Senate Bill 1228e1
CODING: Words stricken are deletions; words underlined are additions.
CS for CS for CS for SB 1228 First
Engrossed
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
CODING: Words stricken are deletions; words underlined are additions.
CS for CS for CS for SB 1228 First
Engrossed
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. 409.8132, F.S.;
7
creating and establishing the purpose of the
8
Medikids program component; providing for
9
administration of Medikids by the Agency for
10
Health Care Administration; exempting Medikids
11
from licensure under the Florida Insurance
12
Code; providing applicability of certain
13
Medicaid requirements; establishing benefit
14
requirements; providing for eligibility;
15
providing enrollment requirements; authorizing
16
penalties for nonpayment of premiums; creating
17
s. 409.8135, F.S.; providing for program
18
enrollment and expenditure ceilings; creating
19
s. 409.814, F.S.; providing eligibility
20
requirements; creating s. 409.815, F.S.;
21
establishing requirements for health benefits
22
coverage under the Florida Kids Health program;
23
creating s. 409.816, F.S.; providing for
24
limitations on premiums and cost-sharing;
25
creating s. 409.817, F.S.; providing for
26
approval of health benefits coverage as a
27
condition of financial assistance; creating s.
28
409.8175, F.S.; authorizing health maintenance
29
organizations and health insurers to reimburse
30
providers in rural counties according to the
31
Medicaid Fee schedule; creating s. 409.818,
2
CODING: Words stricken are deletions; words underlined are additions.
CS for CS for CS for SB 1228 First
Engrossed
1
F.S.; providing for program administration;
2
specifying duties of the Department of Children
3
and Family Services, the Department of Health,
4
the Agency for Health Care Administration, the
5
Department of Insurance, and the Florida
6
Healthy Kids Corporation; authorizing certain
7
program modifications related to federal
8
approval; transferring, renumbering, and
9
amending s. 154.508, F.S., relating to outreach
10
activities to identify low-income, uninsured
11
children; creating s. 409.820, F.S.; requiring
12
that the Department of Health develop standards
13
for quality assurance and program access;
14
establishing performance measures and standards
15
for the Florida Kids Health program; directing
16
the Agency for Health Care Administration to
17
conduct a study of Medicaid presumptive
18
eligibility and report its findings to the
19
legislature; repealing s. 624.92, F.S.;
20
deleting the requirement that the Agency for
21
Health Care Administration apply for a Medicaid
22
federal waiver relating to the Healthy Kids
23
Corporation; providing an appropriation;
24
providing for application of the act to certain
25
contracts between providers and the Florida
26
Healthy Kids Corporation; providing an
27
effective date.
28
29
Be It Enacted by the Legislature of the State of Florida:
30
31
3
CODING: Words stricken are deletions; words underlined are additions.
CS for CS for CS for SB 1228 First
Engrossed
1
Section 1. Section 409.904, Florida Statutes, is
2
amended to read:
3
409.904 Optional payments for eligible persons.--The
4
agency may make payments for medical assistance and related
5
services on behalf of the following persons who are determined
6
to be eligible subject to the income, assets, and categorical
7
eligibility tests set forth in federal and state law. Payment
8
on behalf of these Medicaid eligible persons is subject to the
9
availability of moneys and any limitations established by the
10
General Appropriations Act or chapter 216.
11
(1) A person who is age 65 or older or is determined
12
to be disabled, whose income is at or below 100 percent of
13
federal poverty level, and whose assets do not exceed
14
established limitations.
15
(2) A family, a pregnant woman, a child under age 18,
16
a person age 65 or over, or a blind or disabled person who
17
would be eligible under any group listed in s. 409.903(1),
18
(2), or (3), except that the income or assets of such family
19
or person exceed established limitations. For a family or
20
person in this group, medical expenses are deductible from
21
income in accordance with federal requirements in order to
22
make a determination of eligibility. A family or person in
23
this group, which group is known as the "medically needy," is
24
eligible to receive the same services as other Medicaid
25
recipients, with the exception of services in skilled nursing
26
facilities and intermediate care facilities for the
27
developmentally disabled.
28
(3) A person who is in need of the services of a
29
licensed nursing facility, a licensed intermediate care
30
facility for the developmentally disabled, or a state mental
31
hospital, whose income does not exceed 300 percent of the SSI
4
CODING: Words stricken are deletions; words underlined are additions.
CS for CS for CS for SB 1228 First
Engrossed
1
income standard, and who meets the assets standards
2
established under federal and state law.
3
(4) A low-income person who meets all other
4
requirements for Medicaid eligibility except citizenship and
5
who is in need of emergency medical services. The eligibility
6
of such a recipient is limited to the period of the emergency,
7
in accordance with federal regulations.
8
(5) Subject to specific federal authorization, a
9
postpartum woman living in a family that has an income that is
10
at or below 185 percent of the most current federal poverty
11
level is eligible for family planning services as specified in
12
s. 409.905(3) for a period of up to 24 months following a
13
pregnancy for which Medicaid paid for pregnancy-related
14
services.
15
(6) A child under 1 year of age who lives in a family
16
whose income is above 185 percent of the most current federal
17
poverty level but equal to or below 200 percent of the most
18
current federal poverty level. In determining the eligibility
19
of such a child, an assets test is not required.
20
(7) A child under 19 years of age who is not eligible
21
for coverage under subsection (6) or under s. 409.903(5), (6),
22
or (7) and who lives in a family whose income is at or below
23
100 percent of the most current federal poverty level. In
24
determining the eligibility of such a child, an assets test is
25
not required.
26
Section 2. Section 409.9045, Florida Statutes, is
27
created to read:
28
409.9045 Continuous eligibility for children.--Once a
29
child is determined eligible for Medicaid coverage under s.
30
409.903 or s. 409.904, the child is eligible for coverage
31
5
CODING: Words stricken are deletions; words underlined are additions.
CS for CS for CS for SB 1228 First
Engrossed
1
under the Medicaid program for 6 months without a
2
redetermination or reverification of eligibility.
3
Section 3. Section 409.9126, Florida Statutes, is
4
amended to read:
5
409.9126 Children with special health care needs.--
6
(1) As used in this section, the term:
7
(a) "Behavioral health services" means specialized
8
behavioral and substance abuse services for children with
9
serious emotional disturbances or substance abuse problems.
10
(b)(a) "Children's Medical Services network" means an
11
alternative service network that includes health care
12
providers and health care facilities specified in chapter 391
13
and ss. 383.15-383.21, 383.216, and 415.5055.
14
(c)(b) "Children with special health care needs" means
15
those children whose serious or chronic physical, behavioral,
16
or developmental conditions require extensive preventive and
17
maintenance care beyond that required by typically healthy
18
children. Health care utilization by these children exceeds
19
the statistically expected usage of the normal child matched
20
for chronological age and often needs complex care requiring
21
multiple providers, rehabilitation services, and specialized
22
equipment in a number of different settings.
