as provided in this section. If an enrolled
327 individual is determined to be ineligible for coverage, he or
328 she must be immediately disenrolled from the respective Florida
329 Kidcare program component and referred to another insurance
330 affordability program, if appropriate, through a combined
331 eligibility notice.
332 (1) A child who is eligible for Medicaid coverage under s.
333 409.903 or s. 409.904 must be offered the opportunity to enroll
334 enrolled in Medicaid and is not eligible to receive health
335 benefits under any other health benefits coverage authorized
336 under the Florida Kidcare program. A child who is eligible for
337 Medicaid and opts to enroll in CHIP may disenroll from CHIP at
338 any time and transition to Medicaid. This transition must occur
339 without any break in coverage.
340 (2) A child who is not eligible for Medicaid, but who is
341 eligible for the Florida Kidcare program, may obtain health
342 benefits coverage under any of the other components listed in s.
343 409.813 if such coverage is approved and available in the county
344 in which the child resides.
345 (3) A Title XXI-funded child who is eligible for the
346 Florida Kidcare program who is a child with special health care
347 needs, as determined through a medical or behavioral screening
348 instrument, is eligible for health benefits coverage from and
349 shall be assigned to and may opt out of the Children’s Medical
350 Services Network.
351 (4) The following children are not eligible to receive
352 Title XXI-funded premium assistance for health benefits coverage
353 under the Florida Kidcare program, except under Medicaid if the
354 child would have been eligible for Medicaid under s. 409.903 or
355 s. 409.904 as of June 1, 1997:
356 (a) A child who is covered under a family member’s group
357 health benefit plan or under other private or employer health
358 insurance coverage, if the cost of the child’s participation is
359 not greater than 5 percent of the household’s family’s income.
360 If a child is otherwise eligible for a subsidy under the Florida
361 Kidcare program and the cost of the child’s participation in the
362 family member’s health insurance benefit plan is greater than 5
363 percent of the household’s family’s income, the child may enroll
364 in the appropriate subsidized Kidcare program.
365 (b) A child who is seeking premium assistance for the
366 Florida Kidcare program through employer-sponsored group
367 coverage, if the child has been covered by the same employer’s
368 group coverage during the 60 days before the family submitted an
369 application for determination of eligibility under the program.
370 (b)(c) A child who is an alien, but who does not meet the
371 definition of qualified alien, in the United States.
372 (c)(d) A child who is an inmate of a public institution or
373 a patient in an institution for mental diseases.
374 (d)(e) A child who is otherwise eligible for premium
375 assistance for the Florida Kidcare program and has had his or
376 her coverage in an employer-sponsored or private health benefit
377 plan voluntarily canceled in the last 60 days, except those
378 children whose coverage was voluntarily canceled for good cause,
379 including, but not limited to, the following circumstances:
380 1. The cost of participation in an employer-sponsored
381 health benefit plan is greater than 5 percent of the household’s
382 modified adjusted gross family’s income;
383 2. The parent lost a job that provided an employer
384 sponsored health benefit plan for children;
385 3. The parent who had health benefits coverage for the
386 child is deceased;
387 4. The child has a medical condition that, without medical
388 care, would cause serious disability, loss of function, or
389 death;
390 5. The employer of the parent canceled health benefits
391 coverage for children;
392 6. The child’s health benefits coverage ended because the
393 child reached the maximum lifetime coverage amount;
394 7. The child has exhausted coverage under a COBRA
395 continuation provision;
396 8. The health benefits coverage does not cover the child’s
397 health care needs; or
398 9. Domestic violence led to loss of coverage.
399 (5) A child who is otherwise eligible for the Florida
400 Kidcare program and who has a preexisting condition that
401 prevents coverage under another insurance plan as described in
402 paragraph (4)(a) which would have disqualified the child for the
403 Florida Kidcare program if the child were able to enroll in the
404 plan is eligible for Florida Kidcare coverage when enrollment is
405 possible.
406 (5)(6) A child whose household’s modified adjusted gross
407 family income is above 200 percent of the federal poverty level
408 or a child who is excluded under the provisions of subsection
409 (4) may participate in the Florida Kidcare program as provided
410 in s. 409.8132 or, if the child is ineligible for Medikids by
411 reason of age, in the Florida Healthy Kids program, subject to
412 the following:
413 (a) The family is not eligible for premium assistance
414 payments and must pay the full cost of the premium, including
415 any administrative costs.
416 (b) The board of directors of the Florida Healthy Kids
417 Corporation may offer a reduced benefit package to these
418 children in order to limit program costs for such families.
419 (c) By August 15, 2013, the Florida Healthy Kids
420 Corporation shall notify all current full-pay enrollees of the
421 availability of the exchange and how to access other insurance
422 affordability options. New applications for full-pay coverage
423 may not be accepted after September 30, 2013.
424 (6)(7) Once a child is enrolled in the Florida Kidcare
425 program, the child is eligible for coverage for 12 months
426 without a redetermination or reverification of eligibility, if
427 the family continues to pay the applicable premium. Eligibility
428 for program components funded through Title XXI of the Social
429 Security Act terminates when a child attains the age of 19. A
430 child who has not attained the age of 5 and who has been
431 determined eligible for the Medicaid program is eligible for
432 coverage for 12 months without a redetermination or
433 reverification of eligibility.
434 (7)(8) When determining or reviewing a child’s eligibility
435 under the Florida Kidcare program, the applicant shall be
436 provided with reasonable notice of changes in eligibility which
437 may affect enrollment in one or more of the program components.
438 If a transition from one program component to another is
439 authorized, there shall be cooperation between the program
440 components and the affected family which promotes continuity of
441 health care coverage. Any authorized transfers must be managed
442 within the program’s overall appropriated or authorized levels
443 of funding. Each component of the program shall establish a
444 reserve to ensure that transfers between components will be
445 accomplished within current year appropriations. These reserves
446 shall be reviewed by each convening of the Social Services
447 Estimating Conference to determine the adequacy of such reserves
448 to meet actual experience.
449 (8)(9) In determining the eligibility of a child, an assets
450 test is not required. Each applicant shall provide documentation
451 during the application process and the redetermination process,
452 including, but not limited to, the following:
453 (a) Proof of household family income, which must be
454 verified electronically to determine financial eligibility for
455 the Florida Kidcare program. Written documentation, which may
456 include wages and earnings statements or pay stubs, W-2 forms,
457 or a copy of the applicant’s most recent federal income tax
458 return, is required only if the electronic verification is not
459 available or does not substantiate the applicant’s income. This
460 paragraph expires December 31, 2013.
