Senate Bill 1228c2
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By the Committees on Banking and Insurance, Health Care and
Senators Brown-Waite, Myers, Bankhead, Burt, Silver and Forman
311-1968-98
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. 409.8175, F.S.;
18 authorizing health maintenance organizations
19 and health insurers to reimburse providers in
20 rural counties according to the Medicaid Fee
21 schedule; creating s. 409.818, F.S.; providing
22 for program administration; specifying duties
23 of the Department of Children and Family
24 Services, the Department of Health, the Agency
25 for Health Care Administration, the Department
26 of Insurance, and the Florida Healthy Kids
27 Corporation; authorizing certain program
28 modifications related to federal approval;
29 transferring, renumbering, and amending s.
30 154.508, F.S., relating to outreach activities
31 to identify low-income, uninsured children;
2
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1 creating s. 409.820, F.S.; requiring that the
2 Department of Health develop standards for
3 quality assurance and program access;
4 establishing performance measures and standards
5 for the Florida Kids Health program; repealing
6 s. 624.92, F.S.; deleting the requirement that
7 the Agency for Health Care Administration apply
8 for a Medicaid federal waiver relating to the
9 Healthy Kids Corporation; providing an
10 appropriation; providing for application of the
11 act to certain contracts between providers and
12 the Florida Healthy Kids Corporation; providing
13 an effective date.
14
15 Be It Enacted by the Legislature of the State of Florida:
16
17 Section 1. Section 409.904, Florida Statutes, is
18 amended to read:
19 409.904 Optional payments for eligible persons.--The
20 agency may make payments for medical assistance and related
21 services on behalf of the following persons who are determined
22 to be eligible subject to the income, assets, and categorical
23 eligibility tests set forth in federal and state law. Payment
24 on behalf of these Medicaid eligible persons is subject to the
25 availability of moneys and any limitations established by the
26 General Appropriations Act or chapter 216.
27 (1) A person who is age 65 or older or is determined
28 to be disabled, whose income is at or below 100 percent of
29 federal poverty level, and whose assets do not exceed
30 established limitations.
31
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1 (2) A family, a pregnant woman, a child under age 18,
2 a person age 65 or over, or a blind or disabled person who
3 would be eligible under any group listed in s. 409.903(1),
4 (2), or (3), except that the income or assets of such family
5 or person exceed established limitations. For a family or
6 person in this group, medical expenses are deductible from
7 income in accordance with federal requirements in order to
8 make a determination of eligibility. A family or person in
9 this group, which group is known as the "medically needy," is
10 eligible to receive the same services as other Medicaid
11 recipients, with the exception of services in skilled nursing
12 facilities and intermediate care facilities for the
13 developmentally disabled.
14 (3) A person who is in need of the services of a
15 licensed nursing facility, a licensed intermediate care
16 facility for the developmentally disabled, or a state mental
17 hospital, whose income does not exceed 300 percent of the SSI
18 income standard, and who meets the assets standards
19 established under federal and state law.
20 (4) A low-income person who meets all other
21 requirements for Medicaid eligibility except citizenship and
22 who is in need of emergency medical services. The eligibility
23 of such a recipient is limited to the period of the emergency,
24 in accordance with federal regulations.
25 (5) Subject to specific federal authorization, a
26 postpartum woman living in a family that has an income that is
27 at or below 185 percent of the most current federal poverty
28 level is eligible for family planning services as specified in
29 s. 409.905(3) for a period of up to 24 months following a
30 pregnancy for which Medicaid paid for pregnancy-related
31 services.
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1 (6) A child under 1 year of age who lives in a family
2 whose income is above 185 percent of the most current federal
3 poverty level but equal to or below 200 percent of the most
4 current federal poverty level. In determining the eligibility
5 of such a child, an assets test is not required.
6 (7) A child under 19 years of age who is not eligible
7 for coverage under subsection (6) or under s. 409.903(5), (6),
8 or (7) and who lives in a family whose income is at or below
9 100 percent of the most current federal poverty level. In
10 determining the eligibility of such a child, an assets test is
11 not required.
12 Section 2. Section 409.9045, Florida Statutes, is
13 created to read:
14 409.9045 Continuous eligibility for children.--Once a
15 child is determined eligible for Medicaid coverage under s.
16 409.903 or s. 409.904, the child is eligible for coverage
17 under the Medicaid program for 6 months without a
18 redetermination or reverification of eligibility.
19 Section 3. Section 409.9126, Florida Statutes, is
20 amended to read:
21 409.9126 Children with special health care needs.--
22 (1) As used in this section, the term:
23 (a) "Behavioral health services" means specialized
24 behavioral and substance abuse services for children with
25 serious emotional disturbances or substance abuse problems.
26 (b)(a) "Children's Medical Services network" means an
27 alternative service network that includes health care
28 providers and health care facilities specified in chapter 391
29 and ss. 383.15-383.21, 383.216, and 415.5055.
30 (c)(b) "Children with special health care needs" means
31 those children whose serious or chronic physical, behavioral,
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1 or developmental conditions require extensive preventive and
2 maintenance care beyond that required by typically healthy
3 children. Health care utilization by these children exceeds
4 the statistically expected usage of the normal child matched
5 for chronological age and often needs complex care requiring
6 multiple providers, rehabilitation services, and specialized
7 equipment in a number of different settings.
8 (2) The Legislature finds that Medicaid-eligible
9 children with special health care needs require a
10 comprehensive, continuous, and coordinated system of health
11 care that links community-based health care with
12 multidisciplinary, regional, and tertiary care. The
13 Legislature finds that Florida's Children's Medical Services
14 program provides a full continuum of coordinated,
15 comprehensive services for children with special health care
16 needs.
17 (3) Except as provided in subsections (8) and (9),
18 children eligible for Children's Medical Services who receive
19 Medicaid benefits, and other Medicaid-eligible children with
20 special health care needs, shall be exempt from the provisions
21 of s. 409.9122 and shall be served through the Children's
22 Medical Services network. The Children's Medical Services
23 network shall also be available to children with special
24 health care needs who are eligible for health benefits
25 coverage other than Medicaid through the Florida Kids Health
26 program.