23
(2) The Legislature finds that Medicaid-eligible
24
children with special health care needs require a
25
comprehensive, continuous, and coordinated system of health
26
care that links community-based health care with
27
multidisciplinary, regional, and tertiary care. The
28
Legislature finds that Florida's Children's Medical Services
29
program provides a full continuum of coordinated,
30
comprehensive services for children with special health care
31
needs.
6
CODING: Words stricken are deletions; words underlined are additions.
CS for CS for CS for SB 1228 First
Engrossed
1
(3) Except as provided in subsections (8) and (9),
2
children eligible for Children's Medical Services who receive
3
Medicaid benefits, and other Medicaid-eligible children with
4
special health care needs, shall be exempt from the provisions
5
of s. 409.9122 and shall be served through the Children's
6
Medical Services network. The Children's Medical Services
7
network shall also be available to children with special
8
health care needs who are eligible for health benefits
9
coverage other than Medicaid through the Florida Kids Health
10
program.
11
(4) The Legislature directs the agency to apply to the
12
federal Health Care Financing Administration for a waiver to
13
assign to the Children's Medical Services network all
14
Medicaid-eligible children who meet the criteria for
15
participation in the Children's Medical Services program as
16
specified in s. 391.021(2), and other Medicaid-eligible
17
children with special health care needs.
18
(5) The Children's Medical Services program shall
19
assign a qualified MediPass primary care provider from the
20
Children's Medical Services network who shall serve as the
21
gatekeeper and who shall be responsible for the provision or
22
authorization of all health services to a child who has been
23
assigned to the Children's Medical Services network by the
24
Medicaid program.
25
(6) Services provided to Medicaid-eligible children
26
through the Children's Medical Services network shall be
27
reimbursed on a fee-for-service basis and shall utilize a
28
primary care case management process. Reimbursement to the
29
Children's Medical Services Network for services provided to
30
children with special health care needs who are enrolled in
31
the Florida Kids Health program and who are not Medicaid
7
CODING: Words stricken are deletions; words underlined are additions.
CS for CS for CS for SB 1228 First
Engrossed
1
recipients shall be on a capitated basis. The agency, in
2
consultation with the Department of Health, shall establish an
3
enhanced premium for services provided by the Children's
4
Medical Services network to children with special health care
5
needs who are enrolled in the Florida Kids Health program and
6
who are not Medicaid recipients.
7
(7) The agency, in consultation with the Children's
8
Medical Services program, shall develop by rule
9
quality-of-care and service integration standards.
10
(8) The agency may issue a request for proposals,
11
based on the quality-of-care and service integration
12
standards, to allow managed care plans that have contracts
13
with the Medicaid program to provide services to
14
Medicaid-eligible children with special health care needs.
15
(9) The agency shall approve requests to provide
16
services to Medicaid-eligible children with special health
17
care needs from managed care plans that meet quality-of-care
18
and service integration standards and are in good standing
19
with the agency. The agency shall monitor on a quarterly
20
basis managed care plans which have been approved to provide
21
services to Medicaid-eligible children with special health
22
care needs.
23
(10) The agency, in consultation with the Department
24
of Health and Rehabilitative Services, shall adopt rules that
25
address Medicaid requirements for referral, enrollment, and
26
disenrollment of children with special health care needs who
27
are enrolled in Medicaid managed care plans and who may
28
benefit from the Children's Medical Services network.
29
(11) The Children's Medical Services network may
30
contract with school districts participating in the certified
31
school match program pursuant to ss. 236.0812 and 409.908(21)
8
CODING: Words stricken are deletions; words underlined are additions.
CS for CS for CS for SB 1228 First
Engrossed
1
for the provision of school-based services, as provided for in
2
s. 409.9071, for Medicaid-eligible children who are enrolled
3
in the Children's Medical Services network.
4
(12) The Children's Medical Services network, when
5
providing services to children who receive Medicaid benefits,
6
other Medicaid-eligible children with special health care
7
needs, and children participating in the Florida Kids Health
8
Program who have special health care needs, shall not be
9
subject to the licensing requirements of the Florida Insurance
10
Code or rules of the Department of Insurance.
11
(13)(12) After 1 complete year of operation, the
12
agency shall conduct an evaluation of the Children's Medical
13
Services network. The evaluation shall include, but not be
14
limited to, an assessment of whether the use of the Children's
15
Medical Services network is less costly than the provision of
16
the services would have been in the Medicaid fee-for-service
17
program. The evaluation also shall include an assessment of
18
patient satisfaction with the Children's Medical Services
19
network, an assessment of the quality of care delivered
20
through the network, and recommendations for further improving
21
the performance of the network. The agency shall report the
22
evaluation findings to the Governor and the chairpersons of
23
the appropriations and health care committees of each chamber
24
of the Legislature.
25
(14) In order to ensure a high level of integration of
26
physical and behavioral health care and to meet the more
27
intensive treatment needs of enrollees with the most serious
28
emotional disturbance or substance abuse problems, the
29
Department of Health shall contract with the Department of
30
Children and Family Services to provide behavioral health
31
services to children with special health care needs. The
9
CODING: Words stricken are deletions; words underlined are additions.
CS for CS for CS for SB 1228 First
Engrossed
1
Department of Children and Family Services in consultation
2
with the Department of Health, is authorized to establish the
3
following:
4
(a) The scope of behavioral health services, including
5
duration and frequency;
6
(b) Clinical guidelines for referral to behavioral
7
health services;
8
(c) Behavioral health services standards;
9
(d) Performance-based measures and outcomes for
10
behavioral health services;
11
(e) Practice guidelines for behavioral health services
12
to ensure cost-effective treatment and to prevent unnecessary
13
expenditures; and
14
(f) Rules to implement this subsection.
15
Section 4. Section 409.810, Florida Statutes, is
16
created to read:
17
409.810 Short title.--Sections 409.810-409.820 may be
18
cited as the "Florida Kids Health Act."
19
Section 5. Section 409.811, Florida Statutes, is
20
created to read:
21
409.811 Definitions.--As used in ss. 409.810-409.820,
22
the term:
23
(1) "Actuarially equivalent" means that:
24
(a) The aggregate value of the benefits included in
25
health benefits coverage is equal to the value of the benefits
26
in the benchmark benefit plan; and
27
(b) The benefits included in health benefits coverage
28
are substantially similar to the benefits included in the
29
benchmark benefit plan, except that preventive health services
30
must be the same as in the benchmark benefit plan.
31
10
CODING: Words stricken are deletions; words underlined are additions.
CS for CS for CS for SB 1228 First
Engrossed
1
(2) "Agency" means the Agency for Health Care
2
Administration.