461 (b) A statement from all applicable, employed household
462 family members that:
463 1. Their employers do not sponsor health benefit plans for
464 employees;
465 2. The potential enrollee is not covered by an employer
466 sponsored health benefit plan; or
467 3. The potential enrollee is covered by an employer
468 sponsored health benefit plan and the cost of the employer
469 sponsored health benefit plan is more than 5 percent of the
470 household’s modified adjusted gross family’s income.
471 (c) To enroll in the Children’s Medical Services Network, a
472 completed application, including a clinical screening.
473 (d) Effective January 1, 2014, eligibility shall be
474 determined through electronic matching using the federally
475 managed data services hub and other resources. Written
476 documentation from the applicant may be accepted if the
477 electronic verification does not substantiate the applicant’s
478 income or if there has been a change in circumstances.
479 (9)(10) Subject to paragraph (4)(a), the Florida Kidcare
480 program shall withhold benefits from an enrollee if the program
481 obtains evidence that the enrollee is no longer eligible,
482 submitted incorrect or fraudulent information in order to
483 establish eligibility, or failed to provide verification of
484 eligibility. The applicant or enrollee shall be notified that
485 because of such evidence program benefits will be withheld
486 unless the applicant or enrollee contacts a designated
487 representative of the program by a specified date, which must be
488 within 10 working days after the date of notice, to discuss and
489 resolve the matter. The program shall make every effort to
490 resolve the matter within a timeframe that will not cause
491 benefits to be withheld from an eligible enrollee.
492 (10)(11) The following individuals may be subject to
493 prosecution in accordance with s. 414.39:
494 (a) An applicant obtaining or attempting to obtain benefits
495 for a potential enrollee under the Florida Kidcare program when
496 the applicant knows or should have known the potential enrollee
497 does not qualify for the Florida Kidcare program.
498 (b) An individual who assists an applicant in obtaining or
499 attempting to obtain benefits for a potential enrollee under the
500 Florida Kidcare program when the individual knows or should have
501 known the potential enrollee does not qualify for the Florida
502 Kidcare program.
503 Section 6. Paragraphs (g), (k), (q), and (w) of subsection
504 (2) of section 409.815, Florida Statutes, are amended to read:
505 409.815 Health benefits coverage; limitations.—
506 (2) BENCHMARK BENEFITS.—In order for health benefits
507 coverage to qualify for premium assistance payments for an
508 eligible child under ss. 409.810-409.821, the health benefits
509 coverage, except for coverage under Medicaid and Medikids, must
510 include the following minimum benefits, as medically necessary.
511 (g) Behavioral health services.—
512 1. Mental health benefits include:
513 a. Inpatient services, limited to 30 inpatient days per
514 contract year for psychiatric admissions, or residential
515 services in facilities licensed under s. 394.875(6) or s.
516 395.003 in lieu of inpatient psychiatric admissions; however, a
517 minimum of 10 of the 30 days shall be available only for
518 inpatient psychiatric services if authorized by a physician; and
519 b. Outpatient services, including outpatient visits for
520 psychological or psychiatric evaluation, diagnosis, and
521 treatment by a licensed mental health professional, limited to
522 40 outpatient visits each contract year.
523 2. Substance abuse services include:
524 a. Inpatient services, limited to 7 inpatient days per
525 contract year for medical detoxification only and 30 days of
526 residential services; and
527 b. Outpatient services, including evaluation, diagnosis,
528 and treatment by a licensed practitioner, limited to 40
529 outpatient visits per contract year.
530
531 Effective October 1, 2009, Covered services include inpatient
532 and outpatient services for mental and nervous disorders as
533 defined in the most recent edition of the Diagnostic and
534 Statistical Manual of Mental Disorders published by the American
535 Psychiatric Association. Such benefits include psychological or
536 psychiatric evaluation, diagnosis, and treatment by a licensed
537 mental health professional and inpatient, outpatient, and
538 residential treatment of substance abuse disorders. Any benefit
539 limitations, including duration of services, number of visits,
540 or number of days for hospitalization or residential services,
541 shall not be any less favorable than those for physical
542 illnesses generally. The program may also implement appropriate
543 financial incentives, peer review, utilization requirements, and
544 other methods used for the management of benefits provided for
545 other medical conditions in order to reduce service costs and
546 utilization without compromising quality of care.
547 (k) Hospice services.—Covered services include reasonable
548 and necessary services for palliation or management of an
549 enrollee’s terminal illness, with the following exceptions:
550 1. Once a family elects to receive hospice care for an
551 enrollee, other services that treat the terminal condition will
552 not be covered; and
553 2. Services required for conditions totally unrelated to
554 the terminal condition are covered to the extent that the
555 services are included in this section.
556 (q) Dental services.—Effective October 1, 2009, Dental
557 services shall be covered as required under federal law and may
558 also include those dental benefits provided to children by the
559 Florida Medicaid program under s. 409.906(6).
560 (w) Reimbursement of federally qualified health centers and
561 rural health clinics.—Effective October 1, 2009, Payments for
562 services provided to enrollees by federally qualified health
563 centers and rural health clinics under this section shall be
564 reimbursed using the Medicaid Prospective Payment System as
565 provided for under s. 2107(e)(1)(D) of the Social Security Act.
566 If such services are paid for by health insurers or health care
567 providers under contract with the Florida Healthy Kids
568 Corporation, such entities are responsible for this payment. The
569 agency may seek any available federal grants to assist with this
570 transition.
571 Section 7. Section 409.816, Florida Statutes, is amended to
572 read:
573 409.816 Limitations on premiums and cost-sharing.—The
574 following limitations on premiums and cost-sharing are
575 established for the program.
576 (1) Enrollees who receive coverage under the Medicaid
577 program may not be required to pay:
578 (a) Enrollment fees, premiums, or similar charges; or
579 (b) Copayments, deductibles, coinsurance, or similar
580 charges.
581 (2) Enrollees in households that have families with a
582 modified adjusted gross family income equal to or below 150
583 percent of the federal poverty level, who are not receiving
584 coverage under the Medicaid program, may not be required to pay:
585 (a) Enrollment fees, premiums, or similar charges that
586 exceed the maximum monthly charge permitted under s. 1916(b)(1)
587 of the Social Security Act; or
588 (b) Copayments, deductibles, coinsurance, or similar
589 charges that exceed a nominal amount, as determined consistent
590 with regulations referred to in s. 1916(a)(3) of the Social
591 Security Act. However, such charges may not be imposed for
592 preventive services, including well-baby and well-child care,
593 age-appropriate immunizations, and routine hearing and vision
594 screenings.
