Senate Bill 1228
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Florida Senate - 1998 SB 1228
By Senators Brown-Waite, Myers, Bankhead, Burt and Silver
10-899A-98
1 A bill to be entitled
2 An act relating to children's health care;
3 amending s. 409.904, F.S.; providing for
4 children under specified ages who are not
5 otherwise eligible for the Medicaid program to
6 be eligible for optional payments for medical
7 assistance; amending s. 409.9126, F.S.; making
8 the Children's Medical Services network
9 available to certain children who are eligible
10 for the Florida Kids Health program; revising
11 provisions to reflect the transfer of duties to
12 the Department of Health; creating s. 409.810,
13 F.S.; providing a short title; creating s.
14 409.811, F.S.; providing definitions; creating
15 s. 409.812, F.S.; creating and providing the
16 purpose for the Florida Kids Health program;
17 creating s. 409.813, F.S.; specifying program
18 components; specifying that certain program
19 components are not an entitlement; creating s.
20 409.8135, F.S.; providing for program
21 enrollment and expenditure ceilings; creating
22 s. 409.814, F.S.; providing eligibility
23 requirements; creating s. 409.815, F.S.;
24 establishing requirements for health benefits
25 coverage under the Florida Kids Health program;
26 creating s. 409.816, F.S.; providing for
27 limitations on premiums and cost-sharing;
28 creating s. 409.817, F.S.; providing for
29 approval of health benefits coverage as a
30 condition of financial assistance; creating s.
31 409.818, F.S.; providing for program
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1 administration; specifying duties of the
2 Department of Children and Family Services, the
3 Department of Health, the Agency for Health
4 Care Administration, the Department of
5 Insurance, and the Florida Healthy Kids
6 Corporation; authorizing application for
7 federal waiver for alternative coverage;
8 transferring, renumbering, and amending s.
9 154.508, F.S., relating to outreach activities
10 to identify low-income, uninsured children;
11 creating s. 409.820, F.S.; requiring that the
12 Department of Health develop standards for
13 quality assurance and program access;
14 establishing performance measures and standards
15 for the Florida Kids Health program; providing
16 an appropriation; providing for application of
17 the act to certain contracts between providers
18 and the Florida Healthy Kids Corporation;
19 providing an effective date.
20
21 Be It Enacted by the Legislature of the State of Florida:
22
23 Section 1. Section 409.904, Florida Statutes, is
24 amended to read:
25 409.904 Optional payments for eligible persons.--The
26 agency may make payments for medical assistance and related
27 services on behalf of the following persons who are determined
28 to be eligible subject to the income, assets, and categorical
29 eligibility tests set forth in federal and state law. Payment
30 on behalf of these Medicaid eligible persons is subject to the
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1 availability of moneys and any limitations established by the
2 General Appropriations Act or chapter 216.
3 (1) A person who is age 65 or older or is determined
4 to be disabled, whose income is at or below 100 percent of
5 federal poverty level, and whose assets do not exceed
6 established limitations.
7 (2) A family, a pregnant woman, a child under age 18,
8 a person age 65 or over, or a blind or disabled person who
9 would be eligible under any group listed in s. 409.903(1),
10 (2), or (3), except that the income or assets of such family
11 or person exceed established limitations. For a family or
12 person in this group, medical expenses are deductible from
13 income in accordance with federal requirements in order to
14 make a determination of eligibility. A family or person in
15 this group, which group is known as the "medically needy," is
16 eligible to receive the same services as other Medicaid
17 recipients, with the exception of services in skilled nursing
18 facilities and intermediate care facilities for the
19 developmentally disabled.
20 (3) A person who is in need of the services of a
21 licensed nursing facility, a licensed intermediate care
22 facility for the developmentally disabled, or a state mental
23 hospital, whose income does not exceed 300 percent of the SSI
24 income standard, and who meets the assets standards
25 established under federal and state law.
26 (4) A low-income person who meets all other
27 requirements for Medicaid eligibility except citizenship and
28 who is in need of emergency medical services. The eligibility
29 of such a recipient is limited to the period of the emergency,
30 in accordance with federal regulations.
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1 (5) Subject to specific federal authorization, a
2 postpartum woman living in a family that has an income that is
3 at or below 185 percent of the most current federal poverty
4 level is eligible for family planning services as specified in
5 s. 409.905(3) for a period of up to 24 months following a
6 pregnancy for which Medicaid paid for pregnancy-related
7 services.
8 (6) A child under 1 year of age who lives in a family
9 whose income is above 185 percent of the most current federal
10 poverty level but equal to or below 200 percent of the most
11 current federal poverty level. In determining the eligibility
12 of such a child, an assets test is not required.
13 (7) A child under 19 years of age who is not eligible
14 for coverage under subsection (6) or under s. 409.903(5), (6),
15 or (7) and who lives in a family whose income is at or below
16 100 percent of the most current federal poverty level. In
17 determining the eligibility of such a child, an assets test is
18 not required.
