House Bill 4415
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Florida House of Representatives - 1998 HB 4415
By the Committee on Health Care Services and
Representative Albright
1 A bill to be entitled
2 An act relating to children's health; amending
3 s. 383.011, F.S.; directing the Agency for
4 Health Care Administration to seek a federal
5 waiver for the Healthy Start program; amending
6 s. 391.011, F.S.; providing a short title;
7 amending s. 391.016, F.S.; providing
8 legislative intent relating to the Children's
9 Medical Services program; amending s. 391.021,
10 F.S.; providing definitions; creating s.
11 391.025, F.S.; providing for applicability and
12 scope; amending s. 391.026, F.S.; providing
13 powers and duties of the Department of Health;
14 creating s. 391.028, F.S., and renumbering and
15 amending s. 391.051, F.S.; providing for
16 administration of the program; creating s.
17 391.029, F.S., and renumbering and amending ss.
18 391.046 and 391.07, F.S.; providing program
19 eligibility; creating s. 391.031, F.S.;
20 establishing benefits; creating s. 391.035,
21 F.S., and renumbering and amending ss. 391.036
22 and 391.041, F.S.; establishing provider
23 qualifications; creating s. 391.045, F.S.;
24 providing for provider reimbursement; creating
25 s. 391.047, F.S.; establishing responsibility
26 for payments on behalf of program participants
27 when other parties are liable; creating s.
28 391.055, F.S.; establishing service delivery
29 systems; creating s. 391.065, F.S.; providing
30 for health care provider agreements; creating
31 s. 391.071, F.S.; providing for quality of care
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1 requirements; creating s. 391.081, F.S.;
2 establishing grievance reporting and resolution
3 requirements; creating s. 391.095, F.S.;
4 providing for program integrity; renumbering
5 and amending s. 391.061, F.S.; providing for
6 research and evaluation; renumbering ss.
7 391.201-391.217, F.S., relating to prescribed
8 pediatric extended care centers; designating
9 said sections as pt. IX of ch. 400, F.S.;
10 amending ss. 391.206 and 391.217, F.S.;
11 conforming cross references; designating ss.
12 391.221, 391.222, and 391.223, F.S., as pt. II
13 of ch. 391, F.S., entitled "Children's Medical
14 Services Councils and Panels"; creating s.
15 391.221, F.S.; establishing the Statewide
16 Children's Medical Services Network Advisory
17 Council; creating s. 391.222, F.S.;
18 establishing the Cardiac Advisory Council;
19 creating s. 391.223, F.S.; providing for
20 technical advisory panels; amending ss.
21 391.301, 391.303, 391.304, 391.305, and
22 391.307, F.S.; revising provisions relating to
23 developmental evaluation and intervention
24 programs; amending s. 408.701, F.S.; conforming
25 cross references; creating s. 409.810, F.S.;
26 providing a short title; creating s. 409.811,
27 F.S.; providing definitions; creating s.
28 409.812, F.S.; creating the Florida Children's
29 Healthy Bodies program; providing legislative
30 findings and intent; providing guiding
31 principles; creating s. 409.813, F.S.;
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1 specifying program components; specifying that
2 certain program components are not an
3 entitlement; establishing an enrollment
4 ceiling; creating s. 409.8131, F.S.; creating
5 the Medikids program; providing legislative
6 findings and intent; providing that the program
7 is not an entitlement; providing for a
8 marketing plan; providing for application to
9 Medikids of specified sections of ch. 409,
10 F.S., relating to Medicaid; providing for
11 benefits; providing eligibility standards;
12 providing for enrollment; creating s. 409.8134,
13 F.S.; providing for delivery of services and
14 reimbursement of providers in a rural county;
15 creating s. 409.8135, F.S.; providing
16 behavioral health benefits to
17 non-Medicaid-eligible children with serious
18 emotional needs; creating s. 409.814, F.S.;
19 providing eligibility requirements; creating s.
20 409.815, F.S.; establishing health benefits
21 coverage requirements for the program; creating
22 s. 409.816, F.S.; providing for limitations on
23 premiums and cost-sharing; creating s. 409.817,
24 F.S.; providing for a health insurance pilot
25 project; requiring approval of health benefits
26 coverage as a condition of financial
27 assistance; creating s. 409.8175, F.S.;
28 directing the Agency for Health Care
29 Administration to seek federal approval to
30 establish a family coverage program; providing
31 conditions; creating s. 409.8177, F.S.;
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1 providing for program evaluation; requiring
2 annual reports; creating s. 409.818, F.S.;
3 providing for program administration; providing
4 responsibilities for the Department of Children
5 and Family Services, the Department of Health,
6 the Department of Insurance, the Agency for
7 Health Care Administration, and the Florida
8 Healthy Kids Corporation; authorizing program
9 modifications to obtain federal approval of the
10 state's child health insurance plan;
11 renumbering and amending s. 154.508, F.S.,
12 relating to outreach activities; creating s.
13 409.8195, F.S.; requiring the development of
14 quality assurance and access standards;
15 creating s. 409.821, F.S.; establishing
16 performance measures and standards; providing
17 an enrollment ceiling; amending s. 409.904,
18 F.S.; expanding Medicaid optional eligibility
19 to certain children and providing for
20 continuous eligibility; amending s. 409.9126,
21 F.S.; relating to the provision of Children's
22 Medical Services network services for children
23 with special health care needs; deleting
24 definitions; deleting standards for referral of
25 certain children to the network; providing for
26 certain provider reimbursement; amending s.
27 624.91, F.S., relating to the Florida Healthy
28 Kids Corporation; providing legislative intent;
29 specifying that the program is not an
30 entitlement; revising standards; providing
31 additional duties; repealing ss. 391.031,
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1 391.056, and 391.091, F.S., relating to patient
2 care centers, district children's medical
3 program supervisors, and the Cardiac Advisory
4 Council which was advisory to the Children's
5 Medical Services Program Office; repealing s.
6 624.92, F.S., relating to application for a
7 Medicaid waiver for funds to expand the Florida
8 Health Kids Corporation; providing for future
9 repeal and review of s. 409.814(3), F.S., and
10 ss. 409.810-409.821, F.S., relating to the
11 "Florida Children's Healthy Bodies Act," on
12 specified dates; providing an effective date.
13
14 Be It Enacted by the Legislature of the State of Florida:
15
16 Section 1. Subsection (3) is added to section 383.011,
17 Florida Statutes, to read:
18 383.011 Administration of maternal and child health
19 programs.--
20 (3) The Agency for Health Care Administration, working
21 jointly with the Department of Health and the Florida
22 Association of Healthy Start Coalitions, is directed to seek a
23 federal waiver to secure matching funds under Title XIX of the
24 Social Security Act for the Healthy Start program. The
25 federal waiver application shall seek Medicaid matching funds
26 utilizing existing appropriated general revenue and any local
27 contributions.
28 Section 2. Section 391.011, Florida Statutes, is
29 amended to read:
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1 391.011 Short title.--The provisions of this chapter
2 This act shall be known and may be cited as the "Children's
3 Medical Services Act."
4 Section 3. Section 391.016, Florida Statutes, is
5 amended to read:
6 391.016 Legislative intent.--The Legislature intends
7 that the Children's Medical Services program:
8 (1) Provide to children with special health care needs
9 a family-centered, comprehensive, and coordinated statewide
10 managed system of care that links community-based health care
11 with multidisciplinary, regional, and tertiary pediatric
12 specialty care finds and declares that there is a need to
13 provide medical services for needy children, particularly
14 those with chronic, crippling or potentially crippling and
15 physically handicapping diseases or conditions, and to provide
16 leadership and direction in promoting, planning, and
17 coordinating children's medical care programs so that the full
18 development of each child's potential may be realized.
19 (2) Provide essential preventive, evaluative, and
20 early intervention services for children at risk for or having
21 special health care needs, in order to prevent or reduce long
22 term disabilities.
23 (3) Serve as a principal provider for children with
24 special health care needs under Titles XIX and XXI of the
25 Social Security Act.
26 (4) Be complementary to children's health training
27 programs essential for the maintenance of a skilled pediatric
28 health care workforce for all Floridians.
29 Section 4. Section 391.021, Florida Statutes, is
30 amended to read:
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1 391.021 Definitions.--When used in this act, unless
2 the context clearly indicates otherwise:
3 (1) "Children's Medical Services network" or "network"
4 means a statewide managed care service system that includes
5 health care providers, as defined in this section.
6 (2) "Children with special health care needs" means
7 those children under age 21 years whose serious or chronic
8 physical or developmental conditions require extensive
9 preventive and maintenance care beyond that required by
10 typically healthy children. Health care utilization by these
11 children exceeds the statistically expected usage of the
12 normal child adjusted for chronological age. These children
13 often need complex care requiring multiple providers,
14 rehabilitation services, and specialized equipment in a number
15 of different settings.
16 (3)(1) "Department" means the Department of Health.
17 (4)(2) "Eligible individual" means a child with a
18 special health care need or a female of any age with a
19 high-risk pregnancy, or an individual below the age of 21
20 years who has an organic disease, defect, or condition which
21 may hinder the achievement of his or her normal growth and
22 development, and who meets the financial and medical
23 eligibility standards established in s. 391.029. by the
24 department. In addition, where specific legislative
25 appropriation exists, individuals with long-term chronic
26 diseases, such as cystic fibrosis, which originated during
27 childhood and who received services under this act before the
28 age of 21 years shall continue to be eligible beyond that age.
29 (5) "Health care provider" means a health care
30 professional, health care facility, or entity licensed or
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1 certified to provide health services in this state that meets
2 the criteria as established by the department.
3 (6)(3) "Health Medical services" includes the
4 prevention, diagnosis, and treatment of human disease, pain,
5 injury, deformity, or disabling physical conditions.
6 (7) "Participant" means an eligible individual who is
7 enrolled in the Children's Medical Services program.
8 (8) "Program" means the Children's Medical Services
9 program established in the Division of Children's Medical
10 Services of the department.
11 Section 5. Section 391.025, Florida Statutes, is
12 created to read:
13 391.025 Applicability and scope.--
14 (1) This act applies to health services provided to
15 eligible individuals who are:
16 (a) Enrolled in the Medicaid program;
17 (b) Enrolled in the Florida Children's Healthy Bodies
18 program; and
19 (c) Uninsured or underinsured, provided that they meet
20 the financial eligibility requirements established in this
21 act, and to the extent that resources are appropriated for
22 their care.