595 (3) Enrollees in households that have families with a
596 modified adjusted gross family income above 150 percent of the
597 federal poverty level who are not receiving coverage under the
598 Medicaid program or who are not eligible under s. 409.814(5) s.
599 409.814(6) may be required to pay enrollment fees, premiums,
600 copayments, deductibles, coinsurance, or similar charges on a
601 sliding scale related to income, except that the total annual
602 aggregate cost-sharing with respect to all children in a
603 household family may not exceed 5 percent of the household’s
604 modified adjusted family’s income. However, copayments,
605 deductibles, coinsurance, or similar charges may not be imposed
606 for preventive services, including well-baby and well-child
607 care, age-appropriate immunizations, and routine hearing and
608 vision screenings.
609 Section 8. Section 409.817, Florida Statutes, is repealed.
610 Section 9. Section 409.8175, Florida Statutes, is repealed.
611 Section 10. Paragraph (c) of subsection (1) of section
612 409.8177, Florida Statutes, is amended to read:
613 409.8177 Program evaluation.—
614 (1) The agency, in consultation with the Department of
615 Health, the Department of Children and Families Family Services,
616 and the Florida Healthy Kids Corporation, shall contract for an
617 evaluation of the Florida Kidcare program and shall by January 1
618 of each year submit to the Governor, the President of the
619 Senate, and the Speaker of the House of Representatives a report
620 of the program. In addition to the items specified under s. 2108
621 of Title XXI of the Social Security Act, the report shall
622 include an assessment of crowd-out and access to health care, as
623 well as the following:
624 (c) The characteristics of the children and families
625 assisted under the program, including ages of the children,
626 household family income, and access to or coverage by other
627 health insurance prior to the program and after disenrollment
628 from the program.
629 Section 11. Section 409.818, Florida Statutes, is amended
630 to read:
631 409.818 Administration.—In order to implement ss. 409.810
632 409.821, the following agencies shall have the following duties:
633 (1) The Department of Children and Families Family Services
634 shall:
635 (a) Maintain Develop a simplified eligibility determination
636 and renewal process application mail-in form to be used for
637 determining the eligibility of children for coverage under the
638 Florida Kidcare program, in consultation with the agency, the
639 Department of Health, and the Florida Healthy Kids Corporation.
640 The simplified eligibility process application form must include
641 an item that provides an opportunity for the applicant to
642 indicate whether coverage is being sought for a child with
643 special health care needs. Families applying for children’s
644 Medicaid coverage must also be able to use the simplified
645 application process form without having to pay a premium.
646 (b) Establish and maintain the eligibility determination
647 process under the program except as specified in subsection (3),
648 which includes the following: (5).
649 1. The department shall directly, or through the services
650 of a contracted third-party administrator, establish and
651 maintain a process for determining eligibility of children for
652 coverage under the program. The eligibility determination
653 process must be used solely for determining eligibility of
654 applicants for health benefits coverage under the program. The
655 eligibility determination process must include an initial
656 determination of eligibility for any coverage offered under the
657 program, as well as a redetermination or reverification of
658 eligibility each subsequent 6 months. Effective January 1, 1999,
659 A child who has not attained the age of 5 and who has been
660 determined eligible for the Medicaid program is eligible for
661 coverage for 12 months without a redetermination or
662 reverification of eligibility. In conducting an eligibility
663 determination, the department shall determine if the child has
664 special health care needs.
665 2. The department, in consultation with the Agency for
666 Health Care Administration and the Florida Healthy Kids
667 Corporation, shall develop procedures for redetermining
668 eligibility which enable applicants and enrollees a family to
669 easily update any change in circumstances which could affect
670 eligibility.
671 3. The department may accept changes in a family’s status
672 as reported to the department by the Florida Healthy Kids
673 Corporation or the exchange without requiring a new application
674 from the family. Redetermination of a child’s eligibility for
675 Medicaid may not be linked to a child’s eligibility
676 determination for other programs.
677 4. The department, in consultation with the agency and the
678 Florida Healthy Kids Corporation, shall develop a combined
679 eligibility notice to inform applicants and enrollees of their
680 application or renewal status, as appropriate. The content must
681 be coordinated to meet all federal and state requirements under
682 the federal Patient Protection and Affordable Care Act.
683 (c) Inform program applicants about eligibility
684 determinations and provide information about eligibility of
685 applicants to the Florida Kidcare program and to insurers and
686 their agents, through a centralized coordinating office.
687 (d) Adopt rules necessary for conducting program
688 eligibility functions.
689 (2) The Department of Health shall:
690 (a) Design an eligibility intake process for the program,
691 in coordination with the Department of Children and Family
692 Services, the agency, and the Florida Healthy Kids Corporation.
693 The eligibility intake process may include local intake points
694 that are determined by the Department of Health in coordination
695 with the Department of Children and Family Services.
696 (b) Chair a state-level Florida Kidcare coordinating
697 council to review and make recommendations concerning the
698 implementation and operation of the program. The coordinating
699 council shall include representatives from the department, the
700 Department of Children and Family Services, the agency, the
701 Florida Healthy Kids Corporation, the Office of Insurance
702 Regulation of the Financial Services Commission, local
703 government, health insurers, health maintenance organizations,
704 health care providers, families participating in the program,
705 and organizations representing low-income families.
706 (c) In consultation with the Florida Healthy Kids
707 Corporation and the Department of Children and Family Services,
708 establish a toll-free telephone line to assist families with
709 questions about the program.
710 (d) Adopt rules necessary to implement outreach activities.