19 Section 2. Subsections (2), (3), and (10) of section
20 409.9126, Florida Statutes, are amended to read:
21 409.9126 Children with special health care needs.--
22 (2) The Legislature finds that Medicaid-eligible
23 children with special health care needs require a
24 comprehensive, continuous, and coordinated system of health
25 care that links community-based health care with
26 multidisciplinary, regional, and tertiary care. The
27 Legislature finds that Florida's Children's Medical Services
28 program provides a full continuum of coordinated,
29 comprehensive services for children with special health care
30 needs.
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1 (3) Except as provided in subsections (8) and (9),
2 children eligible for Children's Medical Services who receive
3 Medicaid benefits, and other Medicaid-eligible children with
4 special health care needs, shall be exempt from the provisions
5 of s. 409.9122 and shall be served through the Children's
6 Medical Services network. The Children's Medical Services
7 network shall also be available to children with special
8 health care needs who are eligible for health benefits
9 coverage other that Medicaid through the Florida Kids Health
10 program.
11 (10) The agency, in consultation with the Department
12 of Health and Rehabilitative Services, shall adopt rules that
13 address Medicaid requirements for referral, enrollment, and
14 disenrollment of children with special health care needs who
15 are enrolled in Medicaid managed care plans and who may
16 benefit from the Children's Medical Services network.
17 Section 3. Section 409.810, Florida Statutes, is
18 created to read:
19 409.810 Short title.--Sections 409.810-409.820 may be
20 cited as the "Florida Kids Health Act."
21 Section 4. Section 409.811, Florida Statutes, is
22 created to read:
23 409.811 Definitions.--As used in ss. 409.810-409.820,
24 the term:
25 (1) "Agency" means the Agency for Health Care
26 Administration.
27 (2) "Alternative coverage" means health benefits
28 coverage provided through a community-based health-delivery
29 system authorized under s. 2105 of Title XXI of the Social
30 Security Act, subject to federal approval of a waiver request.
31 Such health-delivery system may include:
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1 (a) A network of health care providers owned,
2 operated, or under contract with a county, political
3 subdivision, or tax district;
4 (b) A rural health network established under s.
5 381.0406;
6 (c) A federally qualified health center that receives
7 funds under s. 330 of the Public Health Service Act;
8 (d) A migrant health center that receives funds under
9 s. 329 of the Public Health Service Act;
10 (e) The Children's Medical Services network
11 established in s. 409.9126; or
12 (f) A hospital that receives Medicaid disproportionate
13 share payments under s. 409.911.
14 (3) "Applicant" means a parent or guardian of a child
15 or a child whose disability of nonage has been removed under
16 chapter 743 who applies for determination of eligibility for
17 health benefits coverage under ss. 409.810-409.820.
18 (4) "Benchmark benefit plan" means the form and level
19 of health benefits coverage established in s. 409.815.
20 (5) "Benchmark premium" means the premium ceiling
21 price for which federal and state assistance payments are
22 available.
23 (6) "Child" means any person under 19 years of age.
24 (7) "Child with special health care needs" means a
25 child whose serious or chronic physical or developmental
26 condition requires extensive preventive and maintenance care
27 beyond that required by typically healthy children. Health
28 care utilization by such a child exceeds the statistically
29 expected usage of the normal child matched for chronological
30 age and such child often needs complex care requiring multiple
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1 providers, rehabilitation services, and specialized equipment
2 in a number of different settings.
3 (8) "Community rate" means a method used to develop
4 premiums for a health insurance plan that spreads financial
5 risk across a large population.
6 (9) "Enrollee" means a child who has been determined
7 eligible for and is receiving coverage under ss.
8 409.810-409.820.
9 (10) "Enrollment ceiling" means the maximum number of
10 children, excluding children enrolled in Medicaid, that may be
11 enrolled at any time in the Florida Kids Health program. The
12 maximum number shall be established annually in the General
13 Appropriations Act or by general law.
14 (11) "Family" means the group or the individuals whose
15 income is considered in determining eligibility for the
16 Florida Kids Health program. The family includes a child,
17 custodial parent, or caretaker relative who resides in the
18 same house or living unit or, in the case of a child whose
19 disability of nonage has been removed under chapter 473, the
20 child. The family may also include individuals whose income
21 and resources are considered in whole or in part in
22 determining eligibility of the child.
23 (12) "Family income" means cash received at periodic
24 intervals from any source, such as wages, benefits,
25 contributions, or rental property. Income also may include any
26 money that would have been counted as income under the AFDC
27 state plan in effect prior to August 22, 1996.
28 (13) "Guarantee issue" means the health benefits
29 coverage that must be offered to an individual regardless of
30 the individual's health status, preexisting condition, or
31 claims history.
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1 (14) "Health benefits coverage" means protection that
2 provides payment of benefits for covered health care services
3 or that otherwise provides, either directly or through
4 arrangements with other persons, covered health care services
5 on a prepaid per capita basis or on a prepaid aggregate
6 fixed-sum basis.