23 (2) The Children's Medical Services program consists
24 of the following components:
25 (a) The infant metabolic screening program established
26 in s. 383.14.
27 (b) The regional perinatal intensive care centers
28 program established in ss. 383.15-383.21.
29 (c) A federal or state program authorized by the
30 Legislature.
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1 (d) The developmental evaluation and intervention
2 program.
3 (e) The Children's Medical Services network.
4 (3) The Children's Medical Services program shall not
5 be deemed an insurer and is not subject to the licensing
6 requirements of the Florida Insurance Code or the rules of the
7 Department of Insurance, when providing services to children
8 who receive Medicaid benefits, other Medicaid-eligible
9 children with special health care needs, and children
10 participating in the Florida Children's Healthy Bodies
11 program. This exemption shall not extend to contractors.
12 Section 6. Section 391.026, Florida Statutes, is
13 amended to read:
14 391.026 Powers and duties of the department.--To
15 administer its programs of children's medical services, The
16 department shall have the following powers, duties, and
17 responsibilities:
18 (1) To provide or contract for the provision of health
19 medical services to eligible individuals.
20 (2) To determine the medical and financial eligibility
21 standards for the program and to determine the medical and
22 financial eligibility of individuals seeking health medical
23 services from the program.
24 (3) To recommend priorities for the implementation of
25 comprehensive plans and budgets.
26 (4) To coordinate a comprehensive delivery system for
27 eligible individuals to take maximum advantage of all
28 available federal funds.
29 (5) To promote, establish, and coordinate programs
30 relating to children's medical services in cooperation with
31 other public and private agencies and to coordinate funding of
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1 health care programs with state or local indigent health care
2 funding mechanisms.
3 (6) To initiate, coordinate, and request review of
4 applications to federal and state agencies for funds,
5 services, or commodities relating to children's medical
6 programs.
7 (7) To sponsor or promote grants for projects,
8 programs, education, or research in the field of medical needs
9 of children, with an emphasis on early diagnosis and
10 treatment.
11 (8) To oversee and operate the Children's Medical
12 Services network contract or be contracted with.
13 (9) To establish reimbursement mechanisms for the
14 Children's Medical Services network standards of eligibility
15 for patients of children's medical services programs.
16 (10) To establish Children's Medical Services network
17 standards and credentialing requirements for health care
18 providers and health care services coordinate funding of
19 medical care programs with state or local indigent health care
20 funding mechanisms.
21 (11) To serve as a provider and principal case manager
22 for children with special health care needs under Titles XIX
23 and XXI of the Social Security Act establish standards for
24 patient care and facilities.
25 (12) To monitor the provision of health services in
26 the program, including the utilization and quality of health
27 services.
28 (13) To administer the Children with Special Health
29 Care Needs program in accordance with Title V of the Social
30 Security Act.
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1 (14) To establish and operate a grievance resolution
2 process for participants and health care providers.
3 (15) To maintain program integrity in the Children's
4 Medical Services program.
5 (16) To receive and manage health care premiums,
6 capitation payments, and funds from federal, state, local, and
7 private entities for the program.
8 (17) To appoint health care consultants for the
9 purpose of providing peer review and making recommendations to
10 enhance the delivery and quality of services in the Children's
11 Medical Services program.
12 (18)(12) To make rules to carry out the provisions of
13 this act.
14 Section 7. Section 391.028, Florida Statutes, is
15 created, and section 391.051, Florida Statutes, is renumbered
16 as subsection (1) of said section and amended, to read:
17 391.028 Administration.--The Children's Medical
18 Services program shall have a central office and area offices.
19 (1) 391.051 Qualifications of director.--The Director
20 of the Division of for Children's Medical Services must be a
21 physician licensed under chapter 458 or chapter 459 who has
22 specialized training and experience in the provision of health
23 medical care to children and who has recognized skills in
24 leadership and the promotion of children's health programs.
25 The division director for Children's Medical Services shall be
26 the deputy secretary and the Deputy State Health Officer for
27 Children's Medical Services and is appointed by and reports to
28 the secretary.
29 (2) The division director shall designate Children's
30 Medical Services area offices to perform operational
31 activities, including, but not limited to:
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1 (a) Providing case management services for the
2 network.
3 (b) Providing local oversight of the program.
4 (c) Determining medical and financial eligibility for
5 the program.
6 (d) Participating in the determination of a level of
7 care and medical complexity for long-term care services.
8 (e) Authorizing services in the program and developing
9 spending plans.
10 (f) Participating in the development of treatment
11 plans.
12 (g) Taking part in the resolution of complaints and
13 grievances from participants and health care providers.
14 (3) Each Children's Medical Services area office shall
15 be directed by a physician licensed under chapter 458 or
16 chapter 459 who has specialized training and experience in the
17 provision of health care to children. The director of a
18 Children's Medical Services area office shall be appointed by
19 the division director from the active panel of Children's
20 Medical Services physician consultants.
21 Section 8. Section 391.029, Florida Statutes, is
22 created, section 391.046, Florida Statutes, is renumbered as
23 subsection (3) of said section and amended, and section
24 391.07, Florida Statutes, is renumbered as subsection (4) of
25 said section and amended, to read:
26 391.029 Program eligibility.--
27 (1) The department shall establish the medical
28 criteria to determine if an applicant for the Children's
29 Medical Services program is an eligible individual.
30 (2) The following individuals are financially eligible
31 for the program:
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1 (a) A high-risk pregnant female who is eligible for
2 Medicaid.
3 (b) A child with special health care needs from birth
4 to age 21 years who is eligible for Medicaid.
5 (c) A child with special health care needs from birth
6 to age 19 years who is eligible for a program under Title XXI
7 of the Social Security Act.
8 (d) A child with special health care needs from birth
9 to age 21 years whose projected annual cost of care adjusts
10 the family income to Medicaid financial criteria. In cases
11 where the family income is adjusted based on a projected
12 annual cost of care, the family shall participate financially
13 in the cost of care based on criteria established by the
14 department.
15
16 The department may continue to serve certain children with
17 special health care needs who are 21 years of age or older and
18 who were receiving services from the program prior to April 1,
19 1998. Such children may be served by the department until
20 July 1, 2000.
21 (3) 391.046 Financial determination.--The department
22 shall determine the financial and medical eligibility of
23 children for the program. The department shall also determine
24 ability of individuals seeking medical services, or the
25 financial ability of the parents, or persons or other agencies
26 having legal custody over such individuals, to pay the costs
27 of health such medical services under the program. The
28 department may pay reasonable travel expenses related to the
29 determination of eligibility for or the provision of health
30 medical services.
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1 (4) 391.07 Indigent and semi-indigent cases.--Any
2 child who has been provided with surgical or medical care or
3 treatment under this act prior to being adopted shall continue
4 to be eligible to be provided with such care or treatment
5 after his or her adoption, regardless of the financial ability
6 of the persons adopting the child.
7 Section 9. Section 391.031, Florida Statutes, is
8 created to read:
9 391.031 Benefits.--Benefits provided under the program
10 shall be the same benefits provided to children as specified
11 in ss. 409.905 and 409.906. The department may offer
12 additional benefits for early intervention services, respite
13 services, genetic testing, genetic and nutritional counseling,
14 and parent support services, if such services are determined
15 to be medically necessary. No child or person determined
16 eligible for the program who is eligible under Title XIX or
17 Title XXI of the Social Security Act shall receive any service
18 other than an initial health care screening or treatment of an
19 emergency medical condition as defined in s. 395.002, until
20 such child or person is enrolled in Medicaid or a Title XXI
21 program.
22 Section 10. Section 391.035, Florida Statutes, is
23 created, section 391.036, Florida Statutes, is renumbered as
24 subsection (2) of said section and amended, and section
25 391.041, Florida Statutes, is renumbered as subsection (3) of
26 said section and amended, to read:
27 391.035 Provider qualifications.--
28 (1) The department shall establish the criteria to
29 designate health care providers to participate in the
30 Children's Medical Services network. The department shall
31 follow, whenever available, national guidelines for selecting
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1 health care providers to serve children with special health
2 care needs.
3 (2) 391.036 Medical services providers;
4 qualifications.--The department shall require that all health
5 care providers under contract with the program of medical
6 services under this act be duly licensed in the state, if such
7 licensure is available, and meet such criteria as may be
8 established by the department.
9 (3) 391.041 Services to other state or local programs
10 or institutions.--The department may initiate agreements with
11 other state or local governmental programs or institutions for
12 the coordination of health medical care to eligible
13 individuals receiving services from such programs or
14 institutions.
15 Section 11. Section 391.045, Florida Statutes, is
16 created to read:
17 391.045 Reimbursement.--
18 (1) The department shall reimburse health care
19 providers for services rendered through the Children's Medical
20 Services network using cost-effective methods, including, but
21 not limited to, capitation, discounted fee-for-service, unit
22 costs, and cost reimbursement. Medicaid reimbursement rates
23 shall be utilized to the maximum extent possible, where
24 applicable.
25 (2) Reimbursement to the Children's Medical Services
26 program for services provided to children with special health
27 care needs who participate in the Florida Children's Healthy
28 Bodies program and who are not Medicaid recipients shall be on
29 a capitated basis.
30 Section 12. Section 391.047, Florida Statutes, is
31 created to read:
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1 391.047 Responsibility for payments on behalf of
2 Children's Medical Services program participants when other
3 parties are liable.--The Children's Medical Services program
4 shall comply with s. 402.24, concerning third-party
5 liabilities and recovery of third-party payments for health
6 services.
7 Section 13. Section 391.055, Florida Statutes, is
8 created to read:
9 391.055 Service delivery systems.--
10 (1) The program shall apply managed care methods to
11 ensure the efficient operation of the Children's Medical
12 Services network. Such methods include, but are not limited
13 to, capitation payments, utilization management and review,
14 prior authorization, and case management.
15 (2) The components of the network are:
16 (a) Qualified primary care physicians who shall serve
17 as the gatekeepers and who shall be responsible for the
18 provision or authorization of health services to an eligible
19 individual who is enrolled in the Children's Medical Services
20 network.