711 (2)(3) The Agency for Health Care Administration, under the
712 authority granted in s. 409.914(1), shall:
713 (a) Calculate the premium assistance payment necessary to
714 comply with the premium and cost-sharing limitations specified
715 in s. 409.816 and the federal Patient Protection and Affordable
716 Care Act. The premium assistance payment for each enrollee in a
717 health insurance plan participating in the Florida Healthy Kids
718 Corporation shall equal the premium approved by the Florida
719 Healthy Kids Corporation and the Office of Insurance Regulation
720 of the Financial Services Commission pursuant to ss. 627.410 and
721 641.31, less any enrollee’s share of the premium established
722 within the limitations specified in s. 409.816. The premium
723 assistance payment for each enrollee in an employer-sponsored
724 health insurance plan approved under ss. 409.810-409.821 shall
725 equal the premium for the plan adjusted for any benchmark
726 benefit plan actuarial equivalent benefit rider approved by the
727 Office of Insurance Regulation pursuant to ss. 627.410 and
728 641.31, less any enrollee’s share of the premium established
729 within the limitations specified in s. 409.816. In calculating
730 the premium assistance payment levels for children with family
731 coverage, the agency shall set the premium assistance payment
732 levels for each child proportionately to the total cost of
733 family coverage.
734 (b) Make premium assistance payments to health insurance
735 plans on a periodic basis. The agency may use its Medicaid
736 fiscal agent or a contracted third-party administrator in making
737 these payments. The agency may require health insurance plans
738 that participate in the Medikids program or employer-sponsored
739 group health insurance to collect premium payments from an
740 enrollee’s family. Participating health insurance plans shall
741 report premium payments collected on behalf of enrollees in the
742 program to the agency in accordance with a schedule established
743 by the agency.
744 (c) Monitor compliance with quality assurance and access
745 standards developed under s. 409.820 and in accordance with s.
746 2103(f) of the Social Security Act, 42 U.S.C. s. 1397cc(f).
747 (d) Establish a mechanism for investigating and resolving
748 complaints and grievances from program applicants, enrollees,
749 and health benefits coverage providers, and maintain a record of
750 complaints and confirmed problems. In the case of a child who is
751 enrolled in a managed care health maintenance organization, the
752 agency must use the provisions of s. 641.511 to address
753 grievance reporting and resolution requirements.
754 (e) Approve health benefits coverage for participation in
755 the program, following certification by the Office of Insurance
756 Regulation under subsection (4).
757 (e)(f) Adopt rules necessary for calculating premium
758 assistance payment levels, making premium assistance payments,
759 monitoring access and quality assurance standards and,
760 investigating and resolving complaints and grievances,
761 administering the Medikids program, and approving health
762 benefits coverage.
763 (f) Contract with the Florida Healthy Kids Corporation for
764 the administration of the Florida Kidcare program and the
765 Healthy Florida program and to facilitate the release of any
766 federal and state funds.
767
768 The agency is designated the lead state agency for Title XXI of
769 the Social Security Act for purposes of receipt of federal
770 funds, for reporting purposes, and for ensuring compliance with
771 federal and state regulations and rules.
772 (4) The Office of Insurance Regulation shall certify that
773 health benefits coverage plans that seek to provide services
774 under the Florida Kidcare program, except those offered through
775 the Florida Healthy Kids Corporation or the Children’s Medical
776 Services Network, meet, exceed, or are actuarially equivalent to
777 the benchmark benefit plan and that health insurance plans will
778 be offered at an approved rate. In determining actuarial
779 equivalence of benefits coverage, the Office of Insurance
780 Regulation and health insurance plans must comply with the
781 requirements of s. 2103 of Title XXI of the Social Security Act.
782 The department shall adopt rules necessary for certifying health
783 benefits coverage plans.
784 (3)(5) The Florida Healthy Kids Corporation shall retain
785 its functions as authorized in s. 624.91, including eligibility
786 determination for participation in the Healthy Kids program.
787 (4)(6) The agency, the Department of Health, the Department
788 of Children and Families Family Services, and the Florida
789 Healthy Kids Corporation, and the Office of Insurance
790 Regulation, after consultation with and approval of the Speaker
791 of the House of Representatives and the President of the Senate,
792 may are authorized to make program modifications that are
793 necessary to overcome any objections of the United States
794 Department of Health and Human Services to obtain approval of
795 the state’s child health insurance plan under Title XXI of the
796 Social Security Act.
797 Section 12. Section 409.820, Florida Statutes, is amended
798 to read:
799 409.820 Quality assurance and access standards.—Except for
800 Medicaid, the Department of Health, in consultation with the
801 agency and the Florida Healthy Kids Corporation, shall develop a
802 minimum set of pediatric and adolescent quality assurance and
803 access standards for all program components. The standards must
804 include a process for granting exceptions to specific
805 requirements for quality assurance and access. Compliance with
806 the standards shall be a condition of program participation by
807 health benefits coverage providers. These standards shall comply
808 with the provisions of this chapter and chapter 641 and Title
809 XXI of the Social Security Act.
810 Section 13. Section 624.91, Florida Statutes, is amended to
811 read:
812 624.91 The Florida Healthy Kids Corporation Act.—
813 (1) SHORT TITLE.—This section may be cited as the “William
814 G. ‘Doc’ Myers Healthy Kids Corporation Act.”
815 (2) LEGISLATIVE INTENT.—
816 (a) The Legislature finds that increased access to health
817 care services could improve children’s health and reduce the
818 incidence and costs of childhood illness and disabilities among
819 children in this state. Many children do not have comprehensive,
820 affordable health care services available. It is the intent of
821 the Legislature that the Florida Healthy Kids Corporation
822 provide comprehensive health insurance coverage to such
823 children. The corporation is encouraged to cooperate with any
824 existing health service programs funded by the public or the
825 private sector.
826 (b) It is the intent of the Legislature that the Florida
827 Healthy Kids Corporation serve as one of several providers of
828 services to children eligible for medical assistance under Title
829 XXI of the Social Security Act. Although the corporation may
830 serve other children, the Legislature intends the primary
831 recipients of services provided through the corporation be
832 school-age children with a family income below 200 percent of
833 the federal poverty level, who do not qualify for Medicaid. It
834 is also the intent of the Legislature that state and local
835 government Florida Healthy Kids funds be used to continue
836 coverage, subject to specific appropriations in the General
837 Appropriations Act, to children not eligible for federal
838 matching funds under Title XXI.
839 (c) It is further the intent of the Legislature that the
840 Florida Healthy Kids Corporation administer and manage services
841 for Healthy Florida, a health care program for uninsured adults
842 using a unique network of providers and contracts. Enrollees in
843 Healthy Florida will receive comprehensive health care services
844 from private, licensed health insurers who meet standards
845 established by the corporation. It is further the intent of the
846 Legislature that these enrollees participate in their own health
847 care decisionmaking and contribute financially toward their
848 medical costs. The Legislature intends to provide an alternative
849 benefit package that includes a full range of services which
850 meet the needs of residents of this state. As a new program, the
851 Legislature shall also ensure that a comprehensive evaluation is
852 conducted to measure the overall impact of the program and
853 identify whether to renew the program after an initial 3-year
854 term.
