Senate Bill 1228c1
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Florida Senate - 1998 CS for SB 1228
By the Committee on Health Care and Senators Brown-Waite,
Myers, Bankhead, Burt, Silver and Forman
317-1874-98
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; creating s. 409.9045, F.S.;
8 providing for a period of continuous
9 eligibility for Medicaid for children; amending
10 s. 409.9126, F.S.; making the Children's
11 Medical Services network available to certain
12 children who are eligible for the Florida Kids
13 Health program; authorizing the inclusion of
14 behavioral health services as part of the
15 Children's Medical Services network;
16 establishing the reimbursement methodology for
17 services provided to certain children through
18 the Children's Medical Services network;
19 specifying that the Children's Medical Services
20 network is not subject to licensure under the
21 insurance code or rules of the Department of
22 Insurance; directing the Department of Health
23 to contract with the Department of Children and
24 Family Services for certain services for
25 children with special health care needs;
26 authorizing the Department of Children and
27 Family Services to establish certain standards
28 and guidelines; revising provisions to reflect
29 the transfer of duties to the Department of
30 Health; creating s. 409.810, F.S.; providing a
31 short title; creating s. 409.811, F.S.;
1
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1 providing definitions; creating s. 409.812,
2 F.S.; creating and providing the purpose for
3 the Florida Kids Health program; creating s.
4 409.813, F.S.; specifying program components;
5 specifying that certain program components are
6 not an entitlement; creating s. 409.8135, F.S.;
7 providing for program enrollment and
8 expenditure ceilings; creating s. 409.814,
9 F.S.; providing eligibility requirements;
10 creating s. 409.815, F.S.; establishing
11 requirements for health benefits coverage under
12 the Florida Kids Health program; creating s.
13 409.816, F.S.; providing for limitations on
14 premiums and cost-sharing; creating s. 409.817,
15 F.S.; providing for approval of health benefits
16 coverage as a condition of financial
17 assistance; creating s. 409.818, F.S.;
18 providing for program administration;
19 specifying duties of the Department of Children
20 and Family Services, the Department of Health,
21 the Agency for Health Care Administration, the
22 Department of Insurance, and the Florida
23 Healthy Kids Corporation; authorizing
24 application for federal waiver for alternative
25 coverage; authorizing certain program
26 modifications related to federal approval;
27 transferring, renumbering, and amending s.
28 154.508, F.S., relating to outreach activities
29 to identify low-income, uninsured children;
30 creating s. 409.820, F.S.; requiring that the
31 Department of Health develop standards for
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1 quality assurance and program access;
2 establishing performance measures and standards
3 for the Florida Kids Health program; repealing
4 s. 624.92, F.S.; deleting the requirement that
5 the Agency for Health Care Administration apply
6 for a Medicaid federal waiver relating to the
7 Healthy Kids Corporation; providing an
8 appropriation; providing for application of the
9 act to certain contracts between providers and
10 the Florida Healthy Kids Corporation; providing
11 an effective date.
12
13 Be It Enacted by the Legislature of the State of Florida:
14
15 Section 1. Section 409.904, Florida Statutes, is
16 amended to read:
17 409.904 Optional payments for eligible persons.--The
18 agency may make payments for medical assistance and related
19 services on behalf of the following persons who are determined
20 to be eligible subject to the income, assets, and categorical
21 eligibility tests set forth in federal and state law. Payment
22 on behalf of these Medicaid eligible persons is subject to the
23 availability of moneys and any limitations established by the
24 General Appropriations Act or chapter 216.
25 (1) A person who is age 65 or older or is determined
26 to be disabled, whose income is at or below 100 percent of
27 federal poverty level, and whose assets do not exceed
28 established limitations.
29 (2) A family, a pregnant woman, a child under age 18,
30 a person age 65 or over, or a blind or disabled person who
31 would be eligible under any group listed in s. 409.903(1),
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1 (2), or (3), except that the income or assets of such family
2 or person exceed established limitations. For a family or
3 person in this group, medical expenses are deductible from
4 income in accordance with federal requirements in order to
5 make a determination of eligibility. A family or person in
6 this group, which group is known as the "medically needy," is
7 eligible to receive the same services as other Medicaid
8 recipients, with the exception of services in skilled nursing
9 facilities and intermediate care facilities for the
10 developmentally disabled.
11 (3) A person who is in need of the services of a
12 licensed nursing facility, a licensed intermediate care
13 facility for the developmentally disabled, or a state mental
14 hospital, whose income does not exceed 300 percent of the SSI
15 income standard, and who meets the assets standards
16 established under federal and state law.
17 (4) A low-income person who meets all other
18 requirements for Medicaid eligibility except citizenship and
19 who is in need of emergency medical services. The eligibility
20 of such a recipient is limited to the period of the emergency,
21 in accordance with federal regulations.
22 (5) Subject to specific federal authorization, a
23 postpartum woman living in a family that has an income that is
24 at or below 185 percent of the most current federal poverty
25 level is eligible for family planning services as specified in
26 s. 409.905(3) for a period of up to 24 months following a
27 pregnancy for which Medicaid paid for pregnancy-related
28 services.
29 (6) A child under 1 year of age who lives in a family
30 whose income is above 185 percent of the most current federal
31 poverty level but equal to or below 200 percent of the most
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1 current federal poverty level. In determining the eligibility
2 of such a child, an assets test is not required.
3 (7) A child under 19 years of age who is not eligible
4 for coverage under subsection (6) or under s. 409.903(5), (6),
5 or (7) and who lives in a family whose income is at or below
6 100 percent of the most current federal poverty level. In
7 determining the eligibility of such a child, an assets test is
8 not required.
9 Section 2. Section 409.9045, Florida Statutes, is
10 created to read:
11 409.9045 Continuous eligibility for children.--Once a
12 child is determined eligible for Medicaid coverage under s.
13 409.903 or s. 409.904, the child is eligible for coverage
14 under the Medicaid program for 6 months without a
15 redetermination or reverification of eligibility.
16 Section 3. Section 409.9126, Florida Statutes, is
17 amended to read:
18 409.9126 Children with special health care needs.--
19 (1) As used in this section, the term:
20 (a) "Behavioral health services" means specialized
21 behavioral and substance abuse services for children with
22 serious emotional disturbances or substance abuse problems.