21 (b) Comprehensive specialty care arrangements that
22 meet the requirements of s. 391.035 to provide acute care,
23 specialty care, long-term care, and chronic disease management
24 for eligible individuals.
25 (c) Case management services.
26 (3) The Children's Medical Services network may
27 contract with school districts participating in the certified
28 school match program pursuant to ss. 236.0812 and 409.908(21)
29 for the provision of school-based services, as provided for in
30 s. 409.9071, for Medicaid-eligible children who are enrolled
31 in the Children's Medical Services network.
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1 Section 14. Section 391.065, Florida Statutes, is
2 created to read:
3 391.065 Health care provider agreements.--The
4 department is authorized to establish health care provider
5 agreements for participation in the Children's Medical
6 Services network.
7 Section 15. Section 391.071, Florida Statutes, is
8 created to read:
9 391.071 Quality of care requirements.--The Children's
10 Medical Services program shall develop quality of care and
11 service integration standards and reporting requirements for
12 health care providers that participate in the Children's
13 Medical Services network. The program shall ensure that these
14 standards are not duplicative of other standards and
15 requirements for health care providers.
16 Section 16. Section 391.081, Florida Statutes, is
17 created to read:
18 391.081 Grievance reporting and resolution
19 requirements.--The department shall adopt and implement a
20 system to provide assistance to eligible individuals and
21 health care providers to resolve complaints and grievances.
22 To the greatest extent possible, the department shall use
23 existing grievance reporting and resolution processes. The
24 department shall ensure that the system developed for the
25 Children's Medical Services program does not duplicate
26 existing grievance reporting and resolution processes.
27 Section 17. Section 391.095, Florida Statutes, is
28 created to read:
29 391.095 Program integrity.--The department shall
30 operate a system to oversee the activities of Children's
31 Medical Services network participants, health care providers,
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1 and their representatives to prevent fraudulent and abusive
2 behavior, overutilization and duplicative utilization, and
3 neglect of participants and to recover overpayments as
4 appropriate. For the purposes of this section, the terms
5 "abuse" and "fraud" have the meanings provided in s. 409.913.
6 The department shall refer incidents of suspected fraud and
7 abuse, and overutilization and duplicative utilization, to the
8 appropriate regulatory agency.
9 Section 18. Section 391.061, Florida Statutes, is
10 renumbered as section 391.097, Florida Statutes, and is
11 amended to read:
12 391.097 391.061 Research and evaluation.--
13 (1) The department may initiate, fund, and conduct
14 research and evaluation projects to improve the delivery of
15 children's medical services. The department may cooperate with
16 public and private agencies engaged in work of a similar
17 nature.
18 (2) The Children's Medical Services network shall be
19 included in any evaluation conducted in accordance with the
20 provisions of Title XXI of the Social Security Act as enacted
21 by the Legislature.
22 Section 19. Sections 391.201 through 391.217, Florida
23 Statutes, are renumbered as sections 400.901 through 400.917,
24 Florida Statutes, and designated as part IX of chapter 400,
25 Florida Statutes.
26 Section 20. Section 391.206, Florida Statutes, is
27 renumbered as section 400.906, Florida Statutes, and
28 subsection (1) of said section is amended to read:
29 400.906 391.206 Initial application for license.--
30 (1) Application for a license shall be made to the
31 agency on forms furnished by it and shall be accompanied by
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1 the appropriate license fee unless the applicant is exempt
2 from payment of the fee as provided in s. 400.905 391.205.
3 Section 21. Section 391.217, Florida Statutes, is
4 renumbered as section 400.917, Florida Statutes, and amended
5 to read:
6 400.917 391.217 Disposition of moneys from fines and
7 fees.--All moneys received from administrative fines pursuant
8 to s. 400.908 391.208 and all moneys received from fees
9 collected pursuant to s. 400.905 391.205 shall be deposited in
10 the Health Care Trust Fund created in s. 408.16 455.2205.
11 Section 22. Sections 391.221, 391.222, and 391.223,
12 Florida Statutes, as created by this act, are designated as
13 part II of chapter 391, Florida Statutes, entitled "Children's
14 Medical Services Councils and Panels."
15 Section 23. Section 391.221, Florida Statutes, is
16 created to read:
17 391.221 Statewide Children's Medical Services Network
18 Advisory Council.--
19 (1) The secretary of the department may appoint a
20 Statewide Children's Medical Services Network Advisory Council
21 for the purpose of acting as an advisory body to the
22 department. Specifically, the duties of the council shall
23 include, but not be limited to:
24 (a) Recommending standards and credentialing
25 requirements for health care providers rendering health
26 services to Children's Medical Services network participants.
27 (b) Making recommendations to the Director of the
28 Division of Children's Medical Services concerning the
29 selection of health care providers for the Children's Medical
30 Services network.
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1 (c) Reviewing and making recommendations concerning
2 network health care provider or participant disputes that are
3 brought to the attention of the advisory council.
4 (d) Providing input to the Children's Medical Services
5 program on the policies governing the Children's Medical
6 Services network.
7 (e) Reviewing the financial reports and financial
8 status of the network and making recommendations concerning
9 the methods of payment and cost controls for the network.
10 (f) Reviewing and recommending the scope of benefits
11 for the network.
12 (g) Reviewing network performance measures and
13 outcomes and making recommendations for improvements to the
14 network and its maintenance and collection of data and
15 information.
16 (2) The council shall be composed of 12 members
17 representing the private health care provider sector, families
18 with children who have special health care needs, the Agency
19 for Health Care Administration, the Department of Insurance,
20 the Florida Chapter of the American Academy of Pediatrics, an
21 academic health center pediatric program, and the health
22 insurance industry. Members shall be appointed for 4-year,
23 staggered terms. In no case shall an employee of the
24 Department of Health serve as a member or as an ex officio
25 member of the advisory council. A vacancy shall be filled for
26 the remainder of the unexpired term in the same manner as the
27 original appointment. A member may not be appointed to more
28 than two consecutive terms. However, a member may be
29 reappointed after being off the council for at least 2 years.
30
31
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1 (3) Members shall receive no compensation, but shall
2 be reimbursed for per diem and travel expenses in accordance
3 with the provisions of s. 112.061.
4 Section 24. Section 391.222, Florida Statutes, is
5 created to read:
6 391.222 Cardiac Advisory Council.--
7 (1) The secretary of the department may appoint a
8 Cardiac Advisory Council for the purpose of acting as the
9 advisory body to the Division of Children's Medical Services
10 in the delivery of cardiac services to children.
11 Specifically, the duties of the council shall include, but not
12 be limited to:
13 (a) Recommending standards for personnel and
14 facilities rendering cardiac services for the Division of
15 Children's Medical Services.
16 (b) Receiving reports of the periodic review of
17 cardiac personnel and facilities to determine if established
18 standards for Children's Medical Services cardiac services are
19 met.
20 (c) Making recommendations to the division director as
21 to the approval or disapproval of reviewed personnel and
22 facilities.
23 (d) Making recommendations as to the intervals for
24 reinspection of approved personnel and facilities.
25 (e) Providing input to the Division of Children's
26 Medical Services on all aspects of Children's Medical Services
27 cardiac programs, including the rulemaking process.
28 (2) The council shall be composed of eight members
29 with technical expertise in cardiac medicine. Members shall
30 be appointed for 4-year, staggered terms. In no case shall an
31 employee of the Department of Health serve as a member or as
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1 an ex officio member of the advisory council. A vacancy shall
2 be filled for the remainder of the unexpired term in the same
3 manner as the original appointment. A member may not be
4 appointed to more than two consecutive terms. However, a
5 member may be reappointed after being off the council for at
6 least 2 years.
7 (3) Members shall receive no compensation, but shall
8 be reimbursed for per diem and travel expenses in accordance
9 with the provisions of s. 112.061.
10 Section 25. Section 391.223, Florida Statutes, is
11 created to read:
12 391.223 Technical advisory panels.--The secretary of
13 the department may establish technical advisory panels to
14 assist the Division of Children's Medical Services in
15 developing specific policies and procedures for the Children's
16 Medical Services program.
17 Section 26. Section 391.301, Florida Statutes, is
18 amended to read:
19 391.301 Developmental evaluation and intervention
20 programs; legislative findings and intent.--
21 (1) The Legislature finds that the high-risk and
22 disabled newborn infants in this state need in-hospital and
23 outpatient developmental evaluation and intervention and that
24 their families need training and support services. The
25 Legislature further finds that there is an identifiable and
26 increasing number of infants who need developmental evaluation
27 and intervention and family support due to the fact that
28 increased numbers of low-birthweight and sick full-term
29 newborn infants are now surviving because of due to the
30 advances in neonatal intensive care medicine; increased
31 numbers of medically involved infants are remaining
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1 inappropriately in hospitals because their parents lack the
2 confidence or skills to care for these infants without
3 support; and increased numbers of infants are at risk due to
4 parent risk factors, such as substance abuse, teenage
5 pregnancy, and other high-risk conditions.
6 (2) It is the intent of the Legislature to establish
7 developmental evaluation and intervention services programs at
8 all hospitals providing Level II or Level III neonatal
9 intensive care services, in order that families with high-risk
10 or disabled infants may gain the services and skills they need
11 to support their infants.
12 (3) It is the intent of the Legislature to provide a
13 statewide coordinated program to screen, diagnose, and manage
14 high-risk infants identified as hearing-impaired. The program
15 shall develop criteria to identify infants who are at risk of
16 having hearing impairments, and shall ensure that all parents
17 or guardians of newborn infants are provided with materials
18 regarding hearing impairments prior to discharge of the
19 newborn infants from the hospital.