855 (3) ELIGIBILITY FOR STATE-FUNDED ASSISTANCE.—Only the
856 following individuals are eligible for state-funded assistance
857 in paying premiums for Healthy Florida or Florida Healthy Kids
858 premiums:
859 (a) Residents of this state who are eligible for the
860 Florida Kidcare program pursuant to s. 409.814 or the Healthy
861 Florida pursuant to s. 624.917.
862 (b) Notwithstanding s. 409.814, legal aliens who are
863 enrolled in the Florida Healthy Kids program as of January 31,
864 2004, who do not qualify for Title XXI federal funds because
865 they are not qualified aliens as defined in s. 409.811.
866 (4) NONENTITLEMENT.—Nothing in this section shall be
867 construed as providing an individual with an entitlement to
868 health care services. No cause of action shall arise against the
869 state, the Florida Healthy Kids Corporation, or a unit of local
870 government for failure to make health services available under
871 this section.
872 (5) CORPORATION AUTHORIZATION, DUTIES, POWERS.—
873 (a) There is created the Florida Healthy Kids Corporation,
874 a not-for-profit corporation.
875 (b) The Florida Healthy Kids Corporation shall:
876 1. Arrange for the collection of any family, individual, or
877 local contributions, or employer payment or premium, in an
878 amount to be determined by the board of directors, to provide
879 for payment of premiums for comprehensive insurance coverage and
880 for the actual or estimated administrative expenses.
881 2. Arrange for the collection of any voluntary
882 contributions to provide for payment of premiums for enrollees
883 in the Florida Kidcare program or Healthy Florida premiums for
884 children who are not eligible for medical assistance under Title
885 XIX or Title XXI of the Social Security Act.
886 3. Subject to the provisions of s. 409.8134, accept
887 voluntary supplemental local match contributions that comply
888 with the requirements of Title XXI of the Social Security Act
889 for the purpose of providing additional Florida Kidcare coverage
890 in contributing counties under Title XXI.
891 4. Establish the administrative and accounting procedures
892 for the operation of the corporation.
893 5. Establish, with consultation from appropriate
894 professional organizations, standards for preventive health
895 services and providers and comprehensive insurance benefits
896 appropriate to children, provided that such standards for rural
897 areas shall not limit primary care providers to board-certified
898 pediatricians.
899 6. Determine eligibility for children seeking to
900 participate in the Title XXI-funded components of the Florida
901 Kidcare program consistent with the requirements specified in s.
902 409.814, as well as the non-Title-XXI-eligible children as
903 provided in subsection (3).
904 7. Establish procedures under which providers of local
905 match to, applicants to and participants in the program may have
906 grievances reviewed by an impartial body and reported to the
907 board of directors of the corporation.
908 8. Establish participation criteria and, if appropriate,
909 contract with an authorized insurer, health maintenance
910 organization, or third-party administrator to provide
911 administrative services to the corporation.
912 9. Establish enrollment criteria that include penalties or
913 waiting periods of 30 days for reinstatement of coverage upon
914 voluntary cancellation for nonpayment of family and individual
915 premiums under the programs.
916 10. Contract with authorized insurers or any provider of
917 health care services, meeting standards established by the
918 corporation, for the provision of comprehensive insurance
919 coverage to participants. Such standards shall include criteria
920 under which the corporation may contract with more than one
921 provider of health care services in program sites.
922 a. Health plans shall be selected through a competitive bid
923 process.
924 b. The Florida Healthy Kids Corporation shall purchase
925 goods and services in the most cost-effective manner consistent
926 with the delivery of quality medical care. The maximum
927 administrative cost for a Florida Healthy Kids Corporation
928 contract shall be 15 percent. For all health care contracts, the
929 minimum medical loss ratio is for a Florida Healthy Kids
930 Corporation contract shall be 85 percent. The calculations must
931 use uniform financial data collected from all plans in a format
932 established by the corporation and shall be computed for each
933 insurer on a statewide basis. Funds shall be classified in a
934 manner consistent with 45 C.F.R. part 158 For dental contracts,
935 the remaining compensation to be paid to the authorized insurer
936 or provider under a Florida Healthy Kids Corporation contract
937 shall be no less than an amount which is 85 percent of premium;
938 to the extent any contract provision does not provide for this
939 minimum compensation, this section shall prevail.
940 c. The health plan selection criteria and scoring system,
941 and the scoring results, shall be available upon request for
942 inspection after the bids have been awarded.
943 11. Establish disenrollment criteria in the event local
944 matching funds are insufficient to cover enrollments.
945 12. Develop and implement a plan to publicize the Florida
946 Kidcare program and Healthy Florida, the eligibility
947 requirements of the programs program, and the procedures for
948 enrollment in the program and to maintain public awareness of
949 the corporation and the programs program.
950 13. Secure staff necessary to properly administer the
951 corporation. Staff costs shall be funded from state and local
952 matching funds and such other private or public funds as become
953 available. The board of directors shall determine the number of
954 staff members necessary to administer the corporation.
955 14. In consultation with the partner agencies, annually
956 provide a report on the Florida Kidcare program annually to the
957 Governor, the Chief Financial Officer, the Commissioner of
958 Education, the President of the Senate, the Speaker of the House
959 of Representatives, and the Minority Leaders of the Senate and
960 the House of Representatives.
961 15. Provide information on a quarterly basis to the
962 Legislature and the Governor which compares the costs and
963 utilization of the full-pay enrolled population and the Title
964 XXI-subsidized enrolled population in the Florida Kidcare
965 program. The information, at a minimum, must include:
966 a. The monthly enrollment and expenditure for full-pay
967 enrollees in the Medikids and Florida Healthy Kids programs
968 compared to the Title XXI-subsidized enrolled population; and
969 b. The costs and utilization by service of the full-pay
970 enrollees in the Medikids and Florida Healthy Kids programs and
971 the Title XXI-subsidized enrolled population. This subparagraph
972 is repealed effective December 31, 2013.
973
974 By February 1, 2010, the Florida Healthy Kids Corporation shall
975 provide a study to the Legislature and the Governor on premium
976 impacts to the subsidized portion of the program from the
977 inclusion of the full-pay program, which shall include
978 recommendations on how to eliminate or mitigate possible impacts
979 to the subsidized premiums.