23 (b)(a) "Children's Medical Services network" means an
24 alternative service network that includes health care
25 providers and health care facilities specified in chapter 391
26 and ss. 383.15-383.21, 383.216, and 415.5055.
27 (c)(b) "Children with special health care needs" means
28 those children whose serious or chronic physical, behavioral,
29 or developmental conditions require extensive preventive and
30 maintenance care beyond that required by typically healthy
31 children. Health care utilization by these children exceeds
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1 the statistically expected usage of the normal child matched
2 for chronological age and often needs complex care requiring
3 multiple providers, rehabilitation services, and specialized
4 equipment in a number of different settings.
5 (2) The Legislature finds that Medicaid-eligible
6 children with special health care needs require a
7 comprehensive, continuous, and coordinated system of health
8 care that links community-based health care with
9 multidisciplinary, regional, and tertiary care. The
10 Legislature finds that Florida's Children's Medical Services
11 program provides a full continuum of coordinated,
12 comprehensive services for children with special health care
13 needs.
14 (3) Except as provided in subsections (8) and (9),
15 children eligible for Children's Medical Services who receive
16 Medicaid benefits, and other Medicaid-eligible children with
17 special health care needs, shall be exempt from the provisions
18 of s. 409.9122 and shall be served through the Children's
19 Medical Services network. The Children's Medical Services
20 network shall also be available to children with special
21 health care needs who are eligible for health benefits
22 coverage other than Medicaid through the Florida Kids Health
23 program.
24 (4) The Legislature directs the agency to apply to the
25 federal Health Care Financing Administration for a waiver to
26 assign to the Children's Medical Services network all
27 Medicaid-eligible children who meet the criteria for
28 participation in the Children's Medical Services program as
29 specified in s. 391.021(2), and other Medicaid-eligible
30 children with special health care needs.
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1 (5) The Children's Medical Services program shall
2 assign a qualified MediPass primary care provider from the
3 Children's Medical Services network who shall serve as the
4 gatekeeper and who shall be responsible for the provision or
5 authorization of all health services to a child who has been
6 assigned to the Children's Medical Services network by the
7 Medicaid program.
8 (6) Services provided to Medicaid-eligible children
9 through the Children's Medical Services network shall be
10 reimbursed on a fee-for-service basis and shall utilize a
11 primary care case management process. Reimbursement to the
12 Children's Medical Services Network for services provided to
13 children with special health care needs who are enrolled in
14 the Florida Kids Health program and who are not Medicaid
15 recipients shall be on a capitated basis. The agency, in
16 consultation with the Department of Health, shall establish an
17 enhanced benchmark premium for services provided by the
18 Children's Medical Services network to children with special
19 health care needs who are enrolled in the Florida Kids Health
20 program and who are not Medicaid recipients.
21 (7) The agency, in consultation with the Children's
22 Medical Services program, shall develop by rule
23 quality-of-care and service integration standards.
24 (8) The agency may issue a request for proposals,
25 based on the quality-of-care and service integration
26 standards, to allow managed care plans that have contracts
27 with the Medicaid program to provide services to
28 Medicaid-eligible children with special health care needs.
29 (9) The agency shall approve requests to provide
30 services to Medicaid-eligible children with special health
31 care needs from managed care plans that meet quality-of-care
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1 and service integration standards and are in good standing
2 with the agency. The agency shall monitor on a quarterly
3 basis managed care plans which have been approved to provide
4 services to Medicaid-eligible children with special health
5 care needs.
6 (10) The agency, in consultation with the Department
7 of Health and Rehabilitative Services, shall adopt rules that
8 address Medicaid requirements for referral, enrollment, and
9 disenrollment of children with special health care needs who
10 are enrolled in Medicaid managed care plans and who may
11 benefit from the Children's Medical Services network.
12 (11) The Children's Medical Services network may
13 contract with school districts participating in the certified
14 school match program pursuant to ss. 236.0812 and 409.908(21)
15 for the provision of school-based services, as provided for in
16 s. 409.9071, for Medicaid-eligible children who are enrolled
17 in the Children's Medical Services network.
18 (12) The Children's Medical Services network, when
19 providing services to children who receive Medicaid benefits,
20 other Medicaid-eligible children with special health care
21 needs, and children participating in the Florida Kids Health
22 Program who have special health care needs, shall not be
23 subject to the licensing requirements of the Florida Insurance
24 Code or rules of the Department of Insurance.
25 (13)(12) After 1 complete year of operation, the
26 agency shall conduct an evaluation of the Children's Medical
27 Services network. The evaluation shall include, but not be
28 limited to, an assessment of whether the use of the Children's
29 Medical Services network is less costly than the provision of
30 the services would have been in the Medicaid fee-for-service
31 program. The evaluation also shall include an assessment of
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1 patient satisfaction with the Children's Medical Services
2 network, an assessment of the quality of care delivered
3 through the network, and recommendations for further improving
4 the performance of the network. The agency shall report the
5 evaluation findings to the Governor and the chairpersons of
6 the appropriations and health care committees of each chamber
7 of the Legislature.
8 (14) In order to ensure a high level of integration of
9 physical and behavioral health care and to meet the more
10 intensive treatment needs of enrollees with the most serious
11 emotional disturbance or substance abuse problems, the
12 Department of Health shall contract with the Department of
13 Children and Family Services to provide behavioral health
14 services to children with special health care needs. The
15 Department of Children and Family Services in consultation
16 with the Department of Health, is authorized to establish the
17 following:
18 (a) The scope of behavioral health services, including
19 duration and frequency;
20 (b) Clinical guidelines for referral to behavioral
21 health services;
22 (c) Behavioral health services standards;
23 (d) Performance-based measures and outcomes for
24 behavioral health services;
25 (e) Practice guidelines for behavioral health services
26 to ensure cost-effective treatment and to prevent unnecessary
27 expenditures; and
28 (f) Rules to implement this subsection.
29 Section 4. Section 409.810, Florida Statutes, is
30 created to read:
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1 409.810 Short title.--Sections 409.810-409.820 may be
2 cited as the "Florida Kids Health Act."