3
(3) "Applicant" means a parent or guardian of a child
4
or a child whose disability of nonage has been removed under
5
chapter 743 who applies for determination of eligibility for
6
health benefits coverage under ss. 409.810-409.820.
7
(4) "Benchmark benefit plan" means the form and level
8
of health benefits coverage established in s. 409.815.
9
(5) "Child" means any person under 19 years of age.
10
(6) "Child with special health care needs" means a
11
child whose serious or chronic physical or developmental
12
condition requires extensive preventive and maintenance care
13
beyond that required by typically healthy children. Health
14
care utilization by such a child exceeds the statistically
15
expected usage of the normal child matched for chronological
16
age and such child often needs complex care requiring multiple
17
providers, rehabilitation services, and specialized equipment
18
in a number of different settings.
19
(7) "Community rate" means a method used to develop
20
premiums for a health insurance plan that spreads financial
21
risk across a large population and allows adjustments only for
22
age, gender, family composition, and geographic area.
23
(8) "Enrollee" means a child who has been determined
24
eligible for and is receiving coverage under ss.
25
409.810-409.820.
26
(9) "Enrollment ceiling" means the maximum number of
27
children receiving premium assistance payments, excluding
28
children enrolled in Medicaid, that may be enrolled at any
29
time in the Florida Kids Health program. The maximum number
30
shall be established annually in the General Appropriations
31
Act or by general law.
11
CODING: Words stricken are deletions; words underlined are additions.
CS for CS for CS for SB 1228 First
Engrossed
1
(10) "Family" means the group or the individuals whose
2
income is considered in determining eligibility for the
3
Florida Kids Health program. The family includes a child,
4
custodial parent, or caretaker relative who resides in the
5
same house or living unit or, in the case of a child whose
6
disability of nonage has been removed under chapter 473, the
7
child. The family may also include individuals whose income
8
and resources are considered in whole or in part in
9
determining eligibility of the child.
10
(11) "Family income" means cash received at periodic
11
intervals from any source, such as wages, benefits,
12
contributions, or rental property. Income also may include any
13
money that would have been counted as income under the AFDC
14
state plan in effect prior to August 22, 1996.
15
(12) "Guarantee issue" means that health benefits
16
coverage must be offered to an individual regardless of the
17
individual's health status, preexisting condition, or claims
18
history.
19
(13) "Health benefits coverage" means protection that
20
provides payment of benefits for covered health care services
21
or that otherwise provides, either directly or through
22
arrangements with other persons, covered health care services
23
on a prepaid per capita basis or on a prepaid aggregate
24
fixed-sum basis.
25
(14) "Health insurance plan" means health benefits
26
coverage under the following:
27
(a) A health plan offered by any certified health
28
maintenance organization or authorized health insurer, except
29
a plan that is limited to the following: a limited benefit,
30
specified disease, or specified accident; hospital indemnity;
31
accident only; limited benefit convalescent care; Medicare
12
CODING: Words stricken are deletions; words underlined are additions.
CS for CS for CS for SB 1228 First
Engrossed
1
supplement; credit disability; dental; vision; long-term care;
2
disability income; coverage issued as a supplement to another
3
health plan; workers' compensation liability or other
4
insurance; or motor vehicle medical payment only; or
5
(b) An employee welfare benefit plan that includes
6
health benefits established under the Employee Retirement
7
Income Security Act of 1974, as amended.
8
(15) "Medicaid" means the medical assistance program
9
authorized by Title XIX of the Social Security Act, and
10
regulations thereunder, and ss. 409.901-409.9205, as
11
administered in this state by the agency.
12
(16) "Medically necessary" means the use of any
13
medical treatment, service, equipment, or supply necessary to
14
palliate the effects of a terminal condition, or to prevent,
15
diagnose, correct, cure, alleviate, or preclude deterioration
16
of a condition that threatens life, causes pain or suffering,
17
or results in illness or infirmity and which is:
18
(a) Consistent with the symptom, diagnosis, and
19
treatment of the enrollee's condition;
20
(b) Provided in accordance with generally accepted
21
standards of medical practice;
22
(c) Not primarily intended for the convenience of the
23
enrollee, the enrollee's family, or the health care provider;
24
(d) The most appropriate level of supply or service
25
for the diagnosis and treatment of the enrollee's condition;
26
and
27
(e) Approved by the appropriate medical body or health
28
care specialty involved as effective, appropriate, and
29
essential for the care and treatment of the enrollee's
30
condition.
31
13
CODING: Words stricken are deletions; words underlined are additions.
CS for CS for CS for SB 1228 First
Engrossed
1
(17) "Preexisting condition exclusion" means, with
2
respect to coverage, a limitation or exclusion of benefits
3
relating to a condition based on the fact that the condition
4
was present before the date of enrollment for such coverage,
5
whether or not any medical advice, diagnosis, care, or
6
treatment was recommended or received before such date.
7
(18) "Premium" means the entire cost of a health
8
insurance plan, including the administration fee or the risk
9
assumption charge.
10
(19) "Premium assistance payment" means the monthly
11
consideration paid by the agency per enrollee in the Florida
12
Kids Health program towards health insurance premiums.
13
(20) "Program" means the Florida Kids Health program,
14
the medical assistance program authorized by Title XXI of the
15
Social Security Act as part of the federal Balanced Budget Act
16
of 1997.
17
(21) "Qualified alien" means an alien as defined in s.
18
431 of the Personal Responsibility and Work Opportunity
19
Reconciliation Act of 1996, as amended, Pub. L. No. 104-193.
20
(22) "Resident" means a United States citizen, or
21
qualified alien, who is domiciled in this state.
22
(23) "Rural county" means a county having a population
23
density of less than 100 persons per square mile, or a county
24
defined by the most recent United States Census as rural, in
25
which there is no prepaid health plan participating in the
26
Medicaid program as of July 1, 1998.
27
(24) "Substantially similar" means that, with respect
28
to additional services as defined in s. 2103(c)(2) of Title
29
XXI of the Social Security Act, these services must have an
30
actuarial value equal to at least 75 percent of the actuarial
31
value of the coverage for that service in the benchmark
14
CODING: Words stricken are deletions; words underlined are additions.
CS for CS for CS for SB 1228 First
Engrossed
1
benefit plan and, with respect to the basic services as
2
defined in s. 2103(c)(1) of Title XXI of the Social Security
3
Act, these services must be the same as the services in the
4
benchmark benefit plan.
5
Section 6. Section 409.812, Florida Statutes, is
6
created to read:
7
409.812 Program created; purpose.--The Florida Kids
8
Health program is created to provide a defined set of health
9
benefits to previously uninsured, low-income children through
10
the establishment of a variety of affordable health benefits
11
coverage options from which families may select coverage and
12
through which families may contribute financially to the
13
health care of their children.