980 16. By August 15, 2013, the corporation shall notify all
981 current full-pay enrollees of the availability of the exchange,
982 as defined in the federal Patient Protection and Affordable Care
983 Act, and how to access other insurance affordability options.
984 New applications for full-pay coverage may not be accepted after
985 September 30, 2013.
986 17.16. Establish benefit packages that conform to the
987 provisions of the Florida Kidcare program, as created in ss.
988 409.810-409.821.
989 (c) Coverage under the corporation’s program is secondary
990 to any other available private coverage held by, or applicable
991 to, the participant child or family member. Insurers under
992 contract with the corporation are the payors of last resort and
993 must coordinate benefits with any other third-party payor that
994 may be liable for the participant’s medical care.
995 (d) The Florida Healthy Kids Corporation shall be a private
996 corporation not for profit, registered, incorporated, and
997 organized pursuant to chapter 617, and shall have all powers
998 necessary to carry out the purposes of this act, including, but
999 not limited to, the power to receive and accept grants, loans,
1000 or advances of funds from any public or private agency and to
1001 receive and accept from any source contributions of money,
1002 property, labor, or any other thing of value, to be held, used,
1003 and applied for the purposes of this act. The corporation and
1004 any committees it forms shall act in compliance with part III of
1005 chapter 112, and chapters 119 and 286.
1006 (6) BOARD OF DIRECTORS AND MANAGEMENT SUPERVISION.—
1007 (a) The Florida Healthy Kids Corporation shall operate
1008 subject to the supervision and approval of a board of directors
1009 chaired by an appointee designated by the Governor Chief
1010 Financial Officer or her or his designee, and composed of 12
1011 other members. The Senate shall confirm the designated chair and
1012 other board appointees selected for 3-year terms of office as
1013 follows:
1014 1. The Secretary of Health Care Administration, or his or
1015 her designee.
1016 2. One member appointed by the Commissioner of Education
1017 from the Office of School Health Programs of the Florida
1018 Department of Education.
1019 3. One member appointed by the Chief Financial Officer from
1020 among three members nominated by the Florida Pediatric Society.
1021 4. One member, appointed by the Governor, who represents
1022 the Children’s Medical Services Program.
1023 5. One member appointed by the Chief Financial Officer from
1024 among three members nominated by the Florida Hospital
1025 Association.
1026 6. One member, appointed by the Governor, who is an expert
1027 on child health policy.
1028 7. One member, appointed by the Chief Financial Officer,
1029 from among three members nominated by the Florida Academy of
1030 Family Physicians.
1031 8. One member, appointed by the Governor, who represents
1032 the state Medicaid program.
1033 9. One member, appointed by the Chief Financial Officer,
1034 from among three members nominated by the Florida Association of
1035 Counties.
1036 10. The State Health Officer or her or his designee.
1037 11. The Secretary of Children and Family Services, or his
1038 or her designee.
1039 12. One member, appointed by the Governor, from among three
1040 members nominated by the Florida Dental Association.
1041 (b) A member of the board of directors serves at the
1042 pleasure of the Governor may be removed by the official who
1043 appointed that member. The board shall appoint an executive
1044 director, who is responsible for other staff authorized by the
1045 board.
1046 (c) Board members are entitled to receive, from funds of
1047 the corporation, reimbursement for per diem and travel expenses
1048 as provided by s. 112.061.
1049 (d) There shall be no liability on the part of, and no
1050 cause of action shall arise against, any member of the board of
1051 directors, or its employees or agents, for any action they take
1052 in the performance of their powers and duties under this act.
1053 (e) Board members who are serving on or before the date of
1054 enactment of this act or similar legislation may remain until
1055 July 1, 2013.
1056 (f) An executive steering committee is created to provide
1057 management direction and support and to make recommendations to
1058 the board on the programs. The steering committee is composed of
1059 the Secretary of Health Care Administration, the Secretary of
1060 Children and Families, and the State Surgeon General. Committee
1061 members may not delegate their membership or attendance.
1062 (7) LICENSING NOT REQUIRED; FISCAL OPERATION.—
1063 (a) The corporation shall not be deemed an insurer. The
1064 officers, directors, and employees of the corporation shall not
1065 be deemed to be agents of an insurer. Neither the corporation
1066 nor any officer, director, or employee of the corporation is
1067 subject to the licensing requirements of the insurance code or
1068 the rules of the Department of Financial Services or Office of
1069 Insurance Regulation. However, any marketing representative
1070 utilized and compensated by the corporation must be appointed as
1071 a representative of the insurers or health services providers
1072 with which the corporation contracts.
1073 (b) The board has complete fiscal control over the
1074 corporation and is responsible for all corporate operations.
1075 (c) The Department of Financial Services shall supervise
1076 any liquidation or dissolution of the corporation and shall
1077 have, with respect to such liquidation or dissolution, all power
1078 granted to it pursuant to the insurance code.
1079 Section 14. Section 624.915, Florida Statutes, is repealed.
1080 Section 15. Section 624.917, Florida Statutes, is created
1081 to read:
1082 624.917 Healthy Florida program.—
1083 (1) PROGRAM CREATION.—There is created Healthy Florida, a
1084 health care program for lower income, uninsured adults who meet
1085 the eligibility guidelines established under s. 624.91. The
1086 Florida Healthy Kids Corporation shall administer the program
1087 under its existing corporate governance and structure.
1088 (2) DEFINITIONS.—As used in this section, the term:
1089 (a) “Actuarially equivalent” means:
1090 1. The aggregate value of the benefits included in health
1091 benefits coverage is equal to the value of the benefits in the
1092 child benchmark benefit plan as defined in s. 409.811; and
1093 2. The benefits included in health benefits coverage are
1094 substantially similar to the benefits included in the child
1095 benchmark benefit plan, except that preventive health services
1096 do not include dental services.
1097 (b) “Agency” means the Agency for Health Care
1098 Administration.
1099 (c) “Applicant” means the individual who applies for
1100 determination of eligibility for health benefits coverage under
1101 this section.
1102 (d) “Child benchmark benefit plan” means the form and level
1103 of health benefits coverage established in s. 409.815.
1104 (e) “Child” means any person younger than 19 years of age.
1105 (f) “Corporation” means the Florida Healthy Kids
1106 Corporation.
1107 (g) “Enrollee” means an individual who has been determined
1108 eligible for and is receiving coverage under this section.