3 Section 5. Section 409.811, Florida Statutes, is
4 created to read:
5 409.811 Definitions.--As used in ss. 409.810-409.820,
6 the term:
7 (1) "Agency" means the Agency for Health Care
8 Administration.
9 (2) "Alternative coverage" means health benefits
10 coverage provided through a community-based health-delivery
11 system authorized under s. 2105 of Title XXI of the Social
12 Security Act, subject to federal approval of a waiver request.
13 Such health-delivery system may include, but is not limited
14 to:
15 (a) A network of health care providers owned,
16 operated, or under contract with a county, political
17 subdivision, or tax district;
18 (b) A rural health network established under s.
19 381.0406;
20 (c) A federally qualified health center that receives
21 funds under s. 330 of the Public Health Service Act;
22 (d) A migrant health center that receives funds under
23 s. 329 of the Public Health Service Act; or
24 (e) A hospital that receives Medicaid disproportionate
25 share payments under s. 409.911.
26 (3) "Applicant" means a parent or guardian of a child
27 or a child whose disability of nonage has been removed under
28 chapter 743 who applies for determination of eligibility for
29 health benefits coverage under ss. 409.810-409.820.
30 (4) "Benchmark benefit plan" means the form and level
31 of health benefits coverage established in s. 409.815.
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1 (5) "Benchmark premium" means the premium ceiling
2 price for which federal and state assistance payments are
3 available.
4 (6) "Child" means any person under 19 years of age.
5 (7) "Child with special health care needs" means a
6 child whose serious or chronic physical or developmental
7 condition requires extensive preventive and maintenance care
8 beyond that required by typically healthy children. Health
9 care utilization by such a child exceeds the statistically
10 expected usage of the normal child matched for chronological
11 age and such child often needs complex care requiring multiple
12 providers, rehabilitation services, and specialized equipment
13 in a number of different settings.
14 (8) "Community rate" means a method used to develop
15 premiums for a health insurance plan that spreads financial
16 risk across a large population.
17 (9) "Enrollee" means a child who has been determined
18 eligible for and is receiving coverage under ss.
19 409.810-409.820.
20 (10) "Enrollment ceiling" means the maximum number of
21 children, excluding children enrolled in Medicaid, that may be
22 enrolled at any time in the Florida Kids Health program. The
23 maximum number shall be established annually in the General
24 Appropriations Act or by general law.
25 (11) "Family" means the group or the individuals whose
26 income is considered in determining eligibility for the
27 Florida Kids Health program. The family includes a child,
28 custodial parent, or caretaker relative who resides in the
29 same house or living unit or, in the case of a child whose
30 disability of nonage has been removed under chapter 473, the
31 child. The family may also include individuals whose income
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1 and resources are considered in whole or in part in
2 determining eligibility of the child.
3 (12) "Family income" means cash received at periodic
4 intervals from any source, such as wages, benefits,
5 contributions, or rental property. Income also may include any
6 money that would have been counted as income under the AFDC
7 state plan in effect prior to August 22, 1996.
8 (13) "Guarantee issue" means the health benefits
9 coverage that must be offered to an individual regardless of
10 the individual's health status, preexisting condition, or
11 claims history.
12 (14) "Health benefits coverage" means protection that
13 provides payment of benefits for covered health care services
14 or that otherwise provides, either directly or through
15 arrangements with other persons, covered health care services
16 on a prepaid per capita basis or on a prepaid aggregate
17 fixed-sum basis.
18 (15) "Health insurance plan" means health benefits
19 coverage under the following:
20 (a) A health plan offered by any certified health
21 maintenance organization or authorized health insurer, except
22 a plan that is limited to the following: a limited benefit,
23 specified disease, or specified accident; hospital indemnity;
24 accident only; limited benefit convalescent care; Medicare
25 supplement; credit disability; dental; vision; long-term care;
26 disability income; coverage issued as a supplement to another
27 health plan; workers' compensation liability or other
28 insurance; or motor vehicle medical payment only; or
29 (b) An employee welfare benefit plan that includes
30 health benefits established under the Employee Retirement
31 Income Security Act of 1974, as amended.
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1 (16) "Medicaid" means the medical assistance program
2 authorized by Title XIX of the Social Security Act, and
3 regulations thereunder, and ss. 409.901-409.9205, as
4 administered in this state by the agency.
5 (17) "Medically necessary" means the use of any
6 medical treatment, service, equipment, or supply necessary to
7 palliate the effects of a terminal condition, or to prevent,
8 diagnose, correct, cure, alleviate, or preclude deterioration
9 of a condition that threatens life, causes pain or suffering,
10 or results in illness or infirmity and which is:
11 (a) Consistent with the symptom, diagnosis, and
12 treatment of the enrollee's condition;
13 (b) Provided in accordance with generally accepted
14 standards of medical practice;
15 (c) Not primarily intended for the convenience of the
16 enrollee, the enrollee's family, or the health care provider;
17 (d) The most appropriate level of supply or service
18 for the diagnosis and treatment of the enrollee's condition;
19 and
20 (e) Approved by the appropriate medical body or health
21 care specialty involved as effective, appropriate, and
22 essential for the care and treatment of the enrollee's
23 condition.
24 (18) "Preexisting condition exclusion" means, with
25 respect to coverage, a limitation or exclusion of benefits
26 relating to a condition based on the fact that the condition
27 was present before the date of enrollment for such coverage,
28 whether or not any medical advice, diagnosis, care, or
29 treatment was recommended or received before such date.
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1 (19) "Premium" means the entire cost of an insurance
2 plan, including the administration fee or the risk assumption
3 charge.
4 (20) "Premium assistance payment" means the monthly
5 consideration paid by the agency per enrollee in the Florida
6 Kids Health program towards health insurance premiums.
7 (21) "Program" means the Florida Kids Health program,
8 the medical assistance program authorized by Title XXI of the
9 Social Security Act as part of the federal Balanced Budget Act
10 of 1997.
11 (22) "Qualified alien" means an alien as defined in s.
12 431 of the Personal Responsibility and Work Opportunity
13 Reconciliation Act of 1996, as amended, Pub. L. No. 104-193.
14 (23) "Resident" means a United States citizen, or
15 qualified alien, who is domiciled in this state.
16 (24) "Rural" means an area with a population density
17 of less than 100 individuals per square mile or an area
18 defined by the most recent United States Census as rural.