27 (4) The Legislature directs the agency to apply to the
28 federal Health Care Financing Administration for a waiver to
29 assign to the Children's Medical Services network all
30 Medicaid-eligible children who meet the criteria for
31 participation in the Children's Medical Services program as
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1 specified in s. 391.021(2), and other Medicaid-eligible
2 children with special health care needs.
3 (5) The Children's Medical Services program shall
4 assign a qualified MediPass primary care provider from the
5 Children's Medical Services network who shall serve as the
6 gatekeeper and who shall be responsible for the provision or
7 authorization of all health services to a child who has been
8 assigned to the Children's Medical Services network by the
9 Medicaid program.
10 (6) Services provided to Medicaid-eligible children
11 through the Children's Medical Services network shall be
12 reimbursed on a fee-for-service basis and shall utilize a
13 primary care case management process. Reimbursement to the
14 Children's Medical Services Network for services provided to
15 children with special health care needs who are enrolled in
16 the Florida Kids Health program and who are not Medicaid
17 recipients shall be on a capitated basis. The agency, in
18 consultation with the Department of Health, shall establish an
19 enhanced premium for services provided by the Children's
20 Medical Services network to children with special health care
21 needs who are enrolled in the Florida Kids Health program and
22 who are not Medicaid recipients.
23 (7) The agency, in consultation with the Children's
24 Medical Services program, shall develop by rule
25 quality-of-care and service integration standards.
26 (8) The agency may issue a request for proposals,
27 based on the quality-of-care and service integration
28 standards, to allow managed care plans that have contracts
29 with the Medicaid program to provide services to
30 Medicaid-eligible children with special health care needs.
31
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1 (9) The agency shall approve requests to provide
2 services to Medicaid-eligible children with special health
3 care needs from managed care plans that meet quality-of-care
4 and service integration standards and are in good standing
5 with the agency. The agency shall monitor on a quarterly
6 basis managed care plans which have been approved to provide
7 services to Medicaid-eligible children with special health
8 care needs.
9 (10) The agency, in consultation with the Department
10 of Health and Rehabilitative Services, shall adopt rules that
11 address Medicaid requirements for referral, enrollment, and
12 disenrollment of children with special health care needs who
13 are enrolled in Medicaid managed care plans and who may
14 benefit from the Children's Medical Services network.
15 (11) The Children's Medical Services network may
16 contract with school districts participating in the certified
17 school match program pursuant to ss. 236.0812 and 409.908(21)
18 for the provision of school-based services, as provided for in
19 s. 409.9071, for Medicaid-eligible children who are enrolled
20 in the Children's Medical Services network.
21 (12) The Children's Medical Services network, when
22 providing services to children who receive Medicaid benefits,
23 other Medicaid-eligible children with special health care
24 needs, and children participating in the Florida Kids Health
25 Program who have special health care needs, shall not be
26 subject to the licensing requirements of the Florida Insurance
27 Code or rules of the Department of Insurance.
28 (13)(12) After 1 complete year of operation, the
29 agency shall conduct an evaluation of the Children's Medical
30 Services network. The evaluation shall include, but not be
31 limited to, an assessment of whether the use of the Children's
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1 Medical Services network is less costly than the provision of
2 the services would have been in the Medicaid fee-for-service
3 program. The evaluation also shall include an assessment of
4 patient satisfaction with the Children's Medical Services
5 network, an assessment of the quality of care delivered
6 through the network, and recommendations for further improving
7 the performance of the network. The agency shall report the
8 evaluation findings to the Governor and the chairpersons of
9 the appropriations and health care committees of each chamber
10 of the Legislature.
11 (14) In order to ensure a high level of integration of
12 physical and behavioral health care and to meet the more
13 intensive treatment needs of enrollees with the most serious
14 emotional disturbance or substance abuse problems, the
15 Department of Health shall contract with the Department of
16 Children and Family Services to provide behavioral health
17 services to children with special health care needs. The
18 Department of Children and Family Services in consultation
19 with the Department of Health, is authorized to establish the
20 following:
21 (a) The scope of behavioral health services, including
22 duration and frequency;
23 (b) Clinical guidelines for referral to behavioral
24 health services;
25 (c) Behavioral health services standards;
26 (d) Performance-based measures and outcomes for
27 behavioral health services;
28 (e) Practice guidelines for behavioral health services
29 to ensure cost-effective treatment and to prevent unnecessary
30 expenditures; and
31 (f) Rules to implement this subsection.
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1 Section 4. Section 409.810, Florida Statutes, is
2 created to read:
3 409.810 Short title.--Sections 409.810-409.820 may be
4 cited as the "Florida Kids Health Act."
5 Section 5. Section 409.811, Florida Statutes, is
6 created to read:
7 409.811 Definitions.--As used in ss. 409.810-409.820,
8 the term:
9 (1) "Actuarially equivalent" means that:
10 (a) The aggregate value of the benefits included in
11 health benefits coverage is equal to the value of the benefits
12 in the benchmark benefit plan; and
13 (b) The benefits included in health benefits coverage
14 are substantially similar to the benefits included in the
15 benchmark benefit plan, except that preventive health services
16 must be the same as in the benchmark benefit plan.
17 (2) "Agency" means the Agency for Health Care
18 Administration.
19 (3) "Applicant" means a parent or guardian of a child
20 or a child whose disability of nonage has been removed under
21 chapter 743 who applies for determination of eligibility for
22 health benefits coverage under ss. 409.810-409.820.
23 (4) "Benchmark benefit plan" means the form and level
24 of health benefits coverage established in s. 409.815.
25 (5) "Child" means any person under 19 years of age.
26 (6) "Child with special health care needs" means a
27 child whose serious or chronic physical or developmental
28 condition requires extensive preventive and maintenance care
29 beyond that required by typically healthy children. Health
30 care utilization by such a child exceeds the statistically
31 expected usage of the normal child matched for chronological
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1 age and such child often needs complex care requiring multiple
2 providers, rehabilitation services, and specialized equipment
3 in a number of different settings.