7 (15) "Health insurance plan" means health benefits
8 coverage under the following:
9 (a) A health plan offered by any certified health
10 maintenance organization or authorized health insurer, except
11 a plan that is limited to the following: a limited benefit,
12 specified disease, or specified accident; hospital indemnity;
13 accident only; limited benefit convalescent care; Medicare
14 supplement; credit disability; dental; vision; long-term care;
15 disability income; coverage issued as a supplement to another
16 health plan; workers' compensation liability or other
17 insurance; or motor vehicle medical payment only; or
18 (b) An employee welfare benefit plan that includes
19 health benefits established under the Employee Retirement
20 Income Security Act of 1974, as amended.
21 (16) "Medicaid" means the medical assistance program
22 authorized by Title XIX of the Social Security Act, and
23 regulations thereunder, and ss. 409.901-409.9205, as
24 administered in this state by the agency.
25 (17) "Medically necessary" means the use of any
26 medical treatment, service, equipment, or supply necessary to
27 palliate the effects of a terminal condition, or to prevent,
28 diagnose, correct, cure, alleviate, or preclude deterioration
29 of a condition that threatens life, causes pain or suffering,
30 or results in illness or infirmity and which is:
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1 (a) Consistent with the symptom, diagnosis, and
2 treatment of the enrollee's condition;
3 (b) Provided in accordance with generally accepted
4 standards of medical practice;
5 (c) Not primarily intended for the convenience of the
6 enrollee, the enrollee's family, or the health care provider;
7 (d) The most appropriate level of supply or service
8 for the diagnosis and treatment of the enrollee's condition;
9 and
10 (e) Approved by the appropriate medical body or health
11 care specialty involved as effective, appropriate, and
12 essential for the care and treatment of the enrollee's
13 condition.
14 (18) "Preexisting condition exclusion" means, with
15 respect to coverage, a limitation or exclusion of benefits
16 relating to a condition based on the fact that the condition
17 was present before the date of enrollment for such coverage,
18 whether or not any medical advice, diagnosis, care, or
19 treatment was recommended or received before such date.
20 (19) "Premium" means the entire cost of an insurance
21 plan, including the administration fee or the risk assumption
22 charge.
23 (20) "Premium assistance payment" means the monthly
24 consideration paid by the agency per enrollee in the Florida
25 Kids Health program towards health insurance premiums.
26 (21) "Program" means the Florida Kids Health program,
27 the medical assistance program authorized by Title XXI of the
28 Social Security Act as part of the federal Balanced Budget Act
29 of 1997.
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1 (22) "Qualified alien" means an alien as defined in s.
2 431 of the Personal Responsibility and Work Opportunity
3 Reconciliation Act of 1996, as amended, Pub. L. No. 104-193.
4 (23) "Resident" means a United States citizen, or
5 qualified alien, who is domiciled in this state.
6 Section 5. Section 409.812, Florida Statutes, is
7 created to read:
8 409.812 Program created; purpose.--The Florida Kids
9 Health program is created to provide a defined set of health
10 benefits to previously uninsured, low-income children through
11 the establishment of a variety of affordable health benefits
12 coverage options from which families may select coverage and
13 through which families may contribute financially to the
14 health care of their children.
15 Section 6. Section 409.813, Florida Statutes, is
16 created to read:
17 409.813 Program components; entitlement and
18 nonentitlement.--The Florida Kids Health program includes
19 health benefits coverage provided to children through:
20 (1) Medicaid;
21 (2) The Florida Healthy Kids Corporation program as
22 created in s. 624.91;
23 (3) Health insurance plans approved under ss.
24 409.810-409.820; and
25 (4) Alternative coverage approved under ss.
26 409.810-409.820.
27
28 Except for coverage under the Medicaid program, coverage under
29 the Florida Kids Health program is not an entitlement.
30 Section 7. Section 409.8135, Florida Statutes, is
31 created to read:
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1 409.8135 Program enrollment and expenditure
2 ceilings.--
3 (1) Except for the Medicaid program, a ceiling shall
4 be placed on annual federal and state expenditures and on
5 enrollment in the Florida Kids Health program as provided each
6 year in the General Appropriations Act. The agency, in
7 consultation with the Department of Health, may propose to
8 increase the enrollment ceiling in accordance with chapter
9 216.
10 (2) Except for the Medicaid program, whenever the
11 Social Services Estimating Conference determines that there is
12 presently, or will be by the end of the current fiscal year,
13 insufficient funds to finance the current or projected
14 enrollment in the program, all additional enrollment must
15 cease and additional enrollment may not resume until
16 sufficient funds are available to finance such enrollment.
17 (3) The agency shall collect and analyze the data
18 needed to project program enrollment, including participation
19 rates, caseloads, and expenditures. The agency shall report
20 the caseload and expenditure trends to the Social Services
21 Estimating Conference in accordance with chapter 216.
22 Section 8. Section 409.814, Florida Statutes, is
23 created to read:
24 409.814 Eligibility.--A child whose family income is
25 equal to or below 200 percent of the federal poverty level is
26 eligible for the Florida Kids Health program as provided in
27 this section. In determining the eligibility of such a child,
28 an assets test is not required.