19 Section 6. Section 409.812, Florida Statutes, is
20 created to read:
21 409.812 Program created; purpose.--The Florida Kids
22 Health program is created to provide a defined set of health
23 benefits to previously uninsured, low-income children through
24 the establishment of a variety of affordable health benefits
25 coverage options from which families may select coverage and
26 through which families may contribute financially to the
27 health care of their children.
28 Section 7. Section 409.813, Florida Statutes, is
29 created to read:
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1 409.813 Program components; entitlement and
2 nonentitlement.--The Florida Kids Health program includes
3 health benefits coverage provided to children through:
4 (1) Medicaid;
5 (2) The Florida Healthy Kids Corporation program as
6 created in s. 624.91;
7 (3) Health insurance plans approved under ss.
8 409.810-409.820;
9 (4) The Children's Medical Services network
10 established in s. 409.9126; and
11 (5) Alternative coverage approved under ss.
12 409.810-409.820.
13
14 Except for coverage under the Medicaid program, coverage under
15 the Florida Kids Health program is not an entitlement.
16 Section 8. Section 409.8135, Florida Statutes, is
17 created to read:
18 409.8135 Program enrollment and expenditure
19 ceilings.--
20 (1) Except for the Medicaid program, a ceiling shall
21 be placed on annual federal and state expenditures and on
22 enrollment in the Florida Kids Health program as provided each
23 year in the General Appropriations Act. The agency, in
24 consultation with the Department of Health, may propose to
25 increase the enrollment ceiling in accordance with chapter
26 216.
27 (2) Except for the Medicaid program, whenever the
28 Social Services Estimating Conference determines that there is
29 presently, or will be by the end of the current fiscal year,
30 insufficient funds to finance the current or projected
31 enrollment in the program, all additional enrollment must
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1 cease and additional enrollment may not resume until
2 sufficient funds are available to finance such enrollment.
3 (3) The agency shall collect and analyze the data
4 needed to project program enrollment, including participation
5 rates, caseloads, and expenditures. The agency shall report
6 the caseload and expenditure trends to the Social Services
7 Estimating Conference in accordance with chapter 216.
8 Section 9. Section 409.814, Florida Statutes, is
9 created to read:
10 409.814 Eligibility.--A child whose family income is
11 equal to or below 200 percent of the federal poverty level is
12 eligible for the Florida Kids Health program as provided in
13 this section. In determining the eligibility of such a child,
14 an assets test is not required.
15 (1) A child who is eligible for Medicaid coverage
16 under s. 409.903 or s. 409.904 must be enrolled in Medicaid
17 and is not eligible to receive health benefits under any other
18 health benefits coverage authorized under ss. 409.810-409.820.
19 (2) A child who is not eligible for Medicaid, but who
20 is eligible for the program, may obtain coverage under any of
21 the other types of health benefits coverage authorized in ss.
22 409.810-409.820 if such coverage is approved and available in
23 the county in which the child resides.
24 (3) A child who is eligible for the program under
25 subsection (1) or (2) and who is a child with special health
26 care needs, as determined through a risk-screening instrument,
27 is eligible for health benefits coverage from and may be
28 referred to the Children's Medical Services network.
29 (4) The following children are not eligible to receive
30 health benefits coverage under ss. 409.810-409.820, except
31
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1 under Medicaid if the child would have been eligible for
2 Medicaid under s. 409.903 or s. 409.904 as of June 1, 1997:
3 (a) A child who is eligible for coverage under a state
4 health benefits plan on the basis of a family member's
5 employment with a public agency in the state;
6 (b) A child who is covered, or who has been covered
7 during the 6 months prior to submission of an application for
8 determination of eligibility under the program, under a group
9 health benefit plan or under other health insurance coverage,
10 excluding coverage provided under the Florida Healthy Kids
11 Corporation as established under s. 624.91;
12 (c) A child who is an alien, but who does not meet the
13 definition of qualified alien, in the United States; or
14 (d) A child who is an inmate of a public institution
15 or a patient in an institution for mental diseases.
16 (5) A child whose family income is above 200 percent
17 of the federal poverty level may participate in the program;
18 however, the family is not eligible for premium assistance
19 payments and must pay the full cost of the premium. Children
20 described in this subsection may not be counted in the annual
21 enrollment ceiling for the Florida Kids Health program.
22 (6) Once a child is determined eligible for the
23 program, the child is eligible for coverage under the program
24 for 6 months without a redetermination or reverification of
25 eligibility if the family continues to pay the applicable
26 premium.
27 Section 10. Section 409.815, Florida Statutes, is
28 created to read:
29 409.815 Health benefits coverage; limitations.--
30 (1) MEDICAID BENEFITS.--For purposes of this program,
31 benefits available under the Medicaid program include those
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1 goods and services provided under the medical assistance
2 program authorized by Title XIX of the Social Security Act,
3 and regulations thereunder, as administered in this state by
4 the agency. This includes those mandatory Medicaid services
5 authorized under s. 409.905 and optional Medicaid services
6 authorized under s. 409.906, rendered on behalf of eligible
7 individuals by qualified providers, in accordance with federal
8 requirements for Title XIX, subject to any limitations or
9 directions provided for in the General Appropriations Act or
10 chapter 216, and according to methodologies and limitations
11 set forth in agency rules and policy manuals and handbooks
12 incorporated by reference thereto.
13 (2) BENCHMARK BENEFITS.--In order for health benefits
14 coverage to qualify for premium assistance payments for an
15 eligible child under ss. 409.810-409.820, the health benefits
16 coverage, except for coverage under the Medicaid program, must
17 include the following minimum benefits as medically necessary.
18 (a) Preventive health services.--Covered services
19 include:
20 1. Well-child care, including services recommended in
21 the Guidelines for Health Supervision of Children and Youth as
22 developed by the American Academy of Pediatrics;
23 2. Immunizations and injections;
24 3. Health education counseling and clinical services;
25 4. Vision screening; and
26 5. Hearing screening.
27 (b) Inpatient hospital services.--All covered services
28 provided for the medical care and treatment of an enrollee who
29 is admitted as an inpatient to a hospital licensed under part
30 I of chapter 395, with the following exceptions:
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1 1. All admissions must be authorized by the enrollee's
2 health 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.
6 3. Room and board may be limited to semiprivate
7 accommodations unless a private room is considered medically
8 necessary or semiprivate accommodations are not available.