4 (7) "Community rate" means a method used to develop
5 premiums for a health insurance plan that spreads financial
6 risk across a large population and allows adjustments only for
7 age, gender, family composition, and geographic area.
8 (8) "Enrollee" means a child who has been determined
9 eligible for and is receiving coverage under ss.
10 409.810-409.820.
11 (9) "Enrollment ceiling" means the maximum number of
12 children, excluding children enrolled in Medicaid, that may be
13 enrolled at any time in the Florida Kids Health program. The
14 maximum number shall be established annually in the General
15 Appropriations Act or by general law.
16 (10) "Family" means the group or the individuals whose
17 income is considered in determining eligibility for the
18 Florida Kids Health program. The family includes a child,
19 custodial parent, or caretaker relative who resides in the
20 same house or living unit or, in the case of a child whose
21 disability of nonage has been removed under chapter 473, the
22 child. The family may also include individuals whose income
23 and resources are considered in whole or in part in
24 determining eligibility of the child.
25 (11) "Family income" means cash received at periodic
26 intervals from any source, such as wages, benefits,
27 contributions, or rental property. Income also may include any
28 money that would have been counted as income under the AFDC
29 state plan in effect prior to August 22, 1996.
30 (12) "Guarantee issue" means that health benefits
31 coverage must be offered to an individual regardless of the
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1 individual's health status, preexisting condition, or claims
2 history.
3 (13) "Health benefits coverage" means protection that
4 provides payment of benefits for covered health care services
5 or that otherwise provides, either directly or through
6 arrangements with other persons, covered health care services
7 on a prepaid per capita basis or on a prepaid aggregate
8 fixed-sum basis.
9 (14) "Health insurance plan" means health benefits
10 coverage under the following:
11 (a) A health plan offered by any certified health
12 maintenance organization or authorized health insurer, except
13 a plan that is limited to the following: a limited benefit,
14 specified disease, or specified accident; hospital indemnity;
15 accident only; limited benefit convalescent care; Medicare
16 supplement; credit disability; dental; vision; long-term care;
17 disability income; coverage issued as a supplement to another
18 health plan; workers' compensation liability or other
19 insurance; or motor vehicle medical payment only; or
20 (b) An employee welfare benefit plan that includes
21 health benefits established under the Employee Retirement
22 Income Security Act of 1974, as amended.
23 (15) "Medicaid" means the medical assistance program
24 authorized by Title XIX of the Social Security Act, and
25 regulations thereunder, and ss. 409.901-409.9205, as
26 administered in this state by the agency.
27 (16) "Medically necessary" means the use of any
28 medical treatment, service, equipment, or supply necessary to
29 palliate the effects of a terminal condition, or to prevent,
30 diagnose, correct, cure, alleviate, or preclude deterioration
31
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1 of a condition that threatens life, causes pain or suffering,
2 or results in illness or infirmity and which is:
3 (a) Consistent with the symptom, diagnosis, and
4 treatment of the enrollee's condition;
5 (b) Provided in accordance with generally accepted
6 standards of medical practice;
7 (c) Not primarily intended for the convenience of the
8 enrollee, the enrollee's family, or the health care provider;
9 (d) The most appropriate level of supply or service
10 for the diagnosis and treatment of the enrollee's condition;
11 and
12 (e) Approved by the appropriate medical body or health
13 care specialty involved as effective, appropriate, and
14 essential for the care and treatment of the enrollee's
15 condition.
16 (17) "Preexisting condition exclusion" means, with
17 respect to coverage, a limitation or exclusion of benefits
18 relating to a condition based on the fact that the condition
19 was present before the date of enrollment for such coverage,
20 whether or not any medical advice, diagnosis, care, or
21 treatment was recommended or received before such date.
22 (18) "Premium" means the entire cost of an insurance
23 plan, including the administration fee or the risk assumption
24 charge.
25 (19) "Premium assistance payment" means the monthly
26 consideration paid by the agency per enrollee in the Florida
27 Kids Health program towards health insurance premiums.
28 (20) "Program" means the Florida Kids Health program,
29 the medical assistance program authorized by Title XXI of the
30 Social Security Act as part of the federal Balanced Budget Act
31 of 1997.
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1 (21) "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 (22) "Resident" means a United States citizen, or
5 qualified alien, who is domiciled in this state.
6 (23) "Rural county" means a county having a population
7 density of less than 100 persons per square mile, or a county
8 defined by the most recent United States Census as rural, in
9 which there is no prepaid health plan participating in the
10 Medicaid program as of July 1, 1998.
11 Section 6. Section 409.812, Florida Statutes, is
12 created to read:
13 409.812 Program created; purpose.--The Florida Kids
14 Health program is created to provide a defined set of health
15 benefits to previously uninsured, low-income children through
16 the establishment of a variety of affordable health benefits
17 coverage options from which families may select coverage and
18 through which families may contribute financially to the
19 health care of their children.
20 Section 7. Section 409.813, Florida Statutes, is
21 created to read:
22 409.813 Program components; entitlement and
23 nonentitlement.--The Florida Kids Health program includes
24 health benefits coverage provided to children through:
25 (1) Medicaid;
26 (2) The Florida Healthy Kids Corporation program as
27 created in s. 624.91;
28 (3) Health insurance plans approved under ss.
29 409.810-409.820; and
30 (4) The Children's Medical Services network
31 established in s. 409.9126.
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1
2 Except for coverage under the Medicaid program, coverage under
3 the Florida Kids Health program is not an entitlement.
4 Section 8. Section 409.8135, Florida Statutes, is
5 created to read:
6 409.8135 Program enrollment and expenditure
7 ceilings.--
8 (1) Except for the Medicaid program, a ceiling shall
9 be placed on annual federal and state expenditures and on
10 enrollment in the Florida Kids Health program as provided each
11 year in the General Appropriations Act. The agency, in
12 consultation with the Department of Health, may propose to
13 increase the enrollment ceiling in accordance with chapter
14 216.