29 (1) A child who is eligible for Medicaid coverage
30 under s. 409.903 or s. 409.904 must be enrolled in Medicaid
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1 and is not eligible to receive health benefits under any other
2 health benefits coverage authorized under ss. 409.810-409.820.
3 (2) A child who is not eligible for Medicaid, but who
4 is eligible for the program, may obtain coverage under any of
5 the other types of health benefits coverage authorized in ss.
6 409.810-409.820 if such coverage is approved and available in
7 the county in which the child resides.
8 (3) A child who is eligible for the program under
9 subsection (1) or (2) and who is a child with special health
10 care needs, as determined through a risk-screening instrument,
11 is eligible for health benefits coverage from and may be
12 referred to the Children's Medical Services network.
13 Eligibility for coverage under the Children's Medical Services
14 network for a child who is eligible for the program under
15 subsection (2) is subject to federal approval of the network
16 as alternative coverage.
17 (4) The following children are not eligible to receive
18 health benefits coverage under ss. 409.810-409.820, except
19 under Medicaid if the child would have been eligible for
20 Medicaid under s. 409.903 or s. 409.904 as of June 1, 1997:
21 (a) A child who is eligible for coverage under a state
22 health benefits plan on the basis of a family member's
23 employment with a public agency in the state;
24 (b) A child who is covered under a group health
25 benefit plan or under other health insurance coverage,
26 excluding coverage provided under the Florida Healthy Kids
27 Corporation as established under s. 624.91;
28 (c) A child who is an alien, but who does not meet the
29 definition of qualified alien, in the United States; or
30 (d) A child who is an inmate of a public institution
31 or a patient in an institution for mental diseases.
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1 (5) A child whose family income is above 200 percent
2 of the federal poverty level may participate in the program;
3 however, the family is not eligible for premium assistance
4 payments and must pay the full cost of the premium. Children
5 described in this subsection may not be counted in the annual
6 enrollment ceiling for the Florida Kids Health program.
7 (6) Once a child is determined eligible for the
8 program, the child is eligible for coverage under the program
9 for 6 months without a redetermination or reverification of
10 eligibility if the family continues to pay the applicable
11 premium.
12 Section 9. Section 409.815, Florida Statutes, is
13 created to read:
14 409.815 Health benefits coverage; limitations.--
15 (1) MEDICAID BENEFITS.--For purposes of this program,
16 benefits available under the Medicaid program include those
17 goods and services provided under the medical assistance
18 program authorized by Title XIX of the Social Security Act,
19 and regulations thereunder, as administered in this state by
20 the agency. This includes those mandatory Medicaid services
21 authorized under s. 409.905 and optional Medicaid services
22 authorized under s. 409.906, rendered on behalf of eligible
23 individuals by qualified providers, in accordance with federal
24 requirements for Title XIX, subject to any limitations or
25 directions provided for in the General Appropriations Act or
26 chapter 216, and according to methodologies and limitations
27 set forth in agency rules and policy manuals and handbooks
28 incorporated by reference thereto.
29 (2) BENCHMARK BENEFITS.--In order for health benefits
30 coverage to qualify for premium assistance payments for an
31 eligible child under ss. 409.810-409.820, the health benefits
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1 coverage, except for coverage under the Medicaid program, must
2 include the following minimum benefits as medically necessary.
3 (a) Preventive health services.--Covered services
4 include:
5 1. Well-child care, including services recommended in
6 the Guidelines for Health Supervision of Children and Youth as
7 developed by the American Academy of Pediatrics;
8 2. Immunizations and injections;
9 3. Health education counseling and clinical services;
10 4. Vision screening; and
11 5. Hearing screening.
12 (b) Inpatient hospital services.--All covered services
13 provided for the medical care and treatment of an enrollee who
14 is admitted as an inpatient to a hospital licensed under part
15 I of chapter 395, with the following exceptions:
16 1. All admissions must be authorized by the enrollee's
17 health benefits coverage provider.
18 2. The length of the patient stay shall be determined
19 on the medical condition of the enrollee in relation to the
20 necessary and appropriate level of care.
21 3. Room and board may be limited to semiprivate
22 accommodations unless a private room is considered medically
23 necessary or semiprivate accommodations are not available.
24 4. Admissions for rehabilitation and physical therapy
25 are limited to 15 days per contract year.
26 (c) Emergency services.--Covered services include
27 visits to an emergency room or other licensed facility if
28 needed immediately due to an injury or illness and delay means
29 risk of permanent damage to the enrollee's health.
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1 (d) Maternity services.--Covered services include
2 maternity and newborn care, including prenatal and postnatal
3 care with the following limitations:
4 1. Coverage may be limited to vaginal deliveries; and
5 2. Initial inpatient care for newborn infants of
6 enrolled adolescents shall be covered, including normal
7 newborn care, nursery charges, and the initial pediatric or
8 neonatal examination, and the infant may be covered for up to
9 3 days following birth.