9 4. Admissions for rehabilitation and physical therapy
10 are limited to 15 days per contract year.
11 (c) Emergency services.--Covered services include
12 visits to an emergency room or other licensed facility if
13 needed immediately due to an injury or illness and delay means
14 risk of permanent damage to the enrollee's health.
15 (d) Maternity services.--Covered services include
16 maternity and newborn care, including prenatal and postnatal
17 care with the following limitations:
18 1. Coverage may be limited to the fee for vaginal
19 deliveries; and
20 2. Initial inpatient care for newborn infants of
21 enrolled adolescents shall be covered, including normal
22 newborn care, nursery charges, and the initial pediatric or
23 neonatal examination, and the infant may be covered for up to
24 3 days following birth.
25 (e) Organ transplantation services.--Covered services
26 include pretransplant, transplant, and postdischarge services
27 and treatment of complications after transplantation for
28 transplants deemed necessary and appropriate within the
29 guidelines set by the Agency for Health Care Administration
30 Organ Transplant Advisory Council under s. 381.0602 or the
31
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1 Agency for Health Care Administration Bone Marrow Transplant
2 Advisory Panel under s. 627.4236.
3 (f) Outpatient services.--Covered services include
4 preventive, diagnostic, therapeutic, palliative care, and
5 other services provided to an enrollee in the outpatient
6 portion of a health facility licensed under chapter 395,
7 except for the following limitations:
8 1. Services must be authorized by the enrollee's
9 health benefits coverage provider; and
10 2. Treatment for temporomandibular joint disease (TMJ)
11 is specifically excluded.
12 (g) Behavioral health services.--
13 1. Mental health benefits include:
14 a. Inpatient services, limited to not more than 30
15 inpatient days per contract year for psychiatric admissions or
16 30 days of residential services in lieu of inpatient
17 psychiatric admission; and
18 b. Outpatient services, including outpatient visits
19 for psychological or psychiatric evaluation, diagnosis, and
20 treatment by a licensed mental health professional, limited to
21 a maximum of 40 outpatient visits each contract year.
22 2. Substance abuse services include:
23 a. Inpatient services limited to no more than 7
24 inpatient days per contract year for medical detoxification
25 only and 30 days of residential services; and
26 b. Outpatient services, including evaluation,
27 diagnosis, and treatment by a licensed practitioner, limited
28 to a maximum of 40 outpatient visits per contract year.
29 (h) Durable medical equipment.--Covered services
30 include equipment and devices that are medically indicated to
31 assist in the treatment of a medical condition and
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1 specifically prescribed as medically necessary, with the
2 following limitations:
3 1. Low vision and telescopic aides are not included.
4 2. Corrective lenses and frames may be limited to one
5 pair every 2 years, unless the prescription or head size of
6 the enrollee changes.
7 3. Hearing aids shall be covered only when medically
8 indicated to assist in the treatment of a medical condition.
9 4. Covered prosthetic devices include artificial eyes
10 and limbs, braces, and other artificial aids.
11 (i) Health practitioner services.--Covered services
12 include services and procedures rendered to an enrollee when
13 performed to diagnose and treat diseases, injuries, or other
14 conditions, including care rendered by health practitioners
15 acting within the scope of their practice, with the following
16 exceptions:
17 1. Chiropractic services shall be covered with the
18 same benefits and limitations as provided under the Florida
19 Medicaid program.
20 2. Podiatric services may be limited to one visit per
21 day totaling two visits per month for specific foot disorders.
22 (j) Home health services.--Covered services include
23 prescribed home visits by both registered and licensed
24 practical nurses to provide skilled nursing services on a
25 part-time intermittent basis, subject to the following
26 limitations:
27 1. Coverage may be limited to include skilled nursing
28 services only;
29 2. Meals, housekeeping, and personal comfort items may
30 be excluded; and
31
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1 3. Private duty nursing is limited to circumstances
2 where such care is medically necessary.
3 (k) Hospice services.--Covered services include
4 reasonable and necessary services for palliation or management
5 of an enrollee's terminal illness, with the following
6 exceptions:
7 1. Once a family elects to receive hospice care for an
8 enrollee, other services that treat the terminal condition
9 will not be covered; and
10 2. Services required for conditions totally unrelated
11 to the terminal condition are covered to the extent that the
12 services are included in this section.
13 (l) Laboratory and X-ray services.--Covered services
14 include diagnostic testing, including clinical radiologic,
15 laboratory, and other diagnostic tests.
16 (m) Nursing facility services.--Covered services
17 include regular nursing services, rehabilitation services,
18 drugs and biologicals, medical supplies, and the use of
19 appliances and equipment furnished by the facility, with the
20 following limitations:
21 1. All admissions must be authorized by the health
22 benefits coverage provider.
23 2. The length of the patient stay shall be determined
24 on the medical condition of the enrollee in relation to the
25 necessary and appropriate level of care, but is limited to not
26 more than 100 days per contract year.
27 3. Room and board may be limited to semiprivate
28 accommodations, unless a private room is considered medically
29 necessary or semiprivate accommodations are not available.
30 4. Specialized treatment centers and independent
31 kidney disease treatment centers are excluded.
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1 5. Private duty nurses, television, and custodial care
2 are excluded.
3 6. Admissions for rehabilitation and physical therapy
4 are limited to 15 days per contract year.
5 (n) Prescribed drugs.--
6 1. Coverage shall include drugs prescribed for the
7 treatment of illness or injury when prescribed by a licensed
8 health practitioner acting within the scope of his or her
9 practice.
10 2. Prescribed drugs may be limited to generics if
11 available and brand name products if a generic substitution is
12 not available, unless the prescribing licensed health
13 practitioner indicates that a brand name is medically
14 necessary.
15 3. Prescribed drugs covered under this section shall
16 include all prescribed drugs covered under the Florida
17 Medicaid program.
18 (o) Dental health services.--Covered services include
19 diagnostic, preventive, restorative, endodontic, periodontal,
20 surgical, and limited prosthodontic services, excluding
21 orthodontics. Dental health services for children covered
22 under this section shall include the limits established for
23 children under the Florida Medicaid Dental Program.