20 (4) It is the intent of the Legislature that a
21 methodology be developed to integrate information on infants
22 with potentially disabling conditions with other early
23 intervention programs, including Part C of Pub. L. No. 105-17
24 and the reporting system to be established under the Healthy
25 Start program.
26 Section 27. Section 391.303, Florida Statutes, is
27 amended to read:
28 391.303 Program requirements.--
29 (1) A Developmental evaluation and intervention
30 services program shall be established at each hospital that
31 provides Level II or Level III neonatal intensive care
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1 services. Program services shall be made available to an
2 infant or toddler identified as being at risk for
3 developmental disabilities, or identified as medically
4 involved, who, along with his or her family, would benefit
5 from program services. Program services shall be made
6 available to infants or toddlers in a Level II or Level III
7 neonatal intensive care unit or in a pediatric intensive care
8 unit, infants who are identified as being at high risk for
9 hearing impairment or who are hearing-impaired, or infants who
10 have a metabolic or genetic disorder. The developmental
11 evaluation and intervention programs are subject to the
12 availability of moneys and the limitations established by the
13 General Appropriations Act or chapter 216. Hearing screening,
14 evaluation and referral services, and initial developmental
15 assessments services shall be provided to each infant or
16 toddler. Other program services may be provided to an infant
17 or toddler, and the family of the infant or toddler, who do
18 not meet the financial eligibility criteria for the Children's
19 Medical Services program based on the availability of funding,
20 including insurance and fees.
21 (2) Each developmental evaluation and intervention
22 program shall have a program director, a medical director, and
23 necessary staff to carry out the program. The program director
24 shall establish and coordinate the developmental evaluation
25 and intervention program. The program shall include, but is
26 not limited to:
27 (a) In-hospital evaluation and intervention services,
28 parent support and training, and family support planning and
29 case management.
30 (b) Screening and evaluation services to identify each
31 infant at risk of hearing impairment, and a medical and
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1 educational followup and care management program for an infant
2 who is identified as hearing-impaired, with management
3 beginning as soon after birth as practicable. The medical
4 management program must include the genetic evaluation of an
5 infant suspected to have genetically determined deafness and
6 an evaluation of the relative risk.
7 (c) Regularly held multidisciplinary team meetings to
8 develop and update the family support plan. In addition to the
9 family, a multidisciplinary team may include a physician,
10 physician assistant, psychologist, psychotherapist, educator,
11 social worker, nurse, physical or occupational therapist,
12 speech pathologist, developmental evaluation and intervention
13 program director, case manager, and others who are involved
14 with the in-hospital and posthospital discharge care plan, and
15 anyone the family wishes to include as a member of the team.
16 The family support plan is a written plan that describes the
17 infant or toddler, and the therapies and services the infant
18 or toddler and his or her family need, and the intended
19 outcomes of the services.
20 (d) Discharge planning by the multidisciplinary team,
21 including referral and followup to primary medical care and
22 modification of the family support plan.
23 (e) Education and training for neonatal and pediatric
24 intensive care services staff, volunteers, and others, as
25 needed, in order to expand the services provided to high-risk,
26 developmentally disabled, medically involved, or
27 hearing-impaired infants and toddlers and their families.
28 (f) Followup intervention services after hospital
29 discharge, to aid the family and the high-risk,
30 developmentally disabled, medically involved, or
31 hearing-impaired infant's or toddler's transition into the
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1 community. These services shall include, but are not limited
2 to, home intervention services and other intervention
3 services, both contractual and voluntary. Support services
4 shall be coordinated at the request of the family and within
5 the context of the family support plan.
6 (g) Referral to and coordination of services with
7 community providers.
8 (h) Educational materials about infant care, infant
9 growth and development, community resources, medical
10 conditions and treatments, and family advocacy. Materials
11 regarding hearing impairments shall be provided to each parent
12 or guardian of a hearing-impaired infant or toddler.
13 (i) Involvement of the parents and guardians of each
14 identified high-risk, developmentally disabled, medically
15 involved, or hearing-impaired infant or toddler.
16 Section 28. Paragraph (a) of subsection (1) of section
17 391.304, Florida Statutes, is amended to read:
18 391.304 Program coordination.--
19 (1) The Department of Health shall:
20 (a) Coordinate with the Department of Education, the
21 Offices of Prevention, Early Assistance, and Child
22 Development, the Florida Interagency Coordinating Council for
23 Infants and Toddlers, and the State Coordinating Council for
24 Early Childhood Services in planning and administering ss.
25 391.301-391.307. This coordination shall be in accordance with
26 s. 411.222.
27 Section 29. Subsection (1) of section 391.305, Florida
28 Statutes, is amended to read:
29 391.305 Program standards; rules.--The Department of
30 Health shall adopt rules for the administration of the
31 developmental evaluation and intervention program. The rules
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1 shall specify standards for the development and operation of
2 the program, including, but not limited to:
3 (1) Standards governing the eligibility need for
4 program services and the requirements of the population to be
5 served.
6 Section 30. Subsection (1) of section 391.307, Florida
7 Statutes, is amended to read:
8 391.307 Program review.--
9 (1) At least annually during the contract period, the
10 Department of Health shall evaluate each developmental
11 evaluation and intervention program. The department shall
12 develop criteria to evaluate child and family patient outcome,
13 program participation, service coordination case management,
14 and program effectiveness.
15 Section 31. Subsection (13) of section 408.701,
16 Florida Statutes, is amended to read:
17 408.701 Community health purchasing; definitions.--As
18 used in ss. 408.70-408.706, the term:
19 (13) "Health care provider" or "provider" means a
20 state-licensed or state-authorized facility, a facility
21 principally supported by a local government or by funds from a
22 charitable organization that holds a current exemption from
23 federal income tax under s. 501(c)(3) of the Internal Revenue
24 Code, a licensed practitioner, a county health department
25 established under part I of chapter 154, a patient care center
26 described in s. 391.031, a prescribed pediatric extended care
27 center defined in s. 400.902 391.202, a federally supported
28 primary care program such as a migrant health center or a
29 community health center authorized under s. 329 or s. 330 of
30 the United States Public Health Services Act that delivers
31 health care services to individuals, or a community facility
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1 that receives funds from the state under the Community
2 Alcohol, Drug Abuse, and Mental Health Services Act and
3 provides mental health services to individuals.
4 Section 32. Section 409.810, Florida Statutes, is
5 created to read:
6 409.810 Short title.--Sections 409.810-409.821 may be
7 cited as the "Florida Children's Healthy Bodies Act."
8 Section 33. Section 409.811, Florida Statutes, is
9 created to read:
10 409.811 Definitions.--
11 (1) "Agency" means the Agency for Health Care
12 Administration.
13 (2) "Applicant" means a parent or guardian of a child
14 or, in the case of a child whose disability of nonage has been
15 removed under chapter 743, a child who applies for
16 determination of eligibility under Title XXI of the Social
17 Security Act for health benefits coverage under this act.
18 (3) "Benchmark benefit plan" means the form and level
19 of health benefits coverage established in s. 409.815.
20 (4) "Child" means an individual under the age of 19
21 years.
22 (5) "Child with special health care needs" means the
23 term as defined in chapter 391.
24 (6) "Children's Medical Services network" means the
25 term as defined in chapter 391.
26 (7) "Department" means the Department of Health.
27 (8) "Community rate" means a method used to develop
28 premiums for a health insurance plan which spreads risk across
29 a large population.
30
31
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1 (9) "Enrollee" means a child who has been determined
2 eligible for and is receiving health benefits coverage under
3 this act.
4 (10) "Enrollment ceiling" means the maximum number of
5 non-Medicaid children eligible for premium assistance payments
6 who may be enrolled at any time in the Florida Children's
7 Healthy Bodies program. The maximum number shall be
8 established annually in the General Appropriations Act or in
9 provisions of general law.
10 (11) "Family" means the group or the individuals whose
11 income is considered in determining eligibility for the
12 Florida Children's Healthy Bodies program. The family
13 includes a child with a custodial parent or caretaker relative
14 who resides in the same house or living unit, or in the case
15 of a child whose disability of nonage has been removed under
16 chapter 743, the child. The family may also include
17 individuals who are not eligible for medical assistance under
18 Title XXI of the Social Security Act, but whose income and
19 resources are considered in whole or in part in determining
20 eligibility of the child.
21 (12) "Florida Children's Healthy Bodies program" means
22 the medical assistance program authorized by Title XXI of the
23 Social Security Act as part of the federal Balanced Budget Act
24 of 1997.
25 (13) "Family coverage" means purchase of health
26 benefits coverage that is cost-effective as authorized under
27 s. 2105(c)(3) of Title XXI of the Social Security Act, subject
28 to federal approval of a waiver request.
29 (14) "Family income" means cash received at periodic
30 intervals from any source, such as wages, benefits,
31 contributions, and rental property. Income also may include
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1 any money which would have been counted as income under the
2 Aid to Families with Dependent Children state plan in effect
3 prior to August 22, 1996.
4 (15) "Guarantee issue" means that health benefits
5 coverage must be offered to an individual regardless of the
6 individual's health status, preexisting conditions, or claims
7 history.
8 (16) "Health benefits coverage" means covered health
9 care services that are provided to enrollees by a health
10 insurance plan.
11 (17) "Health insurance plan" means health benefits
12 coverage under the following:
13 (a) A health plan offered by any certified health
14 maintenance organization, except plans that are limited to the
15 following: a limited benefit, specified disease, or specified
16 accident; hospital indemnity; accident only; limited benefit
17 convalescent care; Medicare supplement; credit disability;
18 dental; vision; long-term care; disability income; coverage
19 issued as a supplement to another health plan; workers'
20 compensation liability or similar insurance; or automobile
21 medical-payment insurance;
22 (b) A health insurer licensed under chapter 624;
23 (c) An employee welfare benefit plan that includes
24 health benefits established under the Employee Retirement
25 Income Security Act of 1974, as amended; or
26 (d) The Children's Medical Services network.
27 (18) "Medicaid" means the medical assistance program
28 authorized by Title XIX of the Social Security Act, and
29 regulations thereunder, and ss. 409.901-409.920, as
30 administered in the state by the agency.
31
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1 (19) "Medically necessary" means the use of any
2 medical treatment, service, equipment, or supply necessary to
3 palliate the effects of a terminal condition, or to prevent,
4 diagnose, correct, cure, alleviate, or preclude deterioration
5 of a condition that threatens life, causes pain or suffering,
6 or results in illness or infirmity and which is:
7 (a) Consistent with the symptom, diagnosis, and
8 treatment of the enrollee's condition.
9 (b) Provided in accordance with generally accepted
10 standards of medical practice.
11 (c) Not primarily intended for the convenience of the
12 enrollee's family or the health care provider.
13 (d) The most appropriate level of supply or service
14 for the diagnosis and treatment of the enrollee's condition.
15 (e) Approved by the appropriate medical body or health
16 care specialty involved as effective, appropriate, and
17 essential for the care and treatment of the enrollee's
18 condition.