10 (e) Organ transplantation services.--Covered services
11 include pretransplant, transplant, and postdischarge services
12 and treatment of complications after transplantation for
13 transplants deemed necessary and appropriate within the
14 guidelines set by the Agency for Health Care Administration
15 Organ Transplant Advisory Council under s. 381.0602 or the
16 Agency for Health Care Administration Bone Marrow Transplant
17 Advisory Panel under s. 627.4236.
18 (f) Outpatient services.--Covered services include
19 preventive, diagnostic, therapeutic, palliative care, and
20 other services provided to an enrollee in the outpatient
21 portion of a health facility licensed under chapter 395,
22 except for the following limitations:
23 1. Services must be authorized by the enrollee's
24 health benefits coverage provider; and
25 2. Treatment for temporomandibular joint disease (TMJ)
26 is specifically excluded.
27 (g) Behavioral health services.--
28 1. Mental health benefits include:
29 a. Inpatient services, limited to not more than 15
30 inpatient days per contract year for psychiatric admissions;
31 and
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1 b. Outpatient services, including outpatient visits
2 for psychological or psychiatric evaluation, diagnosis, and
3 treatment by a licensed mental health professional, limited to
4 a maximum of twenty outpatient visits each contract year.
5 2. Drug abuse detoxification and rehabilitation
6 services for pregnant adolescents, including inpatient and
7 outpatient services, with inpatient admissions for alcoholism
8 and drug addiction limited to diagnosis and medical
9 detoxification.
10 (h) Durable medical equipment.--Covered services
11 include equipment and devices that are medically indicated to
12 assist in the treatment of a medical condition and
13 specifically prescribed as medically necessary, with the
14 following limitations:
15 1. Low vision and telescopic aides are not included.
16 2. Corrective lenses and frames may be limited to one
17 pair every 2 years, unless the prescription or head size of
18 the enrollee changes.
19 3. Hearing aids shall be covered only when medically
20 indicated to assist in the treatment of a medical condition.
21 4. Covered prosthetic devices include artificial eyes
22 and limbs, braces, and other artificial aids.
23 (i) Health practitioner services.--Covered services
24 include services and procedures rendered to an enrollee when
25 performed to diagnose and treat diseases, injuries, or other
26 conditions, including care rendered by health practitioners
27 acting within the scope of their practice, with the following
28 exceptions:
29 1. Chiropractic services may be limited to six visits
30 in 6 months and one service per day for manual manipulation of
31 the spine and screenings.
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1 2. Podiatric services may be limited to one visit per
2 day totaling two visits per month for specific foot disorders.
3 (j) Home health services.--Covered services include
4 prescribed home visits by both registered and licensed
5 practical nurses to provide skilled nursing services on a
6 part-time intermittent basis, subject to the following
7 limitations:
8 1. Coverage may be limited to include skilled nursing
9 services only;
10 2. Meals, housekeeping, and personal comfort items may
11 be excluded; and
12 3. Private duty nursing is limited to circumstances
13 where such care is medically necessary.
14 (k) Hospice services.--Covered services include
15 reasonable and necessary services for palliation or management
16 of an enrollee's terminal illness, with the following
17 exceptions:
18 1. Once a family elects to receive hospice care for an
19 enrollee, other services that treat the terminal condition
20 will not be covered; and
21 2. Services required for conditions totally unrelated
22 to the terminal condition are covered to the extent that the
23 services are included in this section.
24 (l) Laboratory and X-ray services.--Covered services
25 include diagnostic testing, including clinical radiologic,
26 laboratory, and other diagnostic tests.
27 (m) Nursing facility services.--Covered services
28 include regular nursing services, rehabilitation services,
29 drugs and biologicals, medical supplies, and the use of
30 appliances and equipment furnished by the facility, with the
31 following limitations:
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1 1. All admissions must be authorized by the health
2 benefits coverage provider.
3 2. The length of the patient stay shall be determined
4 on the medical condition of the enrollee in relation to the
5 necessary and appropriate level of care, but is limited to not
6 more than 100 days per contract year.
7 3. Room and board may be limited to semiprivate
8 accommodations, unless a private room is considered medically
9 necessary or semiprivate accommodations are not available.
10 4. Specialized treatment centers and independent
11 kidney disease treatment centers are excluded.
12 5. Private duty nurses, television, and custodial care
13 are excluded.
14 6. Admissions for rehabilitation and physical therapy
15 are limited to 15 days per contract year.
16 (n) Prescribed drugs.--
17 1. Coverage shall include drugs prescribed for the
18 treatment of illness or injury when prescribed by a licensed
19 health practitioner acting within the scope of his or her
20 practice.
21 2. Prescribed drugs may be limited to generics if
22 available and brand name products if a generic substitution is
23 not available, unless the prescribing licensed health
24 practitioner indicates that a brand name is medically
25 necessary.
26 3. Prescribed drugs covered under this section shall
27 include all prescribed drugs covered under the Florida
28 Medicaid program.
29 (o) Therapy services.--Covered services include
30 rehabilitative services, including occupational, physical,
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1 respiratory, and speech therapies, with the following
2 limitations:
3 1. Services must be for short-term rehabilitation
4 where significant improvement in the enrollee's condition will
5 result; and
6 2. Services shall be no more than twenty-four
7 treatment sessions within a 60-day period per episode or
8 injury, with the 60-day period beginning with the first
9 treatment.