24 (p) Therapy services.--Covered services include
25 rehabilitative services, including occupational, physical,
26 respiratory, and speech therapies, with the following
27 limitations:
28 1. Services must be for short-term rehabilitation
29 where significant improvement in the enrollee's condition will
30 result; and
31
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1 2. Services shall be no more than twenty-four
2 treatment sessions within a 60-day period per episode or
3 injury, with the 60-day period beginning with the first
4 treatment.
5 (q) Transportation services.--Covered services include
6 emergency transportation required in response to an emergency
7 situation.
8 (r) Lifetime maximum.--Health benefits coverage
9 obtained under ss. 409.810-409.820 shall pay an enrollee's
10 covered expenses at a lifetime maximum of $1 million per
11 covered child.
12 (s) Cost-sharing.--Cost-sharing provisions must comply
13 with s. 409.816.
14 (t) Exclusions.--
15 1. Experimental or investigational procedures that
16 have not been clinically proven by reliable evidence are
17 excluded;
18 2. Services performed for cosmetic purposes only or
19 for the convenience of the enrollee are excluded; and
20 3. Abortion may be covered only if necessary to save
21 the life of the mother or if the pregnancy is the result of an
22 act of rape or incest.
23 (u) Enhancements to minimum requirements.--
24 1. This section sets the minimum benefits that must be
25 included in any health benefits coverage, other than Medicaid
26 coverage, offered under ss. 409.810-409.820. Health benefits
27 coverage may include additional benefits not included under
28 this subsection, but may not include benefits excluded under
29 paragraph (h).
30 2. Health benefits coverage may extend any limitations
31 beyond the minimum benefits described in this section.
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1
2 Except for the Children's Medical Services network, the agency
3 may not adjust the benchmark premium for either additional
4 benefits provided beyond the minimum benefits described in
5 this section or the imposition of less restrictive service
6 limitations.
7 (v) Applicability of other state laws.--Health
8 insurers, health maintenance organizations, and their agents
9 are subject to the provisions of the Florida Insurance Code,
10 except for any such provisions waived in this section.
11 1. Except as expressly provided in this section, a law
12 requiring coverage for a specific health care service or
13 benefit, or a law requiring reimbursement, utilization, or
14 consideration of a specific category of licensed health care
15 practitioner, does not apply to an insurance health plan
16 policy or contract offered or delivered under ss.
17 409.810-409.820 unless that law is made expressly applicable
18 to such policies or contracts.
19 2. Notwithstanding chapter 641, a health maintenance
20 organization may issue contracts providing benefits equal to
21 the benchmark benefit plan authorized by this section.
22 Section 11. Section 409.816, Florida Statutes, is
23 created to read:
24 409.816 Limitations on premiums and cost-sharing.--The
25 following limitations on premiums and cost-sharing are
26 established for the program.
27 (1) Enrollees who receive coverage under the Medicaid
28 program may not be required to pay:
29 (a) Enrollment fees, premiums, or similar charges; or
30 (b) Copayments, deductibles, coinsurance, or similar
31 charges.
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1 (2) Enrollees in families with a family income equal
2 to or below 150 percent of the federal poverty level and who
3 are not receiving coverage under the Medicaid program may not
4 be required to pay:
5 (a) Enrollment fees, premiums, or similar charges that
6 exceed the maximum monthly charge permitted under s.
7 1916(b)(1) of the Social Security Act; or
8 (b) Copayments, deductibles, coinsurance, or similar
9 charges that exceed a nominal amount, as determined consistent
10 with regulations referred to in s. 1916(a)(3) of the Social
11 Security Act. However, such charges may not be imposed for
12 preventive services, including well-baby and well-child care,
13 age-appropriate immunizations, and routine hearing and vision
14 screenings.
15 (3) Enrollees in families with a family income above
16 150 percent of the federal poverty level and who are not
17 receiving coverage under the Medicaid program may be required
18 to pay enrollment fees, premiums, copayments, deductibles,
19 coinsurance, or similar charges on a sliding scale related to
20 income, except that the total annual aggregate cost-sharing
21 with respect to all children in a family may not exceed 5
22 percent of the family's income. However, copayments,
23 deductibles, coinsurance, or similar charges may not be
24 imposed for preventive services, including well-baby and
25 well-child care, age-appropriate immunizations, and routine
26 hearing and vision screenings.
27 Section 12. Section 409.817, Florida Statutes, is
28 created to read:
29 409.817 Approval of health benefits coverage;
30 financial assistance.--In order for health insurance coverage
31 to qualify for premium assistance payments or for alternative
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1 coverage providers to qualify for reimbursement for an
2 eligible child under ss. 409.810-409.820, the health benefits
3 coverage must:
4 (1) Be certified by the Department of Insurance under
5 s. 409.818 as meeting, or exceeding, the benchmark benefit
6 plan;
7 (2) Be guarantee issued;
8 (3) For health insurance coverage, be community rated;
9 (4) Not impose any preexisting condition exclusion for
10 covered benefits; however, group health insurance plans may
11 permit the imposition of a preexisting condition exclusion,
12 but only insofar as it is permitted under s. 627.6561;
13 (5) Comply with the applicable limitations on premiums
14 and cost-sharing in s. 409.816;
15 (6) Comply with the quality assurance and access
16 standards developed under s. 409.820;
17 (7) Establish periodic open enrollment periods, which
18 may not occur more frequent than quarterly; and
19 (8) For alternative coverage:
20 (a) Not cost more for the benchmark benefit plan, on
21 an average per-child basis, than the cost of coverage under
22 the health insurance component of the program;
23 (b) Meet all applicable marketing, enrollment, and
24 disenrollment requirements and restrictions under the Florida
25 Insurance Code; and
26 (c) Be provided in a rural county where there is no
27 prepaid health plan participating in the Medicaid program as
28 of July 1, 1998, and there are no other health benefits
29 coverage providers approved under the program.
30 Section 13. Section 409.818, Florida Statutes, is
31 created to read:
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1 409.818 Administration.--In order to implement ss.
2 409.810-409.820, the following agencies shall have the
3 following duties:
4 (1) The Department of Children and Family Services
5 shall:
6 (a) Develop a simplified eligibility application
7 mail-in form to be used for determining the eligibility of
8 children for coverage under the program in consultation with
9 the agency, the Department of Health, and the Florida Healthy
10 Kids Corporation. The simplified eligibility application form
11 must include an item that provides an opportunity for the
12 applicant to indicate whether coverage is being sought for a
13 child with special health care needs.