15 (2) Except for the Medicaid program, whenever the
16 Social Services Estimating Conference determines that there is
17 presently, or will be by the end of the current fiscal year,
18 insufficient funds to finance the current or projected
19 enrollment in the program, all additional enrollment must
20 cease and additional enrollment may not resume until
21 sufficient funds are available to finance such enrollment.
22 (3) The agency shall collect and analyze the data
23 needed to project program enrollment, including participation
24 rates, caseloads, and expenditures. The agency shall report
25 the caseload and expenditure trends to the Social Services
26 Estimating Conference in accordance with chapter 216.
27 Section 9. Section 409.814, Florida Statutes, is
28 created to read:
29 409.814 Eligibility.--A child whose family income is
30 equal to or below 200 percent of the federal poverty level is
31 eligible for the Florida Kids Health program as provided in
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1 this section. In determining the eligibility of such a child,
2 an assets test is not required.
3 (1) A child who is eligible for Medicaid coverage
4 under s. 409.903 or s. 409.904 must be enrolled in Medicaid
5 and is not eligible to receive health benefits under any other
6 health benefits coverage authorized under ss. 409.810-409.820.
7 (2) A child who is not eligible for Medicaid, but who
8 is eligible for the program, may obtain coverage under any of
9 the other types of health benefits coverage authorized in ss.
10 409.810-409.820 if such coverage is approved and available in
11 the county in which the child resides.
12 (3) A child who is eligible for the program under
13 subsection (1) or (2) and who is a child with special health
14 care needs, as determined through a risk-screening instrument,
15 is eligible for health benefits coverage from and may be
16 referred to the Children's Medical Services network.
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 seeking premium assistance for
29 employer-sponsored group coverage, if the child has been
30 covered by the same employer's group coverage during the 6
31
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1 months prior to the family's submitting an application for
2 determination of eligibility under the program;
3 (d) A child who is an alien, but who does not meet the
4 definition of qualified alien, in the United States; or
5 (e) A child who is an inmate of a public institution
6 or a patient in an institution for mental diseases.
7 (5) A child whose family income is above 200 percent
8 of the federal poverty level may participate in the program;
9 however, the family is not eligible for premium assistance
10 payments and must pay the full cost of the premium. Children
11 described in this subsection may not be counted in the annual
12 enrollment ceiling for the Florida Kids Health program.
13 (6) Once a child is determined eligible for the
14 program, the child is eligible for coverage under the program
15 for 6 months without a redetermination or reverification of
16 eligibility if the family continues to pay the applicable
17 premium.
18 Section 10. Section 409.815, Florida Statutes, is
19 created to read:
20 409.815 Health benefits coverage; limitations.--
21 (1) MEDICAID BENEFITS.--For purposes of this program,
22 benefits available under the Medicaid program include those
23 goods and services provided under the medical assistance
24 program authorized by Title XIX of the Social Security Act,
25 and regulations thereunder, as administered in this state by
26 the agency. This includes those mandatory Medicaid services
27 authorized under s. 409.905 and optional Medicaid services
28 authorized under s. 409.906, rendered on behalf of eligible
29 individuals by qualified providers, in accordance with federal
30 requirements for Title XIX, subject to any limitations or
31 directions provided for in the General Appropriations Act or
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1 chapter 216, and according to methodologies and limitations
2 set forth in agency rules and policy manuals and handbooks
3 incorporated by reference thereto.
4 (2) BENCHMARK BENEFITS.--In order for health benefits
5 coverage to qualify for premium assistance payments for an
6 eligible child under ss. 409.810-409.820, the health benefits
7 coverage, except for coverage under the Medicaid program, must
8 include the following minimum benefits as medically necessary.
9 (a) Preventive health services.--Covered services
10 include:
11 1. Well-child care, including services recommended in
12 the Guidelines for Health Supervision of Children and Youth as
13 developed by the American Academy of Pediatrics;
14 2. Immunizations and injections;
15 3. Health education counseling and clinical services;
16 4. Vision screening; and
17 5. Hearing screening.
18 (b) Inpatient hospital services.--All covered services
19 provided for the medical care and treatment of an enrollee who
20 is admitted as an inpatient to a hospital licensed under part
21 I of chapter 395, with the following exceptions:
22 1. All admissions must be authorized by the enrollee's
23 health benefits coverage provider.
24 2. The length of the patient stay shall be determined
25 on the medical condition of the enrollee in relation to the
26 necessary and appropriate level of care.
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. Admissions for rehabilitation and physical therapy
31 are limited to 15 days per contract year.
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1 (c) Emergency services.--Covered services include
2 visits to an emergency room or other licensed facility if
3 needed immediately due to an injury or illness and delay means
4 risk of permanent damage to the enrollee's health.
5 (d) Maternity services.--Covered services include
6 maternity and newborn care, including prenatal and postnatal
7 care with the following limitations:
8 1. Coverage may be limited to the fee for vaginal
9 deliveries; and
10 2. Initial inpatient care for newborn infants of
11 enrolled adolescents shall be covered, including normal
12 newborn care, nursery charges, and the initial pediatric or
13 neonatal examination, and the infant may be covered for up to
14 3 days following birth.
15 (e) Organ transplantation services.--Covered services
16 include pretransplant, transplant, and postdischarge services
17 and treatment of complications after transplantation for
18 transplants deemed necessary and appropriate within the
19 guidelines set by the Agency for Health Care Administration
20 Organ Transplant Advisory Council under s. 381.0602 or the
21 Agency for Health Care Administration Bone Marrow Transplant
22 Advisory Panel under s. 627.4236.
23 (f) Outpatient services.--Covered services include
24 preventive, diagnostic, therapeutic, palliative care, and
25 other services provided to an enrollee in the outpatient
26 portion of a health facility licensed under chapter 395,
27 except for the following limitations:
28 1. Services must be authorized by the enrollee's
29 health benefits coverage provider; and
30 2. Treatment for temporomandibular joint disease (TMJ)
31 is specifically excluded.