10 (p) Transportation services.--Covered services include
11 emergency transportation required in response to an emergency
12 situation.
13 (q) Lifetime maximum.--Health benefits coverage
14 obtained under ss. 409.810-409.820 shall pay an enrollee's
15 covered expenses at a lifetime maximum of $1 million per
16 covered child.
17 (r) Cost-sharing.--Cost-sharing provisions must comply
18 with s. 409.816.
19 (s) Exclusions.--
20 1. Experimental or investigational procedures that
21 have not been clinically proven by reliable evidence are
22 excluded;
23 2. Services performed for cosmetic purposes only or
24 for the convenience of the enrollee are excluded; and
25 3. Abortion may be covered only if necessary to save
26 the life of the mother or if the pregnancy is the result of an
27 act of rape or incest.
28 (t) Enhancements to minimum requirements.--
29 1. This section sets the minimum benefits that must be
30 included in any health benefits coverage, other than Medicaid
31 coverage, offered under ss. 409.810-409.820. Health benefits
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1 coverage may include additional benefits not included under
2 this subsection, but may not include benefits excluded under
3 paragraph (h).
4 2. Health benefits coverage may extend any limitations
5 beyond the minimum benefits described in this section.
6
7 The agency may not adjust the benchmark premium for either
8 additional benefits provided beyond the minimum benefits
9 described in this section or the imposition of less
10 restrictive service limitations.
11 (u) Applicability of other state laws.--Health
12 insurers, health maintenance organizations, and their agents
13 are subject to the provisions of the Florida Insurance Code,
14 except for any such provisions waived in this section.
15 1. Except as expressly provided in this section, a law
16 requiring coverage for a specific health care service or
17 benefit, or a law requiring reimbursement, utilization, or
18 consideration of a specific category of licensed health care
19 practitioner, does not apply to an insurance health plan
20 policy or contract offered or delivered under ss.
21 409.810-409.820 unless that law is made expressly applicable
22 to such policies or contracts.
23 2. Notwithstanding chapter 641, a health maintenance
24 organization may issue contracts providing benefits equal to
25 the benchmark benefit plan authorized by this section.
26 Section 10. Section 409.816, Florida Statutes, is
27 created to read:
28 409.816 Limitations on premiums and cost-sharing.--The
29 following limitations on premiums and cost-sharing are
30 established for the program.
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1 (1) Enrollees who receive coverage under the Medicaid
2 program may not be required to pay:
3 (a) Enrollment fees, premiums, or similar charges; or
4 (b) Copayments, deductibles, coinsurance, or similar
5 charges.
6 (2) Enrollees in families with a family income equal
7 to or below 150 percent of the federal poverty level and who
8 are not receiving coverage under the Medicaid program may not
9 be required to pay:
10 (a) Enrollment fees, premiums, or similar charges that
11 exceed the maximum monthly charge permitted under s.
12 1916(b)(1) of the Social Security Act; or
13 (b) Copayments, deductibles, coinsurance, or similar
14 charges that exceed a nominal amount, as determined consistent
15 with regulations referred to in s. 1916(a)(3) of the Social
16 Security Act. However, such charges may not be imposed for
17 preventive services, including well-baby and well-child care,
18 age-appropriate immunizations, and routine hearing and vision
19 screenings.
20 (3) Enrollees in families with a family income above
21 150 percent of the federal poverty level and who are not
22 receiving coverage under the Medicaid program may be required
23 to pay enrollment fees, premiums, copayments, deductibles,
24 coinsurance, or similar charges on a sliding scale related to
25 income, except that the total annual aggregate cost-sharing
26 with respect to all children in a family may not exceed 5
27 percent of the family's income. However, copayments,
28 deductibles, coinsurance, or similar charges may not be
29 imposed for preventive services, including well-baby and
30 well-child care, age-appropriate immunizations, and routine
31 hearing and vision screenings.
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Florida Senate - 1998 SB 1228
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1 Section 11. Section 409.817, Florida Statutes, is
2 created to read:
3 409.817 Approval of health benefits coverage;
4 financial assistance.--In order for health benefits coverage
5 to qualify for premium assistance payments for an eligible
6 child under ss. 409.810-409.820, the health benefits coverage
7 must:
8 (1) Be certified by the Department of Insurance under
9 s. 409.818 as meeting, or exceeding, the benchmark benefit
10 plan;
11 (2) Be guarantee issued;
12 (3) For health insurance coverage, be community rated;
13 (4) Not impose any preexisting condition exclusion for
14 covered benefits; however, group health insurance plans may
15 permit the imposition of a preexisting condition exclusion,
16 but only insofar as it is permitted under s. 627.6561;
17 (5) Comply with the applicable limitations on premiums
18 and cost-sharing in s. 409.816;
19 (6) Comply with the quality assurance and access
20 standards developed under s. 409.820;
21 (7) Establish periodic open enrollment periods, which
22 may not occur more frequent than quarterly; and
23 (8) For alternative coverage, not cost more for the
24 benchmark benefit plan, on an average per child basis, than
25 the cost of coverage under the health insurance component of
26 the program.