14 (b) Establish and maintain the eligibility
15 determination process under the program. The department shall
16 directly, or through the services of a contracted third-party
17 administrator, establish and maintain a process for
18 determining eligibility of children for coverage under the
19 program. The eligibility determination process must be used
20 solely for determining eligibility of applicants for health
21 benefits coverage under the program. The eligibility
22 determination process must include an initial determination of
23 eligibility for any coverage offered under the program, as
24 well as a redetermination or reverification of eligibility
25 each subsequent 6 months. In conducting an eligibility
26 determination, the department shall determine if the child has
27 special health care needs.
28 (c) Inform program applicants about eligibility
29 determinations and provide information about eligibility of
30 applicants to the Medicaid program, the Children's Medical
31 Services network, the Florida Healthy Kids Corporation,
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1 insurers and their agents, and alternative coverage providers
2 through a centralized coordinating office.
3 (d) Adopt rules necessary for conducting program
4 eligibility functions.
5 (2) The Department of Health shall:
6 (a) Design an eligibility intake process for the
7 program, in coordination with the Department of Children and
8 Family Services, the agency, and the Florida Healthy Kids
9 Corporation. The eligibility intake process may include local
10 intake points that are determined by the Department of Health
11 in coordination with the Department of Children and Family
12 Services.
13 (b) Design and implement program outreach activities
14 under s. 409.819.
15 (c) Chair a state-level coordinating council for the
16 program to review and make recommendations concerning the
17 implementation and operation of the program. The coordinating
18 council shall include representatives from the department, the
19 Department of Children and Family Services, the agency, the
20 Florida Healthy Kids Corporation, the Department of Insurance,
21 health insurers, and alternative-coverage providers.
22 (d) Adopt rules necessary to implement outreach
23 activities.
24 (3) The Agency for Health Care Administration, under
25 the authority granted in s. 409.914(1), shall:
26 (a) Calculate the annual benchmark premium. For the
27 first year of program operation, the benchmark premium shall
28 be an actuarially determined premium for the benchmark benefit
29 plan. For subsequent years, the benchmark premium shall be
30 calculated based on the average premiums for all health
31 insurance plans provided under the program.
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1 (b) Calculate the premium assistance payment necessary
2 to comply with the premium and cost-sharing limitations
3 specified in s. 409.816. In calculating the premium assistance
4 payment levels for children with family coverage, the agency
5 shall set the premium assistance payment levels for each child
6 proportionately to the total cost of family coverage.
7 (c) Annually calculate the program enrollment ceiling
8 based on estimated per-child premium assistance payments and
9 the estimated appropriation available for the program.
10 (d) Make premium assistance payments to health
11 insurance plans on a periodic basis and reimburse alternative
12 coverage providers for covered services at Medicaid
13 reimbursement rates. The agency may use its Medicaid fiscal
14 agent or a contracted third-party administrator in making
15 these payments.
16 (e) Monitor compliance with quality assurance and
17 access standards developed under s. 409.820.
18 (f) Establish a mechanism for investigating and
19 resolving complaints and grievances from program applicants,
20 enrollees, and health benefits coverage providers, and
21 maintain a record of complaints and confirmed problems. In the
22 case of a child who is enrolled in a health maintenance
23 organization, the agency must use the provisions of s. 641.511
24 to address grievance reporting and resolution requirements.
25 (g) Approve health benefits coverage for participation
26 in the program, following certification by the Department of
27 Insurance under subsection (3).
28 (h) Adopt rules necessary for calculating the annual
29 benchmark premium, calculating premium assistance payment
30 levels, calculating the program enrollment ceiling, making
31 premium assistance payments, monitoring access and quality
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1 assurance standards, investigating and resolving complaints
2 and grievances, and approving health benefits coverage.
3 (4) The Department of Insurance shall certify that
4 health benefits coverage plans that seek to provide services
5 under the program, except those offered through the Florida
6 Healthy Kids Corporation or the Children's Medical Services
7 network, meet or exceed the benchmark benefit plan and that
8 health insurance plans will be offered at an approved rate.
9 The department shall adopt rules necessary for certifying
10 health benefits coverage plans.
11 (5) The Florida Healthy Kids Corporation shall retain
12 its functions as authorized in s. 624.91, with the exception
13 of its eligibility determination functions relating to
14 coverage under the Florida Kids Health program which shall be
15 assumed by the Department of Children and Family Services.
16 (6) The Agency for Health Care Administration, in
17 conjunction with the Department of Health, shall seek a
18 federal waiver to authorize providers of alternative coverage
19 to participate in the program.
20 (7) The Agency for Health Care Administration, the
21 Department of Health, the Department of Children and Family
22 Services, and the Department of Insurance have the authority
23 to make program modifications and adopt rules not inconsistent
24 with the administrative responsibilities and rulemaking
25 authority granted in this section which are necessary to
26 overcome any objections of the federal Department of Health
27 and Human Services and obtain approval of the state's child
28 health plan under Title XXI of the Social Security Act and a
29 waiver to authorize participation of alternative-coverage
30 providers.
31
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1 Section 14. Section 154.508, Florida Statutes, is
2 transferred, renumbered as section 409.819, Florida Statutes,
3 and amended to read:
4 409.819 154.508 Identification of low-income,
5 uninsured children; determination of Medicaid eligibility for
6 the Florida Kids Health program; alternative health care
7 information.--The Department of Health Agency for Health Care
8 Administration shall develop a program, in conjunction with
9 the Department of Education, the Department of Children and
10 Family Services, the Agency for Health Care Administration,
11 the Florida Healthy Kids Corporation the Department of Health,
12 local governments, employers school districts, and other
13 stakeholders to identify low-income, uninsured children and,
14 to the extent possible and subject to appropriation, refer
15 them to the Department of Children and Family Services for a
16 Medicaid eligibility determination and provide parents with
17 information about choices alternative sources of health
18 benefits coverage under the Florida Kids Health program care.