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1 (g) Behavioral health services.--
2 1. Mental health benefits include:
3 a. Inpatient services, limited to not more than 30
4 inpatient days per contract year for psychiatric admissions or
5 30 days of residential services in lieu of inpatient
6 psychiatric admission; and
7 b. Outpatient services, including outpatient visits
8 for psychological or psychiatric evaluation, diagnosis, and
9 treatment by a licensed mental health professional, limited to
10 a maximum of 40 outpatient visits each contract year.
11 2. Substance abuse services include:
12 a. Inpatient services limited to no more than 7
13 inpatient days per contract year for medical detoxification
14 only and 30 days of residential services; and
15 b. Outpatient services, including evaluation,
16 diagnosis, and treatment by a licensed practitioner, limited
17 to a maximum of 40 outpatient visits per contract year.
18 (h) Durable medical equipment.--Covered services
19 include equipment and devices that are medically indicated to
20 assist in the treatment of a medical condition and
21 specifically prescribed as medically necessary, with the
22 following limitations:
23 1. Low vision and telescopic aides are not included.
24 2. Corrective lenses and frames may be limited to one
25 pair every 2 years, unless the prescription or head size of
26 the enrollee changes.
27 3. Hearing aids shall be covered only when medically
28 indicated to assist in the treatment of a medical condition.
29 4. Covered prosthetic devices include artificial eyes
30 and limbs, braces, and other artificial aids.
31
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1 (i) Health practitioner services.--Covered services
2 include services and procedures rendered to an enrollee when
3 performed to diagnose and treat diseases, injuries, or other
4 conditions, including care rendered by health practitioners
5 acting within the scope of their practice, with the following
6 exceptions:
7 1. Chiropractic services may be limited to six visits
8 in 6 months and one service per day for manual manipulation of
9 the spine and screenings.
10 2. Podiatric services may be limited to one visit per
11 day totaling two visits per month for specific foot disorders.
12 (j) Home health services.--Covered services include
13 prescribed home visits by both registered and licensed
14 practical nurses to provide skilled nursing services on a
15 part-time intermittent basis, subject to the following
16 limitations:
17 1. Coverage may be limited to include skilled nursing
18 services only;
19 2. Meals, housekeeping, and personal comfort items may
20 be excluded; and
21 3. Private duty nursing is limited to circumstances
22 where such care is medically necessary.
23 (k) Hospice services.--Covered services include
24 reasonable and necessary services for palliation or management
25 of an enrollee's terminal illness, with the following
26 exceptions:
27 1. Once a family elects to receive hospice care for an
28 enrollee, other services that treat the terminal condition
29 will not be covered; and
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1 2. Services required for conditions totally unrelated
2 to the terminal condition are covered to the extent that the
3 services are included in this section.
4 (l) Laboratory and X-ray services.--Covered services
5 include diagnostic testing, including clinical radiologic,
6 laboratory, and other diagnostic tests.
7 (m) Nursing facility services.--Covered services
8 include regular nursing services, rehabilitation services,
9 drugs and biologicals, medical supplies, and the use of
10 appliances and equipment furnished by the facility, with the
11 following limitations:
12 1. All admissions must be authorized by the health
13 benefits coverage provider.
14 2. The length of the patient stay shall be determined
15 on the medical condition of the enrollee in relation to the
16 necessary and appropriate level of care, but is limited to not
17 more than 100 days per contract year.
18 3. Room and board may be limited to semiprivate
19 accommodations, unless a private room is considered medically
20 necessary or semiprivate accommodations are not available.
21 4. Specialized treatment centers and independent
22 kidney disease treatment centers are excluded.
23 5. Private duty nurses, television, and custodial care
24 are excluded.
25 6. Admissions for rehabilitation and physical therapy
26 are limited to 15 days per contract year.
27 (n) Prescribed drugs.--
28 1. Coverage shall include drugs prescribed for the
29 treatment of illness or injury when prescribed by a licensed
30 health practitioner acting within the scope of his or her
31 practice.
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1 2. Prescribed drugs may be limited to generics if
2 available and brand name products if a generic substitution is
3 not available, unless the prescribing licensed health
4 practitioner indicates that a brand name is medically
5 necessary.
6 3. Prescribed drugs covered under this section shall
7 include all prescribed drugs covered under the Florida
8 Medicaid program.
9 (o) Therapy services.--Covered services include
10 rehabilitative services, including occupational, physical,
11 respiratory, and speech therapies, with the following
12 limitations:
13 1. Services must be for short-term rehabilitation
14 where significant improvement in the enrollee's condition will
15 result; and
16 2. Services shall be no more than twenty-four
17 treatment sessions within a 60-day period per episode or
18 injury, with the 60-day period beginning with the first
19 treatment.
20 (p) Transportation services.--Covered services include
21 emergency transportation required in response to an emergency
22 situation.
23 (q) Lifetime maximum.--Health benefits coverage
24 obtained under ss. 409.810-409.820 shall pay an enrollee's
25 covered expenses at a lifetime maximum of $1 million per
26 covered child.
27 (r) Cost-sharing.--Cost-sharing provisions must comply
28 with s. 409.816.
29 (s) Exclusions.--
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1 1. Experimental or investigational procedures that
2 have not been clinically proven by reliable evidence are
3 excluded;
4 2. Services performed for cosmetic purposes only or
5 for the convenience of the enrollee are excluded; and
6 3. Abortion may be covered only if necessary to save
7 the life of the mother or if the pregnancy is the result of an
8 act of rape or incest.
9 (t) Enhancements to minimum requirements.--
10 1. This section sets the minimum benefits that must be
11 included in any health benefits coverage, other than Medicaid
12 coverage, offered under ss. 409.810-409.820. Health benefits
13 coverage may include additional benefits not included under
14 this subsection, but may not include benefits excluded under
15 paragraph (h).
16 2. Health benefits coverage may extend any limitations
17 beyond the minimum benefits described in this section.