27 Section 12. Section 409.818, Florida Statutes, is
28 created to read:
29 409.818 Administration.--In order to implement ss.
30 409.810-409.820, the following agencies shall have the
31 following duties:
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1 (1) The Department of Children and Family Services
2 shall:
3 (a) Develop a simplified eligibility application form
4 to be used for determining the eligibility of children for
5 coverage under the program in consultation with the agency,
6 the Department of Health, and the Florida Healthy Kids
7 Corporation. The simplified eligibility application form must
8 include an item that provides an opportunity for the applicant
9 to indicate whether coverage is being sought for a child with
10 special health care needs.
11 (b) Establish and maintain the eligibility
12 determination process under the program. The department shall
13 directly, or through the services of a contracted third-party
14 administrator, establish and maintain a process for
15 determining eligibility of children for coverage under the
16 program. The eligibility determination process must include an
17 initial determination of eligibility for any coverage offered
18 under the program, as well as a redetermination or
19 reverification of eligibility each subsequent 6 months. In
20 conducting an eligibility determination, the department shall
21 determine if the child has special health care needs.
22 (c) Inform program applicants about eligibility
23 determinations and that eligibility information may be shared
24 with the Medicaid program, the Florida Healthy Kids
25 Corporation, insurers and their agents, and alternative
26 coverage providers through a centralized coordinating office.
27 (d) Adopt rules necessary for conducting program
28 eligibility functions.
29 (2) The Department of Health shall:
30 (a) Design an eligibility intake process. The
31 eligibility intake process may include local intake points
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1 that are determined by the Department of Health in
2 coordination with the Department of Children and Family
3 Services.
4 (b) Design and implement program outreach activities
5 under s. 409.819.
6 (c) Adopt rules necessary to implement outreach
7 activities.
8 (3) The Agency for Health Care Administration, under
9 the authority granted in s. 409.914(1), shall:
10 (a) Calculate the annual benchmark premium. For the
11 first year of program operation, the benchmark premium shall
12 be an actuarially determined premium for the benchmark benefit
13 plan. For subsequent years, the benchmark premium shall be
14 calculated based on the average premiums for all health
15 insurance plans provided under the program.
16 (b) Calculate the premium assistance payment necessary
17 to comply with the premium and cost-sharing limitations
18 specified in s. 409.816. In calculating the premium assistance
19 payment levels for children with family coverage, the agency
20 shall set the premium assistance payment levels for each child
21 proportionately to the total cost of family coverage.
22 (c) Annually calculate the program enrollment ceiling
23 based on estimated per-child premium assistance payments and
24 the estimated appropriation available for the program.
25 (d) Make premium assistance payments to health
26 insurance plans on a periodic basis and reimburse alternative
27 coverage providers for covered services at Medicaid
28 reimbursement rates. The agency may use its Medicaid fiscal
29 agent or a contracted third-party administrator in making
30 these payments.
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1 (e) Monitor compliance with quality assurance and
2 access standards developed under s. 409.820.
3 (f) Establish a mechanism for investigating and
4 resolving complaints and grievances from program applicants,
5 enrollees, and health benefits coverage providers, and
6 maintain a record of complaints and confirmed problems. In the
7 case of a child who is enrolled in a health maintenance
8 organization, the agency must use the provisions of s. 641.511
9 to address grievance reporting and resolution requirements.
10 (g) Approve health benefits coverage for participation
11 in the program, following certification by the Department of
12 Insurance under subsection (3).
13 (h) Adopt rules necessary for calculating the annual
14 benchmark premium, calculating premium assistance payment
15 levels, calculating the program enrollment ceiling, making
16 premium assistance payments, monitoring access and quality
17 assurance standards, investigating and resolving complaints
18 and grievances, and approving health benefits coverage.
19 (4) The Department of Insurance shall certify that
20 health benefits coverage plans that seek to provide services
21 under the program, except those offered through the Florida
22 Healthy Kids Corporation, meet or exceed the benchmark benefit
23 plan and that health insurance plans will be offered at an
24 approved rate. The department shall adopt rules necessary for
25 certifying health benefits coverage plans.
26 (5) The Florida Healthy Kids Corporation shall retain
27 its functions as authorized in s. 624.91, with the exception
28 of its eligibility determination functions relating to
29 coverage under the Florida Kids Health program which shall be
30 assumed by the Department of Children and Family Services.
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1 (6) The Agency for Health Care Administration, in
2 conjunction with the Department of Health, shall seek a
3 federal waiver to authorize providers of alternative coverage
4 to participate in the program.