1109 (h) “Florida Kidcare program” or “Kidcare program,” means
1110 the health benefits program administered through ss. 409.810
1111 409.821.
1112 (i) “Health benefits coverage” means protection that
1113 provides payment of benefits for covered health care services or
1114 that otherwise provides, either directly or through arrangements
1115 with other persons, covered health care services on a prepaid
1116 per capita basis or on a prepaid aggregate fixed-sum basis.
1117 (j) “Healthy Florida” means the program created by this
1118 section which is administered by the Florida Healthy Kids
1119 Corporation.
1120 (k) “Healthy Kids” means the Florida Kidcare program
1121 component created under s. 624.91 for children who are 5 through
1122 18 years of age.
1123 (l) “Household income” means the group or the individual
1124 whose income is considered in determining eligibility for the
1125 Healthy Florida program. The term “household” has the same
1126 meaning as provided in s. 36B(d)(2) of the Internal Revenue Code
1127 of 1986.
1128 (m) “Medicaid” means the medical assistance program
1129 authorized by Title XIX of the Social Security Act, and
1130 regulations thereunder, and ss. 409.901-409.920, as administered
1131 in this state by the agency.
1132 (n) “Medically necessary” means the use of any medical
1133 treatment, service, equipment, or supply necessary to palliate
1134 the effects of a terminal condition, or to prevent, diagnose,
1135 correct, cure, alleviate, or preclude deterioration of a
1136 condition that threatens life, causes pain or suffering, or
1137 results in illness or infirmity and which is:
1138 1. Consistent with the symptom, diagnosis, and treatment of
1139 the enrollee’s condition;
1140 2. Provided in accordance with generally accepted standards
1141 of medical practice;
1142 3. Not primarily intended for the convenience of the
1143 enrollee, the enrollee’s family, or the health care provider;
1144 4. The most appropriate level of supply or service for the
1145 diagnosis and treatment of the enrollee’s condition; and
1146 5. Approved by the appropriate medical body or health care
1147 specialty involved as effective, appropriate, and essential for
1148 the care and treatment of the enrollee’s condition.
1149 (o) “Modified adjusted gross income” means the individual
1150 or household’s annual adjusted gross income as defined in s.
1151 36B(d)(2) of the Internal Revenue Code of 1986 which is used to
1152 determine eligibility under the Florida Kidcare program.
1153 (p) “Patient Protection and Affordable Care Act” or “Act”
1154 means the federal law enacted as Pub. L. No. 111-148, as further
1155 amended by the federal Health Care and Education Reconciliation
1156 Act of 2010, Pub. L. No. 111-152, and any amendments,
1157 regulations or guidance thereunder, issued under those acts.
1158 (q) “Premium” means the entire cost of a health insurance
1159 plan, including the administration fee or the risk assumption
1160 charge.
1161 (r) “Premium assistance payment” means the monthly
1162 consideration paid by the agency per enrollee in the Florida
1163 Kidcare program towards health insurance premiums.
1164 (s) “Qualified alien” means an alien as defined in 8 U.S.C.
1165 s. 1641(b) and (c).
1166 (t) “Resident” means a United States citizen or qualified
1167 alien who is domiciled in this state.
1168 (3) ELIGIBILITY.—To be eligible and remain eligible for the
1169 Healthy Florida program, an individual must be a resident of
1170 this state and meet the following additional criteria:
1171 (a) Be identified as newly eligible, as defined in s.
1172 1902(a)(10)(A)(i)(VIII) of the Social Security Act or s. 2001 of
1173 the federal Patient Protection and Affordable Care Act, and as
1174 may be further defined by federal regulation.
1175 (b) Maintain eligibility with the corporation and meet all
1176 renewal requirements as established by the corporation.
1177 (c) Renew eligibility on at least an annual basis.
1178 (4) ENROLLMENT.—The corporation may begin the enrollment of
1179 applicants in the Healthy Florida program on October 1, 2013.
1180 Enrollment may occur directly, through the services of a third
1181 party administrator, referrals from the Department of Children
1182 and Families, and the exchange as defined by the federal Patient
1183 Protection and Affordable Care Act. As an enrollee disenrolls,
1184 the corporation must also provide the enrollee with information
1185 about other insurance affordability programs and electronically
1186 refer the enrollee to the exchange or other programs, as
1187 appropriate. The earliest coverage effective date under the
1188 program shall be January 1, 2014.
1189 (5) DELIVERY OF SERVICES.—The corporation shall contract
1190 with authorized insurers licensed under chapter 627 and managed
1191 care organizations under chapter 641 which meet standards
1192 established by the corporation to provide comprehensive health
1193 care services to enrollees who qualify for services under this
1194 section. The corporation may contract for such services on a
1195 statewide or regional basis.
1196 (a) The corporation shall establish access and network
1197 standards for such contracts and ensure that contracted
1198 providers have sufficient providers to meet enrollee needs.
1199 Quality standards must be developed by the corporation, specific
1200 to the adult population, which take into consideration
1201 recommendations from the National Committee on Quality
1202 Assurance, stakeholders, and other existing performance
1203 indicators from both public and commercial populations.
1204 (b) The corporation shall provide an enrollee a choice of
1205 plans. The corporation may select a plan if no selection has
1206 been received before the coverage start date. Once enrolled, an
1207 enrollee has an initial 90-day, free-look period before a lock
1208 in period of not more than 12 months is applied. Exceptions to
1209 the lock-in period must be offered to an enrollee for reasons
1210 based upon good cause or qualifying events.
1211 (c) The corporation may consider contracts that provide
1212 family plans that would allow members from multiple state and
1213 federally funded programs to remain together under the same
1214 plan.
1215 (d) All contracts must meet the medical loss ratio
1216 requirements under s. 624.91.
1217 (6) BENEFITS.—The corporation shall establish a benefits
1218 package that is actuarially equivalent to the benchmark benefit
1219 plan offered under s. 409.815(2), excluding dental, and meets
1220 the alternative benefits package requirements under s. 1937 of
1221 the Social Security Act. Benefits must be offered as an
1222 integrated, single package.