18
19 Except for the Children's Medical Services network, the agency
20 may not increase the premium assistance payment for either
21 additional benefits provided beyond the minimum benefits
22 described in this section or the imposition of less
23 restrictive service limitations.
24 (u) Applicability of other state laws.--Health
25 insurers, health maintenance organizations, and their agents
26 are subject to the provisions of the Florida Insurance Code,
27 except for any such provisions waived in this section.
28 1. Except as expressly provided in this section, a law
29 requiring coverage for a specific health care service or
30 benefit, or a law requiring reimbursement, utilization, or
31 consideration of a specific category of licensed health care
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1 practitioner, does not apply to an insurance health plan
2 policy or contract offered or delivered under ss.
3 409.810-409.820 unless that law is made expressly applicable
4 to such policies or contracts.
5 2. Notwithstanding chapter 641, a health maintenance
6 organization may issue contracts providing benefits equal to,
7 exceeding, or actuarially equivalent to the benchmark benefit
8 plan authorized by this section and may pay providers located
9 in a rural county negotiated fees or Medicaid reimbursement
10 rates for services provided to enrollees who are residents of
11 the rural county.
12 Section 11. Section 409.816, Florida Statutes, is
13 created to read:
14 409.816 Limitations on premiums and cost-sharing.--The
15 following limitations on premiums and cost-sharing are
16 established for the program.
17 (1) Enrollees who receive coverage under the Medicaid
18 program may not be required to pay:
19 (a) Enrollment fees, premiums, or similar charges; or
20 (b) Copayments, deductibles, coinsurance, or similar
21 charges.
22 (2) Enrollees in families with a family income equal
23 to or below 150 percent of the federal poverty level and who
24 are not receiving coverage under the Medicaid program may not
25 be required to pay:
26 (a) Enrollment fees, premiums, or similar charges that
27 exceed the maximum monthly charge permitted under s.
28 1916(b)(1) of the Social Security Act; or
29 (b) Copayments, deductibles, coinsurance, or similar
30 charges that exceed a nominal amount, as determined consistent
31 with regulations referred to in s. 1916(a)(3) of the Social
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1 Security Act. However, such charges may not be imposed for
2 preventive services, including well-baby and well-child care,
3 age-appropriate immunizations, and routine hearing and vision
4 screenings.
5 (3) Enrollees in families with a family income above
6 150 percent of the federal poverty level and who are not
7 receiving coverage under the Medicaid program may be required
8 to pay enrollment fees, premiums, copayments, deductibles,
9 coinsurance, or similar charges on a sliding scale related to
10 income, except that the total annual aggregate cost-sharing
11 with respect to all children in a family may not exceed 5
12 percent of the family's income. However, copayments,
13 deductibles, coinsurance, or similar charges may not be
14 imposed for preventive services, including well-baby and
15 well-child care, age-appropriate immunizations, and routine
16 hearing and vision screenings.
17 Section 12. Section 409.817, Florida Statutes, is
18 created to read:
19 409.817 Approval of health benefits coverage;
20 financial assistance.--In order for health insurance coverage
21 to qualify for premium assistance payments for an eligible
22 child under ss. 409.810-409.820, the health benefits coverage
23 must:
24 (1) Be certified by the Department of Insurance under
25 s. 409.818 as meeting, exceeding, or being actuarially
26 equivalent to the benchmark benefit plan;
27 (2) Be guarantee issued;
28 (3) Be community rated;
29 (4) Not impose any preexisting condition exclusion for
30 covered benefits; however, group health insurance plans may
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1 permit the imposition of a preexisting condition exclusion,
2 but only insofar as it is permitted under s. 627.6561;
3 (5) Comply with the applicable limitations on premiums
4 and cost-sharing in s. 409.816;
5 (6) Comply with the quality assurance and access
6 standards developed under s. 409.820; and
7 (7) Establish periodic open enrollment periods, which
8 may not occur more frequently than quarterly.
9 Section 13. Section 409.8175, Florida Statutes, is
10 created to read:
11 409.8175 Delivery of services in rural counties.--A
12 health maintenance organization or a health insurer may
13 reimburse providers located in a rural county according to the
14 Medicaid fee schedule for services provided to enrollees in
15 rural counties if the provider agrees to accept such fee
16 schedule.
17 Section 14. Section 409.818, Florida Statutes, is
18 created to read:
19 409.818 Administration.--In order to implement ss.
20 409.810-409.820, the following agencies shall have the
21 following duties:
22 (1) The Department of Children and Family Services
23 shall:
24 (a) Develop a simplified eligibility application
25 mail-in form to be used for determining the eligibility of
26 children for coverage under the program in consultation with
27 the agency, the Department of Health, and the Florida Healthy
28 Kids Corporation. The simplified eligibility application form
29 must include an item that provides an opportunity for the
30 applicant to indicate whether coverage is being sought for a
31 child with special health care needs.
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1 (b) Establish and maintain the eligibility
2 determination process under the program. The department shall
3 directly, or through the services of a contracted third-party
4 administrator, establish and maintain a process for
5 determining eligibility of children for coverage under the
6 program. The eligibility determination process must be used
7 solely for determining eligibility of applicants for health
8 benefits coverage under the program. The eligibility
9 determination process must include an initial determination of
10 eligibility for any coverage offered under the program, as
11 well as a redetermination or reverification of eligibility
12 each subsequent 6 months. In conducting an eligibility
13 determination, the department shall determine if the child has
14 special health care needs.
15 (c) Inform program applicants about eligibility
16 determinations and provide information about eligibility of
17 applicants to the Medicaid program, the Children's Medical
18 Services network, the Florida Healthy Kids Corporation, and
19 insurers and their agents through a centralized coordinating
20 office.
21 (d) Adopt rules necessary for conducting program
22 eligibility functions.
23 (2) The Department of Health shall:
24 (a) Design an eligibility intake process for the
25 program, in coordination with the Department of Children and
26 Family Services, the agency, and the Florida Healthy Kids
27 Corporation. The eligibility intake process may include local
28 intake points that are determined by the Department of Health
29 in coordination with the Department of Children and Family
30 Services.
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1 (b) Design and implement program outreach activities
2 under s. 409.819.