19 (20) "Medikids" means a component of the Florida
20 Children's Healthy Bodies program of medical assistance
21 authorized by Title XXI of the Social Security Act, and
22 regulations thereunder, and s. 409.8131, as administered in
23 the state by the agency.
24 (21) "Preexisting condition exclusion" means, with
25 respect to coverage, a limitation or exclusion of benefits
26 relating to a condition based on the fact that the condition
27 was present before the date of enrollment for such coverage,
28 whether or not any medical advice, diagnosis, care, or
29 treatment was recommended or received before such date.
30
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1 (22) "Premium" means the entire cost of a health
2 insurance plan, including the administration fee or the risk
3 assumption charge.
4 (23) "Premium assistance payment" means the monthly
5 consideration paid by the agency per enrollee in the Florida
6 Children's Healthy Bodies program towards health insurance
7 premiums.
8 (24) "Program" means the Florida Children's Healthy
9 Bodies program.
10 (25) "Qualified alien" means an alien as defined in s.
11 431 of the Personal Responsibility and Work Opportunity
12 Reconciliation Act of 1996, as amended, Pub. L. No. 104-193.
13 (26) "Resident" means a United States citizen or
14 qualified alien who is domiciled in Florida.
15 (27) "Rural county" means either a county with a
16 population density of less than 100 persons per square mile or
17 a county defined by the most recent United States census as
18 rural, and where there is no prepaid health plan participating
19 in the Medicaid program as of July 1, 1998.
20 (28) "Space" means an allocation of a Florida
21 Children's Healthy Bodies program enrollee opening, subject to
22 the enrollment ceiling established in general law or the
23 General Appropriations Act each year.
24 Section 34. Section 409.812, Florida Statutes, is
25 created to read:
26 409.812 Florida Children's Healthy Bodies program.--
27 (1) LEGISLATIVE FINDINGS AND INTENT.--The Legislature
28 finds that a significant number of Florida children are
29 uninsured at any one time and these children do not receive
30 necessary health care services. Further, the Legislature finds
31 that the lack of access to a regular and ongoing source of
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1 medical care causes families to use health care resources
2 inappropriately. The Legislature hereby creates the Florida
3 Children's Healthy Bodies program to provide a defined set of
4 health benefits to low-income children through the
5 establishment of a variety of affordable health benefits
6 coverage options from which families may select coverage and
7 through which families may contribute financially to the
8 health care of their children.
9 (2) GUIDING PRINCIPLES.--In creating the Florida
10 Children's Healthy Bodies program, the Legislature establishes
11 the following guiding principles:
12 (a) No new entitlements to government services shall
13 be created. The Legislature reserves the right to discontinue
14 the program any time revenue shortfalls occur in program
15 funding or any time the Legislature determines the program is
16 no longer meeting the needs it was designed to fulfill.
17 (b) Individual choice of plans, physicians, and other
18 health care providers must be emphasized.
19 (c) Interference in the private insurance market must
20 be minimized, and "crowd-out," that is, moving children from
21 the private insurance market into a government-subsidized
22 market, must be avoided.
23 (d) Children in families with incomes above
24 eligibility levels for the program may be permitted to
25 participate in the program through the payment of premiums and
26 other coinsurance payments that cover the policy's full costs.
27 (e) Quality assurance mechanisms must be included as
28 an integral component of the program.
29 (f) Special emphasis must be placed on ensuring
30 participation in the program by members of the minority
31 community.
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1 Section 35. Section 409.813, Florida Statutes, is
2 created to read:
3 409.813 Components; nonentitlement; enrollment
4 ceilings.--
5 (1) The Florida Children's Healthy Bodies program
6 includes health benefits coverage provided to children
7 through:
8 (a) The Medicaid program as established under s.
9 409.904(6);
10 (b) The Medikids program established under s.
11 409.8131;
12 (c) The Florida Healthy Kids program as created in s.
13 624.91;
14 (d) Health insurance plans certified and approved to
15 participate in the health insurance pilot project established
16 pursuant to s. 409.817;
17 (e) The Children's Medical Services network; and
18 (f) Family coverage authorized under s. 409.8175.
19
20 Except for coverage under the Medicaid program, nothing in
21 this act provides an individual with an entitlement to
22 government-sponsored health care services. No cause of action
23 shall arise against the state, the department, or the agency
24 for failure to make health services available to any person
25 under this act.
26 (2) Except for the Medicaid program, a ceiling shall
27 be placed on annual federal and state expenditures and
28 enrollment in the Florida Children's Healthy Bodies program
29 based on the General Appropriations Act each year, or as
30 specified in general law. The agency, in consultation with the
31
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1 department, may propose to increase the enrollment ceiling in
2 accordance with the provisions of chapter 216.
3 (3) Except for the Medicaid program, whenever the
4 Social Services Estimating Conference determines that there is
5 presently, or will be by the end of the current fiscal year,
6 insufficient funds to finance the current or projected
7 enrollment in the program, all additional enrollment must
8 cease and additional enrollment may not resume until
9 sufficient funds are available to finance such enrollment.
10 (4) The agency shall collect and analyze the data
11 needed to project the Florida Children's Healthy Bodies
12 program enrollment, including participation rates, caseloads
13 and expenditures. The agency shall report the caseload and
14 expenditure trends to the Social Services Estimating
15 Conference in accordance with the provisions of chapter 216.
16 Section 36. Section 409.8131, Florida Statutes, is
17 created to read:
18 409.8131 Medikids program.--
19 (1) LEGISLATIVE FINDINGS AND INTENT.--It is the intent
20 of the Legislature through the creation of the Medikids
21 program to provide health services to eligible children
22 utilizing the administrative structure and provider network of
23 the Medicaid program while avoiding the creation of an
24 entitlement program. The Legislature intends that children
25 participating in the Medikids program be provided health
26 benefits in the same manner as children participating in the
27 Medicaid program, including the benefit package, except as
28 otherwise specified in this act. Differences between Medikids
29 and Medicaid include, but are not limited to, the use of
30 periodic open enrollment periods for Medikids beneficiaries,
31 and the fact that Medikids is not an entitlement program and
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1 may be discontinued any time the Legislature determines the
2 program is no longer needed, or through the provisions of
3 chapter 216 during the occurrence of a funding shortfall.
4 (2) PROGRAM CREATION.--
5 (a) There is hereby created the Medikids program to be
6 administered by the agency. The Medikids program shall not be
7 subject to the requirements of the Department of Insurance or
8 chapter 627. The director of the agency shall appoint an
9 administrator of the Medikids program, which shall be located
10 in the Division of State Health Purchasing.
11 (b) The agency is designated as the state agency
12 authorized to make payments for medical assistance and related
13 services for the Medikids program under Title XXI of the
14 Social Security Act. These payments shall be made, subject to
15 any limitations or directions provided for in the General
16 Appropriations Act, only for services included in the program,
17 shall be made only on behalf of eligible individuals, and
18 shall be made only to qualified providers in accordance with
19 federal requirements for Title XXI of the Social Security Act
20 and the provisions of state law.
21 (3) NONENTITLEMENT.--Nothing in this section shall be
22 construed as providing an individual with an entitlement to
23 health care services. No cause of action shall arise against
24 the state or the agency for failure to make health services
25 available under this section.
26 (4) MARKETING.--The agency, in consultation with the
27 Department of Health, shall develop and implement a plan to
28 publicize the Medikids program, the eligibility requirements
29 for the program, and the procedures for enrolling in the
30 program, and to maintain public awareness of the program.
31
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1 (5) APPLICABILITY.--The provisions of ss. 409.902,
2 409.905, 409.906, 409.907, 409.908, 409.910, 409.912,
3 409.9121, 409.9122, 409.9123, 409.9124, 409.9127, 409.9128,
4 409.913, 409.916, 409.919, 409.920, and 409.9205, apply to the
5 Medikids program to the same extent such sections apply to the
6 Medicaid program; except the applicability of the provisions
7 of s. 409.9122 to the Medikids program shall be subject to the
8 provisions of subsection (7).
9 (6) BENEFITS.--Benefits provided under the Medikids
10 program shall be the same benefits provided to children as
11 specified in ss. 409.905 and 409.906.
12 (7) ELIGIBILITY.--
13 (a) A child who is under the age of 6 years is
14 eligible to participate in the Medikids program if the child
15 is a member of a family that has a family income which exceeds
16 the Medicaid applicable income level as specified in s.
17 409.903, but which is equal to or below 200 percent of the
18 federal poverty level. No assets test shall be required.
19 (b) The provisions of s. 409.814(3), (4), and (5)
20 shall be applicable to the Medikids program.
21 (8) ENROLLMENT.--Enrollment in the Medikids program
22 may only occur during periodic open enrollment periods as
23 specified by the agency. During the first 12 months of the
24 program, there shall be at least one, but no more than three,
25 open enrollment periods. The initial open enrollment period
26 shall be for 60 days, and subsequent open enrollment periods
27 during the first year of the program shall be for 30 days.
28 After the first year of the program, the agency shall
29 determine the frequency and duration of open enrollment
30 periods. A child may apply for participation in the Medikids
31 program and proceed through the eligibility determination
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1 process at any time throughout the year. In addition, once
2 determined eligible, a child may receive choice counseling and
3 select a managed care plan or MediPass. However, enrollment in
4 Medikids shall not begin until the next open enrollment
5 period; nor shall a child be eligible for services under the
6 Medikids program until the child is enrolled in a managed care
7 plan or MediPass. Enrollment in MediPass shall be an option
8 for a child participating in the Medikids program only in
9 counties which have fewer than two managed care plans
10 available to serve Medicaid recipients. Participants shall not
11 have the option of enrolling in MediPass if the federal Health
12 Care Financing Administration determines that MediPass does
13 not constitute "health insurance coverage" as defined in Title
14 XXI of the Social Security Act.
15 (9) SPECIAL ENROLLMENT PERIODS.--The agency shall
16 establish a special enrollment period of 30 days' duration for
17 any child who is enrolled in Medicaid if such child loses
18 Medicaid eligibility and becomes eligible for Medikids, for
19 any newborn child who is eligible for Medikids, or for any
20 child who is enrolled in Medikids if such child moves to
21 another county which is not within the coverage area of the
22 child's Medikids managed care plan or MediPass provider. The
23 provisions of this subsection shall apply only if a space is
24 available within the Medikids program.