14
Section 7. Section 409.813, Florida Statutes, is
15
created to read:
16
409.813 Program components; entitlement and
17
nonentitlement.--The Florida Kids Health program includes
18
health benefits coverage provided to children through:
19
(1) Medicaid;
20
(2) Medikids as created in s. 409.8132;
21
(3) The Florida Healthy Kids Corporation as created in
22
s. 624.91;
23
(4) Employer-sponsored group health insurance plans
24
approved under ss. 409.810-409.820; and
25
(5) The Children's Medical Services network
26
established in s. 409.9126.
27
28
Except for coverage under the Medicaid program, coverage under
29
the Florida Kids Health program is not an entitlement.
30
Section 8. Section 409.8132, Florida Statutes, is
31
created to read:
15
CODING: Words stricken are deletions; words underlined are additions.
CS for CS for CS for SB 1228 First
Engrossed
1
409.8132 Medikids program component.--
2
(1) PROGRAM COMPONENT CREATED; PURPOSE.--The Medikids
3
program component is created in the Agency for Health Care
4
Administration to provide health care services under the
5
Florida Kids Health program to eligible children using the
6
administrative structure and provider network of the Medicaid
7
program.
8
(2) ADMINISTRATION.--The director of the agency shall
9
appoint an administrator of the Medikids program component,
10
which shall be located in the Division of State Health
11
Purchasing. The Agency for Health Care Administration is
12
designated as the state agency authorized to make payments for
13
medical assistance and related services for the Medikids
14
program component of the Florida Kids Health program. Payments
15
shall be made, subject to any limitations or directions in the
16
General Appropriations Act, only for covered services provided
17
to eligible children by qualified health care providers under
18
the Florida Kids Health program.
19
(3) INSURANCE LICENSURE NOT REQUIRED.--The Medikids
20
program component shall not be subject to the licensing
21
requirements of the Florida Insurance Code or rules of the
22
Department of Insurance.
23
(4) APPLICABILITY OF LAWS RELATING TO MEDICAID.--The
24
provisions of ss. 409.907, 409.908, 409.910, 409.912,
25
409.9121, 409.9122, 409.9123, 409.9124, 409.9127, 409.9128,
26
409.913, 409.916, 409.919, 409.920, and 409.9205, apply to the
27
administration of the Medikids program component of the
28
Florida Kids Health program, except that s. 409.9122 applies
29
to Medikids as modified by the provisions of subsection (7).
30
31
16
CODING: Words stricken are deletions; words underlined are additions.
CS for CS for CS for SB 1228 First
Engrossed
1
(5) BENEFITS.--Benefits provided under the Medikids
2
program component shall be the same benefits provided to
3
children as specified in ss. 409.905 and 409.906.
4
(6) ELIGIBILITY.--A child who has attained the age of
5
1 year, but has not attained the age of 4 years, is eligible
6
to enroll in the Medikids program component of the Florida
7
Kids Health program, if the child is a member of a family that
8
has a family income that exceeds 133 percent of the current
9
federal poverty level, but that is equal to or below 200
10
percent of the current federal poverty level. In determining
11
the eligibility of such a child, an assets test is not
12
required. A child who is eligible for Medikids may elect to
13
enroll in Florida Healthy Kids coverage or employer-sponsored
14
group coverage.
15
(7) ENROLLMENT.--Enrollment in the Medikids program
16
component may only occur during periodic open enrollment
17
periods as specified by the agency. During the first 12 months
18
of the program, there shall be at least one, but no more than
19
three, open enrollment periods. The initial open enrollment
20
period shall be for 60 days, and subsequent open enrollment
21
periods during the first year of operation of the program
22
shall be for 30 days. After the first year of the program, the
23
agency shall determine the frequency and duration of open
24
enrollment periods. A child may apply for enrollment in the
25
Medikids program component and proceed through the eligibility
26
determination process at any time throughout the year.
27
However, enrollment in Medikids shall not begin until the next
28
open enrollment period; and a child may not receive services
29
under the Medikids program until the child is enrolled in a
30
managed care plan or MediPass. In addition, once a child is
31
determined eligible, the child may receive choice counseling
17
CODING: Words stricken are deletions; words underlined are additions.
CS for CS for CS for SB 1228 First
Engrossed
1
and select a managed care plan or MediPass. A child may select
2
MediPass under the Medikids program component only in counties
3
that have fewer than two managed care plans available to serve
4
Medicaid recipients and only if the federal Health Care
5
Financing Administration determines that MediPass constitutes
6
"health insurance coverage" as defined in Title XXI of the
7
Social Security Act.
8
(8) SPECIAL ENROLLMENT PERIODS.--The agency shall
9
establish a special enrollment period of 30 days' duration for
10
any child who is enrolled in Medicaid if such child loses
11
Medicaid eligibility and becomes eligible for Medikids or if
12
such child moves to another county that is not within the
13
coverage area of the child's Medikids managed care plan or
14
MediPass provider.
15
(9) PENALTIES FOR VOLUNTARY CANCELLATION.--The agency
16
shall establish enrollment criteria that must include
17
penalties or waiting periods of not fewer than 60 days for
18
reinstatement of coverage upon voluntary cancellation for
19
nonpayment of premiums.
20
Section 9. Section 409.8135, Florida Statutes, is
21
created to read:
22
409.8135 Program enrollment and expenditure
23
ceilings.--
24
(1) Except for the Medicaid program, a ceiling shall
25
be placed on annual federal and state expenditures and on
26
enrollment in the Florida Kids Health program as provided each
27
year in the General Appropriations Act. The agency, in
28
consultation with the Department of Health, may propose to
29
increase the enrollment ceiling in accordance with chapter
30
216.
31
18
CODING: Words stricken are deletions; words underlined are additions.
CS for CS for CS for SB 1228 First
Engrossed
1
(2) Except for the Medicaid program, whenever the
2
Social Services Estimating Conference determines that there is
3
presently, or will be by the end of the current fiscal year,
4
insufficient funds to finance the current or projected
5
enrollment in the program, all additional enrollment must
6
cease and additional enrollment may not resume until
7
sufficient funds are available to finance such enrollment.
8
(3) The agency shall collect and analyze the data
9
needed to project program enrollment, including participation
10
rates, caseloads, and expenditures. The agency shall report
11
the caseload and expenditure trends to the Social Services
12
Estimating Conference in accordance with chapter 216.
13
Section 10. Section 409.814, Florida Statutes, is
14
created to read:
15
409.814 Eligibility.--A child whose family income is
16
equal to or below 200 percent of the federal poverty level is
17
eligible for the Florida Kids Health program as provided in
18
this section. In determining the eligibility of such a child,
19
an assets test is not required.
20
(1) A child who is eligible for Medicaid coverage
21
under s. 409.903 or s. 409.904 must be enrolled in Medicaid
22
and is not eligible to receive health benefits under any other
23
health benefits coverage authorized under ss. 409.810-409.820.