3 (c) Chair a state-level coordinating council for the
4 program to review and make recommendations concerning the
5 implementation and operation of the program. The coordinating
6 council shall include representatives from the department, the
7 Department of Children and Family Services, the agency, the
8 Florida Healthy Kids Corporation, the Department of Insurance,
9 health insurers, families participating in the program, and
10 organizations representing low-income families.
11 (d) Adopt rules necessary to implement outreach
12 activities.
13 (3) The Agency for Health Care Administration, under
14 the authority granted in s. 409.914(1), shall:
15 (a) Calculate the premium assistance payment necessary
16 to comply with the premium and cost-sharing limitations
17 specified in s. 409.816. The premium assistance payment for
18 each enrollee in an insurance plan participating in the
19 Florida Healthy Kids Corporation shall equal the premium
20 approved by the Florida Healthy Kids Corporation and the
21 Department of Insurance pursuant to ss. 627.410 and 641.31,
22 less any enrollee's share of the premium established within
23 the limitations specified in s. 409.816. The premium
24 assistance payment for each enrollee in employer-sponsored
25 health insurance plans approved under ss. 409.810-409.820
26 shall equal the premium for the plan adjusted for any
27 benchmark benefit plan actuarial equivalent benefit rider
28 approved by the Department of Insurance pursuant to ss.
29 627.410 and 641.31, less any enrollee's share of the premium
30 established within the limitations specified in s. 409.816. In
31 calculating the premium assistance payment levels for children
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1 with family coverage, the agency shall set the premium
2 assistance payment levels for each child proportionately to
3 the total cost of family coverage.
4 (b) Annually calculate the program enrollment ceiling
5 based on estimated per-child premium assistance payments and
6 the estimated appropriation available for the program.
7 (c) Make premium assistance payments to health
8 insurance plans on a periodic basis. The agency may use its
9 Medicaid fiscal agent or a contracted third-party
10 administrator in making these payments.
11 (d) Monitor compliance with quality assurance and
12 access standards developed under s. 409.820.
13 (e) Establish a mechanism for investigating and
14 resolving complaints and grievances from program applicants,
15 enrollees, and health benefits coverage providers, and
16 maintain a record of complaints and confirmed problems. In the
17 case of a child who is enrolled in a health maintenance
18 organization, the agency must use the provisions of s. 641.511
19 to address grievance reporting and resolution requirements.
20 (f) Approve health benefits coverage for participation
21 in the program, following certification by the Department of
22 Insurance under subsection (4).
23 (g) Adopt rules necessary for calculating premium
24 assistance payment levels, calculating the program enrollment
25 ceiling, making premium assistance payments, monitoring access
26 and quality assurance standards, investigating and resolving
27 complaints and grievances, and approving health benefits
28 coverage.
29 (4) The Department of Insurance shall certify that
30 health benefits coverage plans that seek to provide services
31 under the program, except those offered through the Florida
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1 Healthy Kids Corporation or the Children's Medical Services
2 network, meet, exceed, or are actuarially equivalent to the
3 benchmark benefit plan and that health insurance plans will be
4 offered at an approved rate. In determining actuarial
5 equivalence of benefits coverage, the Department of Insurance
6 and health insurance plans must comply with the requirements
7 of section 2103 of Title XXI of the Social Security Act. The
8 department shall adopt rules necessary for certifying health
9 benefits coverage plans.
10 (5) The Florida Healthy Kids Corporation shall retain
11 its functions as authorized in s. 624.91, with the exception
12 of its eligibility determination functions relating to
13 coverage under the Florida Kids Health program which shall be
14 assumed by the Department of Children and Family Services.
15 Each fiscal year, the corporation shall establish a maximum
16 number of children by county on a statewide basis who may
17 enroll in the program without requiring local matching funds.
18 Thereafter, the corporation may establish local government
19 matching requirements for supplemental participation in the
20 program. The corporation may vary local matching requirements
21 and enrollment by county depending on factors which may
22 influence the local government's ability to provide local
23 match, including but not limited to, population density, per
24 capita income, existing local tax effort and other factors.
25 (6) The Agency for Health Care Administration, the
26 Department of Health, the Department of Children and Family
27 Services, and the Department of Insurance have the authority
28 to make program modifications and adopt rules not inconsistent
29 with the administrative responsibilities and rulemaking
30 authority granted in this section which are necessary to
31 overcome any objections of the federal Department of Health
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1 and Human Services and obtain approval of the state's child
2 health plan under Title XXI of the Social Security Act.
3 Section 15. Section 154.508, Florida Statutes, is
4 transferred, renumbered as section 409.819, Florida Statutes,
5 and amended to read:
6 409.819 154.508 Identification of low-income,
7 uninsured children; determination of Medicaid eligibility for
8 the Florida Kids Health program; alternative health care
9 information.--The Department of Health Agency for Health Care
10 Administration shall develop a program, in conjunction with
11 the Department of Education, the Department of Children and
12 Family Services, the Agency for Health Care Administration,
13 the Florida Healthy Kids Corporation the Department of Health,
14 local governments, employers school districts, and other
15 stakeholders to identify low-income, uninsured children and,
16 to the extent possible and subject to appropriation, refer
17 them to the Department of Children and Family Services for a
18 Medicaid eligibility determination and provide parents with
19 information about choices alternative sources of health
20 benefits coverage under the Florida Kids Health program care.
21 These activities shall include, but not be limited to:
22 training community providers in effective methods of outreach;
23 conducting public information campaigns designed to publicize
24 the Florida Kids Health program, the eligibility requirements
25 of the program, and the procedures for enrollment in the
26 program; and maintaining public awareness of the Florida Kids
27 Health program.
28 Section 16. Section 409.820, Florida Statutes, is
29 created to read:
30 409.820 Quality assurance and access standards.--The
31 Department of Health, in consultation with the agency and the
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1 Florida Healthy Kids Corporation, shall develop a common set
2 of quality assurance and access standards for all program
3 components. The standards must include a process for granting
4 exceptions to specific requirements for quality assurance and
5 access. Compliance with the standards shall be a condition of
6 program participation by health benefits coverage providers.