25 (10) PENALTIES FOR VOLUNTARY CANCELLATION.--The agency
26 shall establish enrollment criteria which shall include
27 penalties or waiting periods of not fewer than 60 days for
28 reinstatement of coverage upon voluntary cancellation for
29 nonpayment of premiums.
30 Section 37. Section 409.8134, Florida Statutes, is
31 created to read:
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1 409.8134 Delivery of services in rural counties.--In a
2 rural county, the Florida Healthy Kids Corporation may offer
3 Healthy Kids coverage through a health insurer licensed under
4 chapter 624. The indemnity or preferred provider organization
5 product offered by the health insurer must use the Medicaid
6 fee schedule to reimburse providers.
7 Section 38. Section 409.8135, Florida Statutes, is
8 created to read:
9 409.8135 Behavioral health services.--In order to
10 ensure a high level of integration of physical and behavioral
11 health care and to meet the more intensive treatment needs of
12 enrollees with the most serious emotional disturbances or
13 substance abuse problems, the Department of Health shall
14 contract with the Department of Children and Family Services
15 to provide behavioral health services to non-Medicaid-eligible
16 children with special health care needs. The Department of
17 Children and Family Services, in consultation with the
18 Department of Health and the agency, is authorized to
19 establish the following:
20 (1) The scope of behavioral health services, including
21 duration and frequency.
22 (2) Clinical guidelines for referral to behavioral
23 health services.
24 (3) Behavioral health services standards.
25 (4) Performance-based measures and outcomes for
26 behavioral health services.
27 (5) Practice guidelines for behavioral health services
28 to ensure cost-effective treatment and to prevent unnecessary
29 expenditures.
30 (6) Rules to implement this subsection.
31
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1 Section 39. Section 409.814, Florida Statutes, is
2 created to read:
3 409.814 Eligibility.--Except for the Medicaid program,
4 a child whose family income is at or below 200 percent of the
5 federal poverty level is eligible for financial assistance
6 under the Florida Children's Healthy Bodies program as
7 provided in this section. In determining the eligibility of
8 such a child, an assets test is not required.
9 (1) A child who is eligible for Medicaid coverage
10 under s. 409.903 or s. 409.904, is not eligible to receive
11 health benefits under any other health benefits coverage
12 authorized under this act.
13 (2) A child who is not eligible for Medicaid, but who
14 is eligible for the program, may obtain coverage under any of
15 the other types of health benefits coverage authorized in this
16 act, if such health benefits coverage is approved and space is
17 available in the county in which the child resides. However, a
18 child who is eligible for Medikids may participate in the
19 Florida Healthy Kids program only if the child has a sibling
20 participating in the Florida Healthy Kids program and the
21 child's county of residence permits such enrollment.
22 (3) A child who is eligible for the program and who is
23 a child with special health care needs, as determined through
24 a risk screening instrument, is eligible for health benefits
25 coverage from and may be referred to the Children's Medical
26 Services network established in chapter 391.
27 (4) The following children are not eligible to receive
28 financial assistance for health benefits coverage under this
29 act, except under Medicaid if the child would have been
30 eligible for Medicaid services under s. 409.903 or s. 409.904
31 as of June 1, 1997:
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1 (a) A child who is eligible for coverage under a state
2 health benefits plan on the basis of a family member's
3 employment with a public agency in the state;
4 (b) A child who is covered under a group health
5 benefit plan or under other health insurance coverage,
6 excluding coverage provided under the Florida Healthy Kids
7 Corporation as established under s. 624.91;
8 (c) A child who is an alien, but who does not meet the
9 definition of qualified alien, in the United States; or
10 (d) A child who is an inmate of a public institution
11 or a patient in an institution for mental diseases.
12 (5) A child whose family income is above 200 percent
13 of the federal poverty level may participate in the program,
14 excluding the Medicaid program; but is subject to the
15 following provisions:
16 (a) The family is not eligible for premium assistance
17 payments and must pay the full cost of the premium, including
18 any administrative costs. Children described in this
19 subsection are not counted in the annual enrollment ceiling
20 for the Florida Children's Healthy Bodies program.
21 (b) The agency is authorized to place limits on
22 enrollment in Medikids by these children in order to avoid
23 adverse selection. The number of children participating in
24 Medikids whose family income exceeds 200 percent of the
25 federal poverty level must not exceed 10 percent of total
26 enrollees in the Medikids program.
27 (c) The board of directors of the Florida Healthy Kids
28 Corporation is authorized to place limits on enrollment of
29 these children in order to avoid adverse selection. In
30 addition, the board is authorized to offer a reduced benefit
31 package to these children in order to limit program costs for
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1 such families. The number of children participating in Healthy
2 Kids whose family income exceeds 200 percent of the federal
3 poverty level must not exceed 10 percent of total enrollees in
4 the Healthy Kids program.
5 Section 40. Section 409.815, Florida Statutes, is
6 created to read:
7 409.815 Health benefits coverage; limitations.--
8 (1) For purposes of the Florida Children's Healthy
9 Bodies program, benefits available under the Medicaid program
10 and the Medikids program include those goods and services
11 provided under the medical assistance program authorized by
12 Title XIX of the Social Security Act, and regulations
13 thereunder, as administered in this state by the agency. This
14 includes those mandatory Medicaid services authorized under s.
15 409.905 and optional services authorized under s. 409.906,
16 rendered on behalf of eligible individuals and qualified
17 providers, and subject to any limitations or directions
18 provided for in the General Appropriations Act or chapter 216
19 and according to methodologies and limitations set forth in
20 agency rules and policy manuals and handbooks incorporated by
21 reference thereto.
22 (2) Except for coverage under the Medicaid program and
23 the Medikids program, health benefits coverage must include
24 the following minimum benefits of the benchmark benefit plan
25 as determined medically necessary when provided by a
26 participating provider in the enrollee's health insurance
27 plan.
28 (a) Behavioral health services.--
29 1. Mental health benefits include:
30 a. Inpatient services, limited each contract year to
31 no more than 30 inpatient days for psychiatric admissions or
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1 30 days of residential services in lieu of inpatient
2 psychiatric admission; and
3 b. Outpatient services, including outpatient visits
4 for psychological or psychiatric evaluation, diagnosis, and
5 treatment by a licensed mental health professional, limited to
6 a maximum of 40 outpatient visits each contract year.
7 2. Substance abuse services include:
8 a. Inpatient services, limited each contract year to
9 no more than 7 inpatient days for medical detoxification only
10 and 30 days of residential services; and
11 b. Outpatient services, including evaluation,
12 diagnosis, and treatment by a licensed practitioner, limited
13 to a maximum of 40 outpatient visits each contract year.
14 (b) Durable medical equipment.--Covered services
15 include equipment and devices that are medically indicated to
16 assist in the treatment of a medical condition and
17 specifically prescribed as medically necessary with the
18 following limitations:
19 1. Low-vision and telescopic aides are not included.
20 2. Corrective lenses and frames may be limited to one
21 pair every year, unless the prescription or head size of the
22 enrollee changes.
23 3. Hearing aids shall be covered only when medically
24 indicated to assist in the treatment of a medical condition.
25 4. Covered prosthetic devices include only artificial
26 eyes and limbs; braces; and other artificial aids.
27 (c) Emergency services.--Covered services include
28 visits to an emergency room or other licensed facility where
29 needed immediately due to an injury or illness where delay
30 means risk of permanent damage to the participant's health, in
31 accordance with the provisions of s. 641.513.
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1 (d) 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, which shall be provided in
8 the same manner as in the state Medicaid program.
9 2. Podiatric services, which may be limited to one
10 visit per day totaling two visits per month for specific foot
11 disorders.
12 (e) 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, with the following limitations:
16 1. Coverage may be limited to include skilled nursing
17 services only.
18 2. Meals, housekeeping, and personal comfort items may
19 be excluded.
20 3. Private duty nursing is limited to circumstances
21 where such care is medically necessary.
22 (f) Hospice services.--Covered services include
23 reasonable and necessary services for palliation or management
24 of an enrollee's terminal illness, with the following
25 exceptions:
26 1. Once a family elects to receive hospice care for an
27 enrollee, other services that treat the terminal condition
28 shall not be covered.
29 2. Services required for conditions totally unrelated
30 to the terminal condition are covered to the extent that the
31 services are included in this section.
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1 (g) Hospital inpatient services.--All covered services
2 provided for the medical care and treatment of an enrollee who
3 is admitted as an inpatient to a hospital licensed under part
4 I of chapter 395, with the following exceptions:
5 1. All admissions must be authorized by the enrollee's
6 health insurance plan.
7 2. The length of the patient stay shall be determined
8 based on the medical condition of the enrollee in relation to
9 the necessary and appropriate level of care.
10 3. Room and board may be limited to semiprivate
11 accommodations, unless a private room is considered medically
12 necessary or semiprivate accommodations are not available.
13 4. Admissions for rehabilitation and physical therapy
14 are limited to 15 days per contract year.
15 (h) Hospital outpatient and ambulatory surgical
16 services.--Covered services include preventive, diagnostic,
17 therapeutic, palliative care, and other services provided to
18 an enrollee in the outpatient portion of a health facility
19 licensed under chapter 395, except for the following
20 limitations:
21 1. Services must be authorized by the enrollee's
22 health insurance plan.
23 2. Treatment for Temporomandibular Joint disease (TMJ)
24 is specifically excluded.
25 (i) Laboratory and X-ray services.--Covered services
26 include diagnostic testing, including clinical radiologic,
27 laboratory, and other diagnostic tests.
28 (j) Maternity services.--Covered services include
29 maternity and newborn care, including prenatal and postnatal
30 care, with the following limitations:
31 1. Coverage may be limited to vaginal deliveries.
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1 2. Initial inpatient care for newborn infants of
2 enrolled adolescents shall be covered, including normal
3 newborn care, nursery charges, and the initial pediatric or
4 neonatal examination, and the infant may be covered for up to
5 3 days following birth.
6 (k) Nursing facility services.--Covered services
7 include regular nursing services, rehabilitation services,
8 drugs and biologicals, medical supplies, and the use of
9 appliances and equipment furnished by the facility, with the
10 following limitations:
11 1. All admissions must be authorized by the health
12 insurance plan.