24
(2) A child who is not eligible for Medicaid, but who
25
is eligible for the program, may obtain coverage under any of
26
the other types of health benefits coverage authorized in ss.
27
409.810-409.820 if such coverage is approved and available in
28
the county in which the child resides.
29
(3) A child who is eligible for the program under
30
subsection (1) or (2) and who is a child with special health
31
care needs, as determined through a risk-screening instrument,
19
CODING: Words stricken are deletions; words underlined are additions.
CS for CS for CS for SB 1228 First
Engrossed
1
is eligible for health benefits coverage from and may be
2
referred to the Children's Medical Services network.
3
(4) The following children are not eligible to receive
4
health benefits coverage under ss. 409.810-409.820, except
5
under Medicaid if the child would have been eligible for
6
Medicaid under s. 409.903 or s. 409.904 as of June 1, 1997:
7
(a) A child who is eligible for coverage under a state
8
health benefits plan on the basis of a family member's
9
employment with a public agency in the state;
10
(b) A child who is covered under a group health
11
benefit plan or under other health insurance coverage,
12
excluding coverage provided under the Florida Healthy Kids
13
Corporation as established under s. 624.91;
14
(c) A child who is seeking premium assistance for
15
employer-sponsored group coverage, if the child has been
16
covered by the same employer's group coverage during the 6
17
months prior to the family's submitting an application for
18
determination of eligibility under the program;
19
(d) A child who is an alien, but who does not meet the
20
definition of qualified alien, in the United States; or
21
(e) A child who is an inmate of a public institution
22
or a patient in an institution for mental diseases.
23
(5) A child whose family income is above 200 percent
24
of the federal poverty level may participate in the program,
25
excluding the Medicaid program, but is subject to the
26
following provisions:
27
(a) The family is not eligible for premium assistance
28
payments and must pay the full cost of the premium, including
29
any administrative costs. Children described in this
30
subsection are not counted in the annual enrollment ceiling
31
for the Florida Kids Health program.
20
CODING: Words stricken are deletions; words underlined are additions.
CS for CS for CS for SB 1228 First
Engrossed
1
(b) The agency is authorized to place limits on
2
enrollment in Medikids by these children in order to avoid
3
adverse selection. The number of children participating in
4
Medikids whose family income exceeds 200 percent of the
5
federal poverty level must not exceed 10 percent of total
6
enrollees in the Medikids program.
7
(c) The board of directors of the Florida Healthy Kids
8
Corporation is authorized to place limits on enrollment of
9
these children in order to avoid adverse selection. In
10
addition, the board is authorized to offer a reduced benefit
11
package to these children in order to limit program costs for
12
such families. The number of children participating in Healthy
13
Kids whose family income exceeds 200 percent of the federal
14
poverty level must not exceed 10 percent of total enrollees in
15
the Healthy Kids program.
16
(6) Once a child is determined eligible for the
17
program, the child is eligible for coverage under the program
18
for 6 months without a redetermination or reverification of
19
eligibility if the family continues to pay the applicable
20
premium.
21
(7) Once a child is determined eligible for the
22
National School Lunch program, the child is eligible for
23
coverage under the Florida Kids Health program provided the
24
child meets the requirements of s. 409.814 and is enrolled in
25
school. However, a child who is determined to be eligible
26
under s. 409.814 may not be denied coverage.
27
Section 11. 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
21
CODING: Words stricken are deletions; words underlined are additions.
CS for CS for CS for SB 1228 First
Engrossed
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 Medicaid and Medikids,
17
must include the following minimum benefits as medically
18
necessary.
19
(a) Preventive health services.--Covered services
20
include:
21
1. Well-child care, including services recommended in
22
the Guidelines for Health Supervision of Children and Youth as
23
developed by the American Academy of Pediatrics;
24
2. Immunizations and injections;
25
3. Health education counseling and clinical services;
26
4. Vision screening; and
27
5. Hearing screening.
28
(b) Inpatient hospital services.--All covered services
29
provided for the medical care and treatment of an enrollee who
30
is admitted as an inpatient to a hospital licensed under part
31
I of chapter 395, with the following exceptions:
22
CODING: Words stricken are deletions; words underlined are additions.
CS for CS for CS for SB 1228 First
Engrossed
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
23
CODING: Words stricken are deletions; words underlined are additions.
CS for CS for CS for SB 1228 First
Engrossed
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
24
CODING: Words stricken are deletions; words underlined are additions.
CS for CS for CS for SB 1228 First
Engrossed
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 provided in the same
18
manner as in the Florida Medicaid Program.
19
2. Podiatric services may be limited to one visit per
20
day totaling two visits per month for specific foot disorders.
21
(j) Home health services.--Covered services include
22
prescribed home visits by both registered and licensed
23
practical nurses to provide skilled nursing services on a
24
part-time intermittent basis, subject to the following
25
limitations:
26
1. Coverage may be limited to include skilled nursing
27
services only;
28
2. Meals, housekeeping, and personal comfort items may
29
be excluded; and
30
3. Private duty nursing is limited to circumstances
31
where such care is medically necessary.
25
CODING: Words stricken are deletions; words underlined are additions.
CS for CS for CS for SB 1228 First
Engrossed
1
(k) Hospice services.--Covered services include
2
reasonable and necessary services for palliation or management
3
of an enrollee's terminal illness, with the following
4
exceptions:
5
1. Once a family elects to receive hospice care for an
6
enrollee, other services that treat the terminal condition
7
will not be covered; and
8
2. Services required for conditions totally unrelated
9
to the terminal condition are covered to the extent that the
10
services are included in this section.
11
(l) Laboratory and X-ray services.--Covered services
12
include diagnostic testing, including clinical radiologic,
13
laboratory, and other diagnostic tests.
14
(m) Nursing facility services.--Covered services
15
include regular nursing services, rehabilitation services,
16
drugs and biologicals, medical supplies, and the use of
17
appliances and equipment furnished by the facility, with the
18
following limitations:
19
1. All admissions must be authorized by the health
20
benefits coverage provider.
21
2. The length of the patient stay shall be determined
22
on the medical condition of the enrollee in relation to the
23
necessary and appropriate level of care, but is limited to not
24
more than 100 days per contract year.
25
3. Room and board may be limited to semiprivate
26
accommodations, unless a private room is considered medically
27
necessary or semiprivate accommodations are not available.
28
4. Specialized treatment centers and independent
29
kidney disease treatment centers are excluded.
30
5. Private duty nurses, television, and custodial care
31
are excluded.
26
CODING: Words stricken are deletions; words underlined are additions.
CS for CS for CS for SB 1228 First
Engrossed
1
6. Admissions for rehabilitation and physical therapy
2
are limited to 15 days per contract year.