19 These activities shall include, but not be limited to:
20 training community providers in effective methods of outreach;
21 conducting public information campaigns designed to publicize
22 the Florida Kids Health program, the eligibility requirements
23 of the program, and the procedures for enrollment in the
24 program; and maintaining public awareness of the Florida Kids
25 Health program.
26 Section 15. Section 409.820, Florida Statutes, is
27 created to read:
28 409.820 Quality assurance and access standards.--The
29 Department of Health, in consultation with the agency and the
30 Florida Healthy Kids Corporation, shall develop a common set
31 of quality assurance and access standards for all program
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1 components. The standards must include a process for granting
2 exceptions to specific requirements for quality assurance and
3 access. Compliance with the standards shall be a condition of
4 program participation by health benefits coverage providers.
5 Section 16. The following performance measures and
6 standards are adopted for the Florida Kids Health program.--
7 (1) The total number of previously uninsured children
8 who receive health benefits coverage as a result of state
9 activities under Title XXI of the Social Security Act: 235,000
10 uninsured children expected to obtain coverage during the
11 1998-1999 fiscal year.
12 (a) The number of children enrolled in the Medicaid
13 program as a result of eligibility expansions under Title XXI
14 of the Social Security Act: 35,000 children enrolled in
15 Medicaid under new eligibility groups during the 1998-1999
16 fiscal year.
17 (b) The number of children enrolled in the Medicaid
18 program as a result of outreach efforts under Title XXI of the
19 Social Security Act who are eligible for Medicaid but who have
20 not enrolled in the program: 80,000 children previously
21 eligible for Medicaid, but not enrolled in Medicaid, who
22 enroll in Medicaid during the 1998-1999 fiscal year.
23 (c) The number of uninsured children added to the
24 enrollment for the Florida Healthy Kids Corporation program
25 under Title XXI of the Social Security Act: 60,000 additional
26 children enrolled in the Florida Healthy Kids Corporation
27 program during the 1998-1999 fiscal year.
28 (d) The number of uninsured children enrolled in
29 health insurance coverage under Title XXI of the Social
30 Security Act: 50,000 uninsured children enrolled in health
31 insurance coverage during the 1998-1999 fiscal year.
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1 (e) The number of uninsured children enrolled in
2 alternative coverage offered under Title XXI of the Social
3 Security Act: 5,000 uninsured children enrolled in alternative
4 coverage during the 1998-1999 fiscal year.
5 (f) The number of uninsured children enrolled in the
6 Children's Medical Services network under Title XXI of the
7 Social Security Act: 5,000 uninsured children enrolled in the
8 Children's Medical Services network during the 1998-1999
9 fiscal year.
10 (2) The percentage of uninsured children in this state
11 as of July 1, 1998, who receive health benefits coverage under
12 the Florida Kids Health program: 28.5 percent of uninsured
13 children enrolled in the Florida Kids Health program during
14 the 1998-1999 fiscal year.
15 (3) The percentage of children enrolled in the Florida
16 Kids Health program with up-to-date immunizations: 80 percent
17 of enrolled children with up-to-date immunizations.
18 (4) The percentage of compliance with the standards
19 established in the Guidelines for Health Supervision of
20 Children and Youth as developed by the American Academy of
21 Pediatrics for children eligible for the Florida Kids Health
22 program and served under:
23 (a) Medicaid;
24 (b) The Florida Healthy Kids Corporation program;
25 (c) Health insurance products; and
26 (d) Alternative coverage.
27
28 For each category of coverage, the health care provided is in
29 compliance with the health supervision standards for 80
30 percent of enrolled children.
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1 (5) The perception of the enrollee or the enrollee's
2 family concerning coverage provided to children enrolled in
3 the Florida Kids Health program and served under:
4 (a) Medicaid;
5 (b) Florida Healthy Kids Corporation;
6 (c) Health insurance products;
7 (d) Children's Medical Services network; and
8 (e) Alternative coverage.
9
10 For each category of coverage, 90 percent of the enrollees or
11 the enrollee families indicate satisfaction with the care
12 provided under the program.
13 Section 17. Section 624.92, Florida Statutes, as
14 created by section 9 of chapter 97-260, Laws of Florida, is
15 repealed.
16 Section 18. The sum of $2 million is appropriated from
17 funds available under Title XXI of the Social Security Act and
18 shall be used for school health services during the 1998-1999
19 fiscal year.
20 Section 19. The provisions of this act which would
21 require changes to contracts in existence on June 30, 1998,
22 between the Florida Healthy Kids Corporation and its
23 contracted providers shall be applied to such contracts upon
24 the renewal of the contracts, but not later than July 1, 2000.
25 Section 20. This act shall take effect July 1, 1998.
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1 STATEMENT OF SUBSTANTIAL CHANGES CONTAINED IN
COMMITTEE SUBSTITUTE FOR
2 Senate Bill 1228
3
4 Moves the Children's Medical Services (CMS) Network from the
alternative coverage service category to a state-managed
5 health insurance component of the Florida Kids Health program;
includes behavioral health services as part of the CMS
6 network; specifies an enhanced, capitated reimbursement for
the CMS network for special needs children under the program;
7 specifies that certain CMS network services are exempt from
the Florida Insurance Code; and incorporates conforming
8 revisions.
9 Clarifies various aspects of the administration of the
program: eligibility, the application process, inter-agency
10 coordination, and outreach.
11 Enhances the benefits under the benchmark benefit plan for the
following services: mental health and substance abuse; dental;
12 chiropractic; and maternity.
13 Modifies provisions relating to alternative coverage
provisions by: imposing the same requirements for
14 participation under the program for alternative coverage
providers to receive reimbursement as is imposed for health
15 insurance coverage to receive premium assistance; requiring
alternative coverage providers to meet all applicable
16 marketing, enrollment, and disenrollment requirements and
restrictions under the Florida Insurance Code; and
17 specifically limiting alternative coverage providers to
certain rural counties.
18
Provides for a 6-month look-back period for coverage under a
19 group health benefit plan or under other health insurance
coverage, for purposes of excluding children from coverage
20 through the Florida Kids Health program.
21 Provides flexibility in the implementation phase for
administering agencies to have some latitude in meeting
22 federal plan approval and waiver requirements.
23 Repeals language enacted in 1997 that limited the Florida
Healthy Kids Corporation enrollment and that directed AHCA to
24 apply for a federal waiver for Healthy Kids. (s. 624.92, F.S.)
25 Reduces Title XXI school health services funding from $20.36
million to $2 million.
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