13 2. The length of stay may be limited to 100 days per
14 contract year and shall be determined based on the medical
15 condition of the enrollee in relation to the necessary and
16 appropriate level of care.
17 3. Room and board may be limited to semiprivate
18 accommodations, unless a private room is considered medically
19 necessary or semiprivate accommodations are not available.
20 4. Admissions for rehabilitation and physical therapy
21 are limited to 15 days per contract year.
22 5. Specialized treatment centers and independent
23 kidney disease treatment centers are excluded.
24 (l) Organ transplantation services.--Covered services
25 include pretransplant services for donor and recipient,
26 transplant and postdischarge services and treatment of
27 complications after transplantation for transplants deemed
28 necessary and appropriate within the guidelines set by the
29 Organ Transplant Advisory Council under s. 381.0602 or the
30 Bone Marrow Transplant Advisory Panel under s. 627.4236.
31 (m) Prescribed drugs.--
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1 1. Coverage shall include prescribed drugs prescribed
2 for the medically indicated treatment of illness or injury
3 when prescribed by a licensed health practitioner acting
4 within the scope of his or her practice.
5 2. Prescribed drugs may be limited to generics where
6 available and brand name products where a generic substitution
7 is not available, unless the prescribing licensed health
8 practitioner indicates that a brand name is medically
9 necessary.
10 3. Prescribed drugs covered under this section shall
11 include all prescribed drugs covered under the Florida
12 Medicaid program.
13 (n) Preventive health services.--Covered services
14 include:
15 1. Well-child care, including services recommended in
16 the Guidelines for Health Supervision of Children and Youth as
17 developed by the American Academy of Pediatrics.
18 2. Immunizations and injections.
19 3. Health education counseling and clinical services.
20 4. Vision screening.
21 5. Hearing screening.
22 (o) Therapy services.--Covered services include
23 rehabilitative services, including occupational, physical,
24 respiratory, and speech therapies, with the following
25 limitations:
26 1. Services must be for short-term rehabilitation
27 where significant improvement in the enrollee will result.
28 2. Services shall be no more than 24 treatment
29 sessions within a 60-day period per episode or injury, with
30 the 60-day period beginning with the first treatment.
31
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1 (p) Transportation services.--Covered services include
2 emergency transportation required in response to an emergency
3 situation.
4 (q) Lifetime maximum.--Health benefits coverage
5 obtained under this act shall pay an enrollee's covered
6 expenses at a lifetime maximum of $1 million per covered
7 child.
8 (r) Cost-sharing.--Cost-sharing provisions must comply
9 with s. 409.816.
10 (s) Exclusions.--
11 1. Abortion, unless necessary to save the life of the
12 mother or if the pregnancy is the result of an act of rape or
13 incest, is excluded.
14 2. Experimental or investigational procedures that
15 have not been clinically proved by reliable evidence are
16 excluded.
17 3. Services performed for cosmetic purposes only or
18 for the convenience of the enrollee are excluded.
19 (t) Enhancements to minimum requirements.--
20 1. This section sets the minimum benefits that must be
21 included in any health benefits coverage, other than Medicaid
22 coverage, offered under this act. Health benefits coverage
23 may include additional benefits not included under this
24 section, but may not include benefits excluded under paragraph
25 (s).
26 2. Health benefits coverage may exceed the service
27 limitations established in the benchmark benefit plan
28 described under this section. Any additional benefits,
29 however, shall not be eligible for an increase in the premium
30 assistance payment.
31 (u) Applicability to other state laws.--
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1 1. Except as expressly provided in this section, a law
2 requiring coverage for a specific health care service or
3 benefit, or a law requiring reimbursement, utilization, or
4 consideration of a specific category of licensed health
5 practitioner in chapter 627 or chapter 641, does not apply to
6 a health insurance plan policy or contract offered or
7 delivered under this act, unless that law is made expressly
8 applicable to such policies or contracts.
9 2. Notwithstanding chapter 641, a health maintenance
10 organization is authorized to issue contracts providing
11 benefits included in the benchmark benefit plan authorized by
12 this section.
13 Section 41. Section 409.816, Florida Statutes, is
14 created to read:
15 409.816 Limitations on premiums and cost-sharing.--The
16 following limitations on premiums and cost-sharing are
17 established for the Florida Children's Healthy Bodies program.
18 (1) Enrollees who receive coverage under the Medicaid
19 program shall not be required to pay:
20 (a) Enrollment fees, premiums, or similar charges; or
21 (b) Copayments, deductibles, coinsurance, or similar
22 charges.
23 (2) Enrollees in the program whose family income is at
24 or below 150 percent of the federal poverty level and who are
25 not receiving coverage under the Medicaid program may not be
26 required to pay:
27 (a) Enrollment fees, premiums, or similar charges that
28 exceed the maximum monthly charge permitted under s.
29 1916(b)(1) of the Social Security Act; or
30 (b) Copayments, deductibles, coinsurance, or similar
31 charges that exceed a nominal amount as determined consistent
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1 with regulations referred to in s. 1916(a)(3) of the Social
2 Security Act. However, no such charges may be imposed for
3 preventive health services.
4 (3) Enrollees in the program whose family income is
5 above 150 percent of the federal poverty level and who are not
6 receiving coverage under the Medicaid program, or who are not
7 enrolled pursuant to the provisions of s. 409.814(5), may be
8 required to pay enrollment fees, premiums, copayments,
9 deductibles, coinsurance, or similar charges on a sliding
10 scale related to income, except that the total annual
11 aggregate cost-sharing with respect to all children in a
12 family may not exceed 5 percent of the family's income.
13 However, copayments, deductibles, coinsurance, or similar
14 charges may not be imposed for preventive health services.
15 Section 42. Section 409.817, Florida Statutes, is
16 created to read:
17 409.817 Health insurance pilot project; approval of
18 health benefits coverage; financial assistance.--There is
19 created a health insurance pilot project in one urban county
20 to be administered by the agency. The agency shall select the
21 county for the pilot project demonstration site. Any licensed
22 health insurer or health maintenance organization which meets
23 the qualifications of this section may participate in the
24 pilot project. A health plan participating in the pilot
25 project may serve any child eligible to participate in the
26 Florida Healthy Kids program. It is the intent of the
27 Legislature that the Florida Healthy Kids program serve
28 children in the pilot county to determine if these two program
29 types are compatible.
30
31
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1 (1) For families to receive financial assistance to
2 purchase health benefits coverage for an eligible child under
3 this section, the health benefits coverage must:
4 (a) Be certified by the Department of Insurance under
5 s. 409.818 as meeting or exceeding the benchmark benefit plan;
6 (b) Be guarantee issued;
7 (c) Be community-rated for health insurance coverage;
8 (d) Not impose any preexisting condition exclusion for
9 covered benefits;
10 (e) Comply with the applicable limitations on premiums
11 and cost-sharing in s. 409.816; and
12 (f) Comply with the quality assurance and access
13 standards developed under s. 409.8195.
14 (2) The Florida Healthy Kids Corporation and health
15 insurance plans approved under this act shall provide to the
16 agency enrollment information and other information necessary
17 to comply with the requirements of Title XXI of the Social
18 Security Act and related federal regulations.
19 (3) This section is repealed effective October 1,
20 2001.
21 Section 43. Section 409.8175, Florida Statutes, is
22 created to read:
23 409.8175 Family coverage.--The agency is directed to
24 seek federal approval to establish a program for the purchase
25 of family coverage consistent with the requirements of s.
26 2105(b)(3) of Title XXI of the Social Security Act. In
27 providing reimbursement for such coverage, the agency shall
28 ensure that the following conditions are met:
29 (1) The child must not have had workplace coverage
30 within the previous 6 months.
31
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1 (2) The monthly premium for family coverage must be no
2 more than the cumulative cost of serving all children in a
3 family eligible for Medikids, the Florida Healthy Kids
4 program, or the health insurance pilot project.
5 (3) The agency must monitor the program to avoid
6 substitution effects.
7 Section 44. Section 409.8177, Florida Statutes, is
8 created to read:
9 409.8177 Program evaluation.--The agency, in
10 consultation with the Department of Health, the Department of
11 Children and Family Services, and the Florida Healthy Kids
12 Corporation, shall by January 1 of each year submit to the
13 Governor and the Legislature an evaluation of the Florida
14 Children's Healthy Bodies program. For the first 5 years of
15 the program, the agency shall contract with the Institute for
16 Child Health Policy to prepare annual reports and the
17 evaluation in accordance with the provisions of s. 2108 of the
18 Social Security Act. In conducting the evaluation, the
19 contractor shall create an evaluation team which includes
20 individuals with expertise in child health from outside the
21 institute. The evaluation report shall be prepared by the
22 contractor and shall be submitted as prepared, except for
23 written comments, if any, by the consulting agencies. In
24 addition to the items specified under s. 2108 of the Social
25 Security Act, the evaluation shall include an assessment of
26 crowd-out and access to health care, as well as the following:
27 (1) An assessment of the operation of the program,
28 including the progress made in reducing the number of
29 uncovered low-income children.
30 (2) An assessment of the effectiveness in increasing
31 the number of children with creditable health coverage.
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1 (3) The characteristics of the children and families
2 assisted under the program, including ages of the children,
3 family income, and access to or coverage by other health
4 insurance prior to the program and after disenrollment from
5 the program.
6 (4) The quality of health coverage provided, including
7 the types of benefits provided.
8 (5) The amount and level, including payment of part or
9 all of any premium, of assistance provided.
10 (6) The average length of coverage of a child under
11 the program.
12 (7) The program's choice of health benefits coverage
13 and other methods used for providing child health assistance.
14 (8) The sources of nonfederal funding used in the
15 program.
16 (9) An assessment of the effectiveness of Medikids,
17 Children's Medical Services network, and other public and
18 private programs in the state in increasing the availability
19 of affordable quality health insurance and health care for
20 children.
21 (10) A review and assessment of state activities to
22 coordinate the program with other public and private programs.
23 (11) An analysis of changes and trends in the state
24 that affect the provision of health insurance and health care
25 to children.
26 (12) A description of any plans the state has for
27 improving the availability of health insurance and health care
28 for children.
29 (13) Recommendations for improving the program.
30 (14) Other studies as necessary.