3
(n) Prescribed drugs.--
4
1. Coverage shall include drugs prescribed for the
5
treatment of illness or injury when prescribed by a licensed
6
health practitioner acting within the scope of his or her
7
practice.
8
2. Prescribed drugs may be limited to generics if
9
available and brand name products if a generic substitution is
10
not available, unless the prescribing licensed health
11
practitioner indicates that a brand name is medically
12
necessary.
13
3. Prescribed drugs covered under this section shall
14
include all prescribed drugs covered under the Florida
15
Medicaid program.
16
(o) Therapy services.--Covered services include
17
rehabilitative services, including occupational, physical,
18
respiratory, and speech therapies, with the following
19
limitations:
20
1. Services must be for short-term rehabilitation
21
where significant improvement in the enrollee's condition will
22
result; and
23
2. Services shall be no more than twenty-four
24
treatment sessions within a 60-day period per episode or
25
injury, with the 60-day period beginning with the first
26
treatment.
27
(p) Transportation services.--Covered services include
28
emergency transportation required in response to an emergency
29
situation.
30
(q) Lifetime maximum.--Health benefits coverage
31
obtained under ss. 409.810-409.820 shall pay an enrollee's
27
CODING: Words stricken are deletions; words underlined are additions.
CS for CS for CS for SB 1228 First
Engrossed
1
covered expenses at a lifetime maximum of $1 million per
2
covered child.
3
(r) Cost-sharing.--Cost-sharing provisions must comply
4
with s. 409.816.
5
(s) Exclusions.--
6
1. Experimental or investigational procedures that
7
have not been clinically proven by reliable evidence are
8
excluded;
9
2. Services performed for cosmetic purposes only or
10
for the convenience of the enrollee are excluded; and
11
3. Abortion may be covered only if necessary to save
12
the life of the mother or if the pregnancy is the result of an
13
act of rape or incest.
14
(t) Enhancements to minimum requirements.--
15
1. This section sets the minimum benefits that must be
16
included in any health benefits coverage, other than Medicaid
17
or Medikids coverage, offered under ss. 409.810-409.820.
18
Health benefits coverage may include additional benefits not
19
included under this subsection, but may not include benefits
20
excluded under paragraph (s).
21
2. Health benefits coverage may extend any limitations
22
beyond the minimum benefits described in this section.
23
24
Except for the Children's Medical Services network, the agency
25
may not increase the premium assistance payment for either
26
additional benefits provided beyond the minimum benefits
27
described in this section or the imposition of less
28
restrictive service limitations.
29
(u) Applicability of other state laws.--Health
30
insurers, health maintenance organizations, and their agents
31
28
CODING: Words stricken are deletions; words underlined are additions.
CS for CS for CS for SB 1228 First
Engrossed
1
are subject to the provisions of the Florida Insurance Code,
2
except for any such provisions waived in this section.
3
1. Except as expressly provided in this section, a law
4
requiring coverage for a specific health care service or
5
benefit, or a law requiring reimbursement, utilization, or
6
consideration of a specific category of licensed health care
7
practitioner, does not apply to an insurance health plan
8
policy or contract offered or delivered under ss.
9
409.810-409.820 unless that law is made expressly applicable
10
to such policies or contracts.
11
2. Notwithstanding chapter 641, a health maintenance
12
organization may issue contracts providing benefits equal to,
13
exceeding, or actuarially equivalent to the benchmark benefit
14
plan authorized by this section and may pay providers located
15
in a rural county negotiated fees or Medicaid reimbursement
16
rates for services provided to enrollees who are residents of
17
the rural county.
18
Section 12. Section 409.816, Florida Statutes, is
19
created to read:
20
409.816 Limitations on premiums and cost-sharing.--The
21
following limitations on premiums and cost-sharing are
22
established for the program.
23
(1) Enrollees who receive coverage under the Medicaid
24
program may not be required to pay:
25
(a) Enrollment fees, premiums, or similar charges; or
26
(b) Copayments, deductibles, coinsurance, or similar
27
charges.
28
(2) Enrollees in families with a family income equal
29
to or below 150 percent of the federal poverty level and who
30
are not receiving coverage under the Medicaid program may not
31
be required to pay:
29
CODING: Words stricken are deletions; words underlined are additions.
CS for CS for CS for SB 1228 First
Engrossed
1
(a) Enrollment fees, premiums, or similar charges that
2
exceed the maximum monthly charge permitted under s.
3
1916(b)(1) of the Social Security Act; or
4
(b) Copayments, deductibles, coinsurance, or similar
5
charges that exceed a nominal amount, as determined consistent
6
with regulations referred to in s. 1916(a)(3) of the Social
7
Security Act. However, such charges may not be imposed for
8
preventive services, including well-baby and well-child care,
9
age-appropriate immunizations, and routine hearing and vision
10
screenings.
11
(3) Enrollees in families with a family income above
12
150 percent of the federal poverty level and who are not
13
receiving coverage under the Medicaid program, or who are not
14
eligible under s. 409.814(5), may be required to pay
15
enrollment fees, premiums, copayments, deductibles,
16
coinsurance, or similar charges on a sliding scale related to
17
income, except that the total annual aggregate cost-sharing
18
with respect to all children in a family may not exceed 5
19
percent of the family's income. However, copayments,
20
deductibles, coinsurance, or similar charges may not be
21
imposed for preventive services, including well-baby and
22
well-child care, age-appropriate immunizations, and routine
23
hearing and vision screenings.
24
Section 13. Section 409.817, Florida Statutes, is
25
created to read:
26
409.817 Approval of health benefits coverage;
27
financial assistance.--In order for health insurance coverage
28
to qualify for premium assistance payments for an eligible
29
child under ss. 409.810-409.820, the health benefits coverage
30
must:
31
30
CODING: Words stricken are deletions; words underlined are additions.
CS for CS for CS for SB 1228 First
Engrossed
1
(1) Be certified by the Department of Insurance under
2
s. 409.818 as meeting, exceeding, or being actuarially
3
equivalent to the benchmark benefit plan;
4
(2) Be guarantee issued;
5
(3) Be community rated;
6
(4) Not impose any preexisting condition exclusion for
7
covered benefits; however, group health insurance plans may
8
permit the imposition of a preexisting condition exclusion,
9
but only insofar as it is permitted under s. 627.6561;
10
(5) Comply with the applicable limitations on premiums
11
and cost-sharing in s. 409.816;
12
(6) Comply with the quality assurance and access
13
standards developed under s. 409.820; and
14
(7) Establish periodic open enrollment periods, which
15
may not occur more frequently than quarterly.
16
Section 14. Section 409.8175, Florida Statutes, is
17
created to read:
18
409.8175 Delivery of services in rural counties.--A
19
health maintenance organization or a health insurer may
20
reimburse providers located in a rural county according to the
21
Medicaid fee schedule for services provided to enrollees in
22
rural counties if the provider agrees to accept such fee
23
schedule.