7 Section 17. The following performance measures and
8 standards are adopted for the Florida Kids Health program.--
9 (1) The total number of previously uninsured children
10 who receive health benefits coverage as a result of state
11 activities under Title XXI of the Social Security Act: 235,000
12 uninsured children expected to obtain coverage during the
13 1998-1999 fiscal year.
14 (a) The number of children enrolled in the Medicaid
15 program as a result of eligibility expansions under Title XXI
16 of the Social Security Act: 35,000 children enrolled in
17 Medicaid under new eligibility groups during the 1998-1999
18 fiscal year.
19 (b) The number of children enrolled in the Medicaid
20 program as a result of outreach efforts under Title XXI of the
21 Social Security Act who are eligible for Medicaid but who have
22 not enrolled in the program: 80,000 children previously
23 eligible for Medicaid, but not enrolled in Medicaid, who
24 enroll in Medicaid during the 1998-1999 fiscal year.
25 (c) The number of uninsured children added to the
26 enrollment for the Florida Healthy Kids Corporation program
27 under Title XXI of the Social Security Act: 60,000 additional
28 children enrolled in the Florida Healthy Kids Corporation
29 program during the 1998-1999 fiscal year.
30 (d) The number of uninsured children enrolled in
31 health insurance coverage under Title XXI of the Social
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1 Security Act: 55,000 uninsured children enrolled in health
2 insurance coverage during the 1998-1999 fiscal year.
3 (e) The number of uninsured children enrolled in the
4 Children's Medical Services network under Title XXI of the
5 Social Security Act: 5,000 uninsured children enrolled in the
6 Children's Medical Services network during the 1998-1999
7 fiscal year.
8 (2) The percentage of uninsured children in this state
9 as of July 1, 1998, who receive health benefits coverage under
10 the Florida Kids Health program: 28.5 percent of uninsured
11 children enrolled in the Florida Kids Health program during
12 the 1998-1999 fiscal year.
13 (3) The percentage of children enrolled in the Florida
14 Kids Health program with up-to-date immunizations: 80 percent
15 of enrolled children with up-to-date immunizations.
16 (4) The percentage of compliance with the standards
17 established in the Guidelines for Health Supervision of
18 Children and Youth as developed by the American Academy of
19 Pediatrics for children eligible for the Florida Kids Health
20 program and served under:
21 (a) Medicaid;
22 (b) The Florida Healthy Kids Corporation program; and
23 (c) Health insurance products.
24
25 For each category of coverage, the health care provided is in
26 compliance with the health supervision standards for 80
27 percent of enrolled children.
28 (5) The perception of the enrollee or the enrollee's
29 family concerning coverage provided to children enrolled in
30 the Florida Kids Health program and served under:
31 (a) Medicaid;
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1 (b) Florida Healthy Kids Corporation;
2 (c) Health insurance products; and
3 (d) Children's Medical Services network.
4
5 For each category of coverage, 90 percent of the enrollees or
6 the enrollee families indicate satisfaction with the care
7 provided under the program.
8 Section 18. Section 624.92, Florida Statutes, as
9 created by section 9 of chapter 97-260, Laws of Florida, is
10 repealed.
11 Section 19. The sum of $2 million is appropriated from
12 funds available under Title XXI of the Social Security Act and
13 shall be used for school health services during the 1998-1999
14 fiscal year.
15 Section 20. The provisions of this act which would
16 require changes to contracts in existence on June 30, 1998,
17 between the Florida Healthy Kids Corporation and its
18 contracted providers shall be applied to such contracts upon
19 the renewal of the contracts, but not later than July 1, 2000.
20 Section 21. This act shall take effect July 1, 1998.
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1 STATEMENT OF SUBSTANTIAL CHANGES CONTAINED IN
COMMITTEE SUBSTITUTE FOR
2 CS for SB 1228
3
4 Deletes all references to the annual benchmark premium, as
established by the Agency for Health Care Administration and,
5 instead, provides that the premium assistance payment for
enrollees participating in the Florida Healthy Kids
6 Corporation shall equal the premium approved by the Florida
Health Kids Corporation and the Department of Insurance, less
7 any enrollee's share of the premium established within the
limitations specified in s. 409.816. The premium assistance
8 payment for each enrollee in employer sponsored health
insurance plans shall equal the premium for the plan adjusted
9 for any benchmark benefit plan actuarial equivalent benefit
rider approved by the Department of Insurance pursuant to ss.
10 627.410 and 641.31, less any employee's share of the premium
established within the limitations specified in s. 409.816.
11
Deletes all references to "alternative coverage providers"
12 allowed to offer coverage in certain rural counties, thereby
limiting program components to Medicaid, the Florida Healthy
13 Kids program, health insurance policies and HMO contracts, and
the Children's Medical Services network.
14
Authorizes health insurers and HMOs providing coverage under
15 the program in certain rural counties to pay providers on a
negotiated fee for service basis or at Medicaid reimbursement
16 rates, if accepted by the provider.
17 Lowers the enhanced benefits for chiropractic services to the
level currently provided in coverage offered by the Florida
18 Healthy Kids program and deletes required coverage for dental
services.
19
Authorizes the Department of Insurance to approve insurance
20 policies and HMO contracts under the program that provide
"actuarially equivalent" coverage to the benchmark benefit
21 plan, which must include benefits that are substantially
similar to the benefits included in the benchmark benefit plan
22 and the same preventive health services.
23 Revises the definition of "community rating" that applies to
premiums under the program, to limit rating factors to age,
24 gender, family composition, and geographic area.
25 Limits a child's ineligibility for coverage based on the child
having had employer-sponsored health insurance coverage during
26 the 6 months prior to applying for eligibility to only the
employer-sponsored coverage component of the program.
27
Allows the Florida Healthy Kids Corporation to establish a
28 maximum number of children by county on a statewide basis who
may enroll without requiring local matching funds.
29
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