5 Section 13. Section 154.508, Florida Statutes, is
6 transferred, renumbered as section 409.819, Florida Statutes,
7 and amended to read:
8 409.819 154.508 Identification of low-income,
9 uninsured children; determination of Medicaid eligibility for
10 the Florida Kids Health program; alternative health care
11 information.--The Department of Health Agency for Health Care
12 Administration shall develop a program, in conjunction with
13 the Department of Education, the Department of Children and
14 Family Services, the Agency for Health Care Administration,
15 the Florida Healthy Kids Corporation the Department of Health,
16 local governments, employers school districts, and other
17 stakeholders to identify low-income, uninsured children and,
18 to the extent possible and subject to appropriation, refer
19 them to the Department of Children and Family Services for a
20 Medicaid eligibility determination and provide parents with
21 information about choices alternative sources of health
22 benefits coverage under the Florida Kids Health program care.
23 Section 14. Section 409.820, Florida Statutes, is
24 created to read:
25 409.820 Quality assurance and access standards.--The
26 Department of Health, in consultation with the agency and the
27 Florida Healthy Kids Corporation, shall develop a common set
28 of quality assurance and access standards for all program
29 components. The standards must include a process for granting
30 exceptions to specific requirements for quality assurance and
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1 access. Compliance with the standards shall be a condition of
2 program participation by health benefits coverage providers.
3 Section 15. The following performance measures and
4 standards are adopted for the Florida Kids Health program.--
5 (1) The total number of previously uninsured children
6 who receive health benefits coverage as a result of state
7 activities under Title XXI of the Social Security Act: 235,000
8 uninsured children expected to obtain coverage during the
9 1998-1999 fiscal year.
10 (a) The number of children enrolled in the Medicaid
11 program as a result of eligibility expansions under Title XXI
12 of the Social Security Act: 35,000 children enrolled in
13 Medicaid under new eligibility groups during the 1998-1999
14 fiscal year.
15 (b) The number of children enrolled in the Medicaid
16 program as a result of outreach efforts under Title XXI of the
17 Social Security Act who are eligible for Medicaid but who have
18 not enrolled in the program: 80,000 children previously
19 eligible for Medicaid, but not enrolled in Medicaid, who
20 enroll in Medicaid during the 1998-1999 fiscal year.
21 (c) The number of uninsured children added to the
22 enrollment for the Florida Healthy Kids Corporation program
23 under Title XXI of the Social Security Act: 60,000 additional
24 children enrolled in the Florida Healthy Kids Corporation
25 program during the 1998-1999 fiscal year.
26 (d) The number of uninsured children enrolled in
27 health insurance coverage under Title XXI of the Social
28 Security Act: 50,000 uninsured children enrolled in health
29 insurance coverage during the 1998-1999 fiscal year.
30 (e) The number of uninsured children enrolled in
31 alternative coverage offered under Title XXI of the Social
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1 Security Act: 10,000 uninsured children enrolled in
2 alternative coverage during the 1998-1999 fiscal year.
3 (2) The percentage of uninsured children in this state
4 as of July 1, 1998, who receive health benefits coverage under
5 the Florida Kids Health program: 28.5 percent of uninsured
6 children enrolled in the Florida Kids Health program during
7 the 1998-1999 fiscal year.
8 (3) The percentage of children enrolled in the Florida
9 Kids Health program with up-to-date immunizations: 80 percent
10 of enrolled children with up-to-date immunizations.
11 (4) The percentage of compliance with the standards
12 established in the Guidelines for Health Supervision of
13 Children and Youth as developed by the American Academy of
14 Pediatrics for children eligible for the Florida Kids Health
15 program and served under:
16 (a) Medicaid;
17 (b) The Florida Healthy Kids Corporation program;
18 (c) Health insurance products; and
19 (d) Alternative coverage.
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21 For each category of coverage, the health care provided is in
22 compliance with the health supervision standards for 80
23 percent of enrolled children.
24 Section 16. The sum of $20,360,500 is appropriated
25 from funds available under Title XXI of the Social Security
26 Act and shall be used for school health services during the
27 1998-1999 fiscal year.
28 Section 17. The provisions of this act which would
29 require changes to contracts in existence on June 30, 1998,
30 between the Florida Healthy Kids Corporation and its
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1 contracted providers shall be applied to such contracts upon
2 the renewal of the contracts, but not later than July 1, 1999.
3 Section 18. This act shall take effect July 1, 1998.
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6 SENATE SUMMARY
7 Creates the Florida Kids Health program to provide health
care benefits to uninsured, low-income children. Provides
8 for the program to include benefits provided under the
Medicaid program and the Florida Healthy Kids Corporation
9 program. Provides for an enrollment ceiling for the
program to be established each year in the General
10 Appropriations Act. Specifies the minimum benefits to be
provided under the program. Provides certain limitations
11 on and requirements for enrollment fees, copayments, and
similar charges. Requires the Department of Children and
12 Family Services to develop a process for determining
eligibility. Requires the Department of Health to design
13 an intake process and outreach activities for
administering the program. Requires that the Agency for
14 Health Care Administration calculate the annual benchmark
premium and enrollment ceiling, establish a mechanism for
15 investigating and resolving grievances, and approve
health benefits provided under the program. (See bill for
16 details.)
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