24
Section 15. Section 409.818, Florida Statutes, is
25
created to read:
26
409.818 Administration.--In order to implement ss.
27
409.810-409.820, the following agencies shall have the
28
following duties:
29
(1) The Department of Children and Family Services
30
shall:
31
31
CODING: Words stricken are deletions; words underlined are additions.
CS for CS for CS for SB 1228 First
Engrossed
1
(a) Develop a simplified eligibility application
2
mail-in form to be used for determining the eligibility of
3
children for coverage under the program in consultation with
4
the agency, the Department of Health, and the Florida Healthy
5
Kids Corporation. The simplified eligibility application form
6
must include an item that provides an opportunity for the
7
applicant to indicate whether coverage is being sought for a
8
child with special health care needs. Families applying for
9
the program must also be able to use the simplified
10
application form without having to pay a premium.
11
(b) Establish and maintain the eligibility
12
determination process under the program. The department shall
13
directly, or through the services of a contracted third-party
14
administrator, establish and maintain a process for
15
determining eligibility of children for coverage under the
16
program. The eligibility determination process must be used
17
solely for determining eligibility of applicants for health
18
benefits coverage under the program. The eligibility
19
determination process must include an initial determination of
20
eligibility for any coverage offered under the program, as
21
well as a redetermination or reverification of eligibility
22
each subsequent 6 months. In conducting an eligibility
23
determination, the department shall determine if the child has
24
special health care needs.
25
(c) Inform program applicants about eligibility
26
determinations and provide information about eligibility of
27
applicants to the Medicaid program, Medikids, the Children's
28
Medical Services network, the Florida Healthy Kids
29
Corporation, and insurers and their agents through a
30
centralized coordinating office.
31
32
CODING: Words stricken are deletions; words underlined are additions.
CS for CS for CS for SB 1228 First
Engrossed
1
(d) Adopt rules necessary for conducting program
2
eligibility functions.
3
(2) The Department of Health shall:
4
(a) Design an eligibility intake process for the
5
program, in coordination with the Department of Children and
6
Family Services, the agency, and the Florida Healthy Kids
7
Corporation. The eligibility intake process may include local
8
intake points that are determined by the Department of Health
9
in coordination with the Department of Children and Family
10
Services.
11
(b) Design and implement program outreach activities
12
under s. 409.819.
13
(c) Chair a state-level coordinating council for the
14
program to review and make recommendations concerning the
15
implementation and operation of the program. The coordinating
16
council shall include representatives from the department, the
17
Department of Children and Family Services, the agency, the
18
Florida Healthy Kids Corporation, the Department of Insurance,
19
health insurers, families participating in the program, and
20
organizations representing low-income families.
21
(d) Adopt rules necessary to implement outreach
22
activities.
23
(3) The Agency for Health Care Administration, under
24
the authority granted in s. 409.914(1), shall:
25
(a) Calculate the premium assistance payment necessary
26
to comply with the premium and cost-sharing limitations
27
specified in s. 409.816. The premium assistance payment for
28
each enrollee in an insurance plan participating in the
29
Florida Healthy Kids Corporation shall equal the premium
30
approved by the Florida Healthy Kids Corporation and the
31
Department of Insurance pursuant to ss. 627.410 and 641.31,
33
CODING: Words stricken are deletions; words underlined are additions.
CS for CS for CS for SB 1228 First
Engrossed
1
less any enrollee's share of the premium established within
2
the limitations specified in s. 409.816. The premium
3
assistance payment for each enrollee in employer-sponsored
4
health insurance plans approved under ss. 409.810-409.820
5
shall equal the premium for the plan adjusted for any
6
benchmark benefit plan actuarial equivalent benefit rider
7
approved by the Department of Insurance pursuant to ss.
8
627.410 and 641.31, less any enrollee's share of the premium
9
established within the limitations specified in s. 409.816. In
10
calculating the premium assistance payment levels for children
11
with family coverage, the agency shall set the premium
12
assistance payment levels for each child proportionately to
13
the total cost of family coverage.
14
(b) Annually calculate the program enrollment ceiling
15
based on estimated per-child premium assistance payments and
16
the estimated appropriation available for the program.
17
(c) Make premium assistance payments to health
18
insurance plans on a periodic basis. The agency may use its
19
Medicaid fiscal agent or a contracted third-party
20
administrator in making these payments.
21
(d) Monitor compliance with quality assurance and
22
access standards developed under s. 409.820.
23
(e) Establish a mechanism for investigating and
24
resolving complaints and grievances from program applicants,
25
enrollees, and health benefits coverage providers, and
26
maintain a record of complaints and confirmed problems. In the
27
case of a child who is enrolled in a health maintenance
28
organization, the agency must use the provisions of s. 641.511
29
to address grievance reporting and resolution requirements.
30
31
34
CODING: Words stricken are deletions; words underlined are additions.
CS for CS for CS for SB 1228 First
Engrossed
1
(f) Approve health benefits coverage for participation
2
in the program, following certification by the Department of
3
Insurance under subsection (4).
4
(g) Adopt rules necessary for calculating premium
5
assistance payment levels, calculating the program enrollment
6
ceiling, making premium assistance payments, monitoring access
7
and quality assurance standards, investigating and resolving
8
complaints and grievances, administering the Medikids program,
9
and approving health benefits coverage.
10
(4) The Department of Insurance shall certify that
11
health benefits coverage plans that seek to provide services
12
under the program, except those offered through the Florida
13
Healthy Kids Corporation or the Children's Medical Services
14
network, meet, exceed, or are actuarially equivalent to the
15
benchmark benefit plan and that health insurance plans will be
16
offered at an approved rate. In determining actuarial
17
equivalence of benefits coverage, the Department of Insurance
18
and health insurance plans must comply with the requirements
19
of section 2103 of Title XXI of the Social Security Act. The
20
department shall adopt rules necessary for certifying health
21
benefits coverage plans.
22
(5) Notwithstanding any other provision contained in
23
this act, the Florida Healthy Kids Corporation shall continue
24
to provide health care coverage as previously approved by the
25
federal Department of Health and Human Services under Title
26
XXI of the Social Security Act. Each fiscal year, the
27
corporation shall establish a maximum number of children by
28
county on a statewide basis who may enroll in the program
29
without requiring local matching funds. Thereafter, the
30
corporation may establish local matching requirements for
31
supplemental participation in the program. The corporation may
35
CODING: Words stricken are deletions; words underlined are additions.
CS for CS for CS for SB 1228 First
Engrossed
1
vary local matching requirements and enrollment by county
2
depending on factors which may influence the generation of
3
local match, including but not limited to, population density,
4
per capita income, existing local tax effort and other
5
factors.