1223 (a) In addition to benchmark benefits, health reimbursement
1224 accounts or a comparable health savings account for each
1225 enrollee must be established through the corporation or the
1226 contracts managed by the corporation. Enrollees must be rewarded
1227 for healthy behaviors, wellness program adherence, and other
1228 activities established by the corporation which demonstrate
1229 compliance with preventive care or disease management
1230 guidelines. Funds deposited into these accounts may be used to
1231 pay cost-sharing obligations or to purchase over-the-counter
1232 health-related items to the extent allowed under federal law or
1233 regulation.
1234 (b) Enhanced services may be offered if the cost of such
1235 additional services provides savings to the overall plan.
1236 (c) The corporation shall establish a process for the
1237 payment of wrap-around services not covered by the benchmark
1238 benefit plan through a separate subcapitation process to its
1239 contracted providers if it is determined that such services are
1240 required by federal law. Such services would be covered when
1241 deemed medically necessary on an individual basis. The
1242 subcapitation pool is subject to a separate reconciliation
1243 process under the medical loss ratio provisions in s. 624.91.
1244 (d) A prior authorization process and other utilization
1245 controls may be established by the plan for any benefit if
1246 approved by the corporation.
1247 (7) COST SHARING.—The corporation may collect premiums and
1248 copayments from enrollees in accordance with federal law.
1249 Amounts to be collected for the Healthy Florida program must be
1250 established annually in the General Appropriations Act.
1251 (a) Payment of a monthly premium may be required before the
1252 establishment of an enrollee’s coverage start date and to retain
1253 monthly coverage.
1254 (b) An enrollee may be required to make copayments as a
1255 condition of receiving a health care service.
1256 (c) A provider is responsible for the collection of point
1257 of-service cost-sharing obligations. The enrollee’s cost-sharing
1258 contribution is considered part of the provider’s total
1259 reimbursement. Failure to collect an enrollee’s cost sharing
1260 reduces the provider’s share of the reimbursement.
1261 (8) PROGRAM MANAGEMENT.—The corporation is responsible for
1262 the oversight of the Healthy Florida program. The agency shall
1263 seek a state plan amendment or other appropriate federal
1264 approval to implement the Healthy Florida program. The agency
1265 shall consult with the corporation in the amendment’s
1266 development and submit by June 14, 2013, the state plan
1267 amendment to the federal Department of Health and Human
1268 Services. The agency shall contract with the corporation for the
1269 administration of the Healthy Florida program and for the timely
1270 release of federal and state funds. The agency retains its
1271 authorities as provided in ss. 409.902 and 409.963.
1272 (a) The corporation shall establish a process by which
1273 grievances can be resolved and Healthy Florida recipients can be
1274 informed of their rights under the Medicaid Fair Hearing
1275 Process, as appropriate, or any alternative resolution process
1276 adopted by the corporation.
1277 (b) The corporation shall establish a program integrity
1278 process to ensure compliance with program guidelines. At a
1279 minimum, the corporation shall withhold benefits from an
1280 applicant or enrollee if the corporation obtains evidence that
1281 the applicant or enrollee is no longer eligible, submitted
1282 incorrect or fraudulent information in order to establish
1283 eligibility, or failed to provide verification of eligibility.
1284 The corporation shall notify the applicant or enrollee that,
1285 because of such evidence, program benefits must be withheld
1286 unless the applicant or enrollee contacts a designated
1287 representative of the corporation by a specified date, which
1288 must be within 10 working days after the date of notice, to
1289 discuss and resolve the matter. The corporation shall make every
1290 effort to resolve the matter within a timeframe that will not
1291 cause benefits to be withheld from an eligible enrollee. The
1292 following individuals may be subject to specific prosecution in
1293 accordance with s. 414.39:
1294 1. An applicant who obtains or attempts to obtain benefits
1295 for a potential enrollee under the Healthy Florida program when
1296 the applicant knows or should have known that the potential
1297 enrollee does not qualify for the Healthy Florida program.
1298 2. An individual who assists an applicant in obtaining or
1299 attempting to obtain benefits for a potential enrollee under the
1300 Healthy Florida program when the individual knows or should have
1301 known that the potential enrollee does not qualify for the
1302 Healthy Florida program.
1303 (9) APPLICABILITY OF LAWS RELATING TO MEDICAID.—The
1304 provisions of ss. 409.902, 409.9128, and 409.920 apply to the
1305 administration of the Healthy Florida program.
1306 (10) PROGRAM EVALUATION.—The corporation shall collect both
1307 eligibility and enrollment data from program applicants and
1308 enrollees as well as encounter and utilization data from all
1309 contracted entities during the program term. The corporation
1310 shall submit monthly enrollment reports to the President of the
1311 Senate, the Speaker of the House of Representative, and the
1312 Minority Leaders of the Senate and the House of Representatives.
1313 The corporation shall submit an interim independent evaluation
1314 of the Healthy Florida program to the presiding officers no
1315 later than July 1, 2015, with annual evaluations due July 1 each
1316 year thereafter. The evaluations must address, at a minimum,
1317 application and enrollment trends and issues, utilization and
1318 cost data, and customer satisfaction.
1319 (11) PROGRAM EXPIRATION.—The Healthy Florida program shall
1320 expire at the end of the state fiscal year in which any of these
1321 conditions occur, whichever occurs first:
1322 (a) The federal match contribution falls below 90 percent.
1323 (b) The federal match contribution falls below the
1324 increased FMAP for medical assistance for newly eligible
1325 mandatory individuals as specified in the federal Patient
1326 Protection and Affordable Care Act, Pub. L. No. 111-148, as
1327 amended by the federal Health Care and Education Reconciliation
1328 Act of 2010, Pub. L. No. 111-152.
1329 (c) The federal match for the Healthy Florida program and
1330 the Medicaid program are blended under federal law or regulation
1331 in such a way that causes the overall federal contribution to
1332 diminish when compared to separate, nonblended federal
1333 contributions.
1334 Section 16. The Florida Healthy Kids Corporation may make
1335 changes to comply with the objections of the federal Department
1336 of Health and Human Services to gain approval of the Healthy
1337 Florida program in compliance with the federal Patient
1338 Protection and Affordable Care Act, upon giving notice to the
1339 Senate and the House of Representatives of the proposed changes.
1340 If there is a conflict between a provision in this section and
1341 the federal Patient Protection and Affordable Care Act, Pub. L.
1342 No. 111-148, as amended by the federal Health Care and Education
1343 Reconciliation Act of 2010, Pub. L. No. 111-152, the provision
1344 must be interpreted and applied so as to comply with the
1345 requirement of the federal law.
1346 Section 17. This act shall take effect upon becoming a law.