6
(6) The Agency for Health Care Administration, the
7
Department of Health, the Department of Children and Family
8
Services, and the Department of Insurance have the authority
9
to make program modifications and adopt rules not inconsistent
10
with the administrative responsibilities and rulemaking
11
authority granted in this section which are necessary to
12
overcome any objections of the federal Department of Health
13
and Human Services and obtain approval of the state's child
14
health plan under Title XXI of the Social Security Act.
15
Section 16. Section 154.508, Florida Statutes, is
16
transferred, renumbered as section 409.819, Florida Statutes,
17
and amended to read:
18
409.819 154.508 Identification of low-income,
19
uninsured children; determination of Medicaid eligibility for
20
the Florida Kids Health program; alternative health care
21
information.--The Department of Health Agency for Health Care
22
Administration shall develop a program, in conjunction with
23
the Department of Education, the Department of Children and
24
Family Services, the Agency for Health Care Administration,
25
the Florida Healthy Kids Corporation the Department of Health,
26
local governments, employers school districts, and other
27
stakeholders to identify low-income, uninsured children and,
28
to the extent possible and subject to appropriation, refer
29
them to the Department of Children and Family Services for a
30
Medicaid eligibility determination and provide parents with
31
information about choices alternative sources of health
36
CODING: Words stricken are deletions; words underlined are additions.
CS for CS for CS for SB 1228 First
Engrossed
1
benefits coverage under the Florida Kids Health program care.
2
These activities shall include, but not be limited to:
3
training community providers in effective methods of outreach;
4
conducting public information campaigns designed to publicize
5
the Florida Kids Health program, the eligibility requirements
6
of the program, and the procedures for enrollment in the
7
program; and maintaining public awareness of the Florida Kids
8
Health program.
9
Section 17. Section 409.820, Florida Statutes, is
10
created to read:
11
409.820 Quality assurance and access standards.--The
12
Department of Health, in consultation with the agency and the
13
Florida Healthy Kids Corporation, shall develop a minimum set
14
of quality assurance and access standards for all program
15
components. The standards must include a process for granting
16
exceptions to specific requirements for quality assurance and
17
access. Compliance with the standards shall be a condition of
18
program participation by health benefits coverage providers.
19
Section 18. The following performance measures and
20
standards are adopted for the Florida Kids Health program.--
21
(1) The total number of previously uninsured children
22
who receive health benefits coverage as a result of state
23
activities under Title XXI of the Social Security Act: 254,000
24
uninsured children expected to obtain coverage during the
25
1998-1999 fiscal year.
26
(a) The number of children enrolled in the Medicaid
27
program as a result of eligibility expansions under Title XXI
28
of the Social Security Act: 31,000 children enrolled in
29
Medicaid under new eligibility groups during the 1998-1999
30
fiscal year.
31
37
CODING: Words stricken are deletions; words underlined are additions.
CS for CS for CS for SB 1228 First
Engrossed
1
(b) The number of children enrolled in the Medicaid
2
program as a result of outreach efforts under Title XXI of the
3
Social Security Act who are eligible for Medicaid but who have
4
not enrolled in the program: 80,000 children previously
5
eligible for Medicaid, but not enrolled in Medicaid, who
6
enroll in Medicaid during the 1998-1999 fiscal year.
7
(c) The number of uninsured children enrolled in
8
Medikids under Title XXI of the Social Security Act: 15,500
9
children enrolled in Medikids during the 1998-1999 fiscal
10
year.
11
(d) The number of uninsured children added to the
12
enrollment for the Florida Healthy Kids Corporation program
13
under Title XXI of the Social Security Act: 70,000 additional
14
children enrolled in the Florida Healthy Kids Corporation
15
program during the 1998-1999 fiscal year.
16
(e) The number of uninsured children enrolled in
17
employer-sponsored group health insurance coverage under Title
18
XXI of the Social Security Act: 48,000 uninsured children
19
enrolled in health insurance coverage during the 1998-1999
20
fiscal year.
21
(f) The number of uninsured children enrolled in the
22
Children's Medical Services network under Title XXI of the
23
Social Security Act: 9,500 uninsured children enrolled in the
24
Children's Medical Services network during the 1998-1999
25
fiscal year.
26
(2) The percentage of uninsured children in this state
27
as of July 1, 1998, who receive health benefits coverage under
28
the Florida Kids Health program: 30.9 percent of uninsured
29
children enrolled in the Florida Kids Health program during
30
the 1998-1999 fiscal year.
31
38
CODING: Words stricken are deletions; words underlined are additions.
CS for CS for CS for SB 1228 First
Engrossed
1
(3) The percentage of children enrolled in the Florida
2
Kids Health program with up-to-date immunizations: 80 percent
3
of enrolled children with up-to-date immunizations.
4
(4) The percentage of compliance with the standards
5
established in the Guidelines for Health Supervision of
6
Children and Youth as developed by the American Academy of
7
Pediatrics for children eligible for the Florida Kids Health
8
program and served under:
9
(a) Medicaid;
10
(b) Medikids;
11
(c) The Florida Healthy Kids Corporation program; and
12
(d) Health insurance products.
13
14
For each category of coverage, the health care provided is in
15
compliance with the health supervision standards for 80
16
percent of enrolled children.
17
(5) The perception of the enrollee or the enrollee's
18
family concerning coverage provided to children enrolled in
19
the Florida Kids Health program and served under:
20
(a) Medicaid;
21
(b) Medikids;
22
(c) Florida Healthy Kids Corporation;
23
(d) Health insurance products; and
24
(e) Children's Medical Services network.
25
26
For each category of coverage, 90 percent of the enrollees or
27
the enrollee families indicate satisfaction with the care
28
provided under the program.
29
Section 19. The Agency for Health Care Administration
30
shall conduct a study of the feasibility of extending
31
presumptive eligibility for Medicaid to children who have not
39
CODING: Words stricken are deletions; words underlined are additions.
CS for CS for CS for SB 1228 First
Engrossed
1
attained the age of 19. The study shall assess whether
2
families delay seeking health care services or health care
3
coverage because of the lack of presumptive eligibility. The
4
agency shall report its findings to the President of the
5
Senate, the Speaker of the House of Representatives, and the
6
chairpersons of the respective health care committees no later
7
than December 31, 1998.
8
Section 20. Section 624.92, Florida Statutes, as
9
created by section 9 of chapter 97-260, Laws of Florida, is
10
repealed.
11
Section 21. For fiscal year 1998-1999, the enrollment
12
ceiling for the non-Medicaid portion of the Florida Kids
13
Health program is 270,000 children. Thereafter, the enrollment
14
ceiling shall be established in the General Appropriations Act
15
or general law.
16
Section 22. 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 23. 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 24. This act shall take effect July 1, 1998.
26
27
28
29
30
31
40