31
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1 Section 45. Section 409.818, Florida Statutes, is
2 created to read:
3 409.818 Administration.--
4 (1) In order to implement the provisions of the
5 Florida Children's Healthy Bodies Act, the following agencies
6 shall have the following specified duties:
7 (a) The Department of Children and Family Services is
8 responsible for developing, in consultation with the agency,
9 the Department of Health, and the Florida Healthy Kids
10 Corporation, a simplified eligibility application form to be
11 used for determining the eligibility of children for coverage
12 under the program. The simplified eligibility application form
13 may include an item that provides an opportunity for the
14 applicant to indicate whether coverage is being sought for a
15 child with special health care needs. In addition, the
16 department is responsible for establishing and maintaining the
17 eligibility determination process for the Medikids program.
18 (b) The Department of Health is responsible for:
19 1. Designing and implementing program outreach
20 activities under s. 409.819.
21 2. Adopting rules necessary for implementing outreach
22 activities.
23 3. In consultation with the Florida Healthy Kids
24 Corporation and the Department of Children and Family
25 Services, establishing a toll-free telephone line to assist
26 families with questions about the program.
27 4. Chairing a state-level coordinating council for the
28 program, to review and make recommendations concerning the
29 implementation and operation of the program. The coordinating
30 council shall include representatives from the department, the
31 Department of Children and Family Services, the agency, the
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1 Florida Healthy Kids Corporation, the Department of Insurance,
2 health care providers, health insurers, health maintenance
3 organizations, representatives of local government, and
4 representatives of associations advocating the interests of
5 participants in the Florida Children's Healthy Bodies program.
6 (c) The agency, under the authority granted in s.
7 409.914(1), is responsible for:
8 1. Calculating the premium assistance payment
9 necessary to comply with the premium and cost-sharing
10 limitations specified in subparagraph 8. and s. 409.816. In
11 calculating the premium assistance payment levels for children
12 with family coverage, the agency shall set the premium
13 assistance payment levels for each child proportionately to
14 the total cost of family coverage. The agency, in consultation
15 with the department, shall establish an enhanced benchmark
16 premium for services provided by the Children's Medical
17 Services network to non-Medicaid-eligible children with
18 special health care needs who participate in the Florida
19 Children's Healthy Bodies program.
20 2. Annually calculating the program enrollment ceiling
21 based on estimated per-child premium assistance payments and
22 the estimated appropriation available for the program.
23 3. Making premium assistance payments to health
24 insurance plans under ss. 409.817 and 409.8175 and Medikids
25 providers, on a periodic basis. The agency may use its
26 Medicaid fiscal agent or a contracted third-party
27 administrator in making these payments. The agency may require
28 health insurance plans that participate in the Medikids
29 program, the health insurance pilot project, or the family
30 coverage program to collect premium payments from an
31 enrollee's family. Participating health insurance plans shall
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1 report premium payments collected on behalf of enrollees in
2 the program to the agency in accordance with a schedule
3 established by the agency.
4 4. Monitoring compliance with quality assurance and
5 access standards developed under s. 409.8195.
6 5. Establishing a mechanism for investigating and
7 resolving complaints and grievances from program applicants,
8 enrollees, and health benefits coverage providers, and
9 maintaining a record of complaints and confirmed problems. In
10 the case of a child who is enrolled in a health maintenance
11 organization, the agency must use the provisions of s. 641.511
12 to address grievance reporting and resolution requirements.
13 6. Approving health benefits coverage for
14 participation in the program.
15 7. Administering the Medikids program as created in s.
16 409.8131.
17 8. Adopting rules necessary for calculating premium
18 assistance payment levels, calculating the program enrollment
19 ceiling, making premium assistance payments, monitoring access
20 and quality assurance standards, investigating and resolving
21 complaints and grievances, approving health benefits coverage,
22 and administering the Medikids program. The premium
23 assistance for each enrollee in an insurance plan shall equal
24 the premium approved by the Florida Healthy Kids Corporation
25 and the Department of Insurance in accordance with ss. 627.410
26 and 641.31, less any enrollee's share of the premium
27 established within the limitations specified in s. 409.816.
28 (d) The Department of Insurance is responsible for
29 certifying that health benefits coverage plans, except those
30 offered through the Florida Healthy Kids Corporation, seeking
31 to provide services under the program meet or exceed the
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1 benchmark benefit plan, and that health insurance plans will
2 be offered at an approved rate. The department shall adopt
3 rules necessary for certifying health benefits coverage plans.
4 (e) The Florida Healthy Kids program shall retain its
5 functions as authorized in s. 624.91. In addition, the Florida
6 Healthy Kids Corporation shall be responsible for:
7 1. Establishing and maintaining the eligibility
8 determination process under the program, excluding Medicaid
9 and Medikids eligibility determination. The Florida Healthy
10 Kids Corporation shall directly, or through the services of a
11 contracted third-party administrator, establish and maintain a
12 process for determining eligibility of children for coverage
13 under the program. The eligibility determination process must
14 include initial determination of eligibility for any coverage
15 offered under the program, as well as periodic redetermination
16 or reverification of eligibility. In conducting eligibility
17 determination, the Florida Healthy Kids Corporation shall
18 include methods to determine if a child has special health
19 care needs.
20 2. Informing program applicants about eligibility
21 determinations and sharing eligibility information with the
22 Medicaid program, the Department of Children and Family
23 Services, and insurers and their agents, through a centralized
24 coordinating office.
25 (2) The agency, the Department of Health, the
26 Department of Children and Family Services, the Florida
27 Healthy Kids Corporation, and the Department of Insurance,
28 after consultation and approval of the Speaker of the House of
29 Representatives and the President of the Senate, are
30 authorized to make program modifications that are necessary to
31 overcome any objections of the federal Department of Health
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1 and Human Services to obtain approval of the state's child
2 health insurance plan under Title XXI of the Social Security
3 Act.
4 Section 46. Section 154.508, Florida Statutes, is
5 renumbered as section 409.819, Florida Statutes, and amended
6 to read:
7 409.819 154.508 Identification of low-income,
8 uninsured children; determination of Medicaid eligibility for
9 the Florida Children's Healthy Bodies program; alternative
10 health care information.--The department Agency for Health
11 Care Administration shall develop a program, in conjunction
12 with the Department of Education, the Department of Children
13 and Family Services, the Agency for Health Care
14 Administration, the Florida Healthy Kids Corporation,
15 Department of Health, local governments school districts,
16 employers, and other stakeholders to identify low-income,
17 uninsured children and, to the extent possible and subject to
18 appropriation, refer them to the appropriate state agency or
19 entity for Department of Children and Family Services for a
20 Medicaid eligibility determination and provide parents with
21 information about choices of health benefits coverage under
22 the Florida Children's Healthy Bodies program alternative
23 sources of health care. Special emphasis shall be placed on
24 the identification of minority children for referral to and
25 participation in the Florida Children's Healthy Bodies
26 program.
27 Section 47. Section 409.8195, Florida Statutes, is
28 created to read:
29 409.8195 Quality assurance and access
30 standards.--Except for the Medicaid program, the department,
31 in consultation with the agency, shall develop quality
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1 assurance and access standards for the Florida Children's
2 Healthy Bodies program. These standards shall comply with the
3 provisions of chapters 409 and 641 and Title XXI of the Social
4 Security Act.
5 Section 48. Section 409.821, Florida Statutes, is
6 created to read:
7 409.821 Performance measures and standards.--The
8 following performance measures and standards are adopted for
9 the Florida Children's Healthy Bodies program:
10 (1) The total number of previously uninsured children
11 who receive health benefits coverage as a result of state
12 activities under Title XXI of the Social Security Act--235,000
13 uninsured children expected to obtain coverage during fiscal
14 year 1998-1999.
15 (a) The number of children enrolled in the Medicaid
16 program as a result of eligibility expansions under Title XXI
17 of the Social Security Act--35,000 children enrolled in
18 Medicaid under new eligibility groups during fiscal year
19 1998-1999.
20 (b) The number of children enrolled in the Medicaid
21 program as a result of outreach efforts under Title XXI of the
22 Social Security Act who have been eligible for Medicaid, but
23 who have not enrolled in the program--80,000 children
24 previously eligible for Medicaid, but not enrolled in
25 Medicaid, who enroll in Medicaid during fiscal year 1998-1999.
26 (c) The number of uninsured children added to the
27 Florida Healthy Kids program enrollment under Title XXI of the
28 Social Security Act--60,000 additional children enrolled in
29 the Florida Healthy Kids program during fiscal year 1998-1999.
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--50,000 uninsured children enrolled in health
2 insurance coverage during fiscal year 1998-1999.
3 (e) The number of uninsured children enrolled in
4 Medikids coverage offered under Title XXI of the Social
5 Security Act--10,000 uninsured children enrolled in Medikids
6 coverage during fiscal year 1998-1999.
7 (2) The percentage of uninsured children in Florida as
8 of July 1, 1998, who receive health benefits coverage under
9 the Florida Children's Healthy Bodies program--28.5 percent of
10 uninsured children who enroll in the Florida Children's
11 Healthy Bodies program during fiscal year 1998-1999.
12 (3) The percentage of children enrolled in the Florida
13 Children's Healthy Bodies program with up-to-date
14 immunizations--80 percent of enrolled children with up-to-date
15 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 Florida Children's Healthy Bodies program
20 eligible children served under:
21 (a) The Medicaid program as established under s.
22 409.904(6);
23 (b) The Medikids program established under s.
24 409.8131;
25 (c) The Florida Healthy Kids program as created in s.
26 624.91;
27 (d) Health insurance plans certified and approved to
28 participate in the health insurance pilot project established
29 pursuant to s. 409.817;
30 (e) The Children's Medical Services network; and
31 (f) Family coverage authorized under s. 409.8175.
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1
2 For each category of coverage, the health care provided is in
3 compliance with the health supervision standards for 80
4 percent of enrolled children.
5 Section 49. For fiscal year 1998-1999, the enrollment
6 ceiling for the non-Medicaid portion of the Florida Children's
7 Healthy Bodies program is 270,000 children. Thereafter, the
8 enrollment ceiling shall be established in the General
9 Appropriations Act or general law.
10 Section 50. Subsections (6) and (7) are added to
11 section 409.904, Florida Statutes, to read:
12 409.904 Optional payments for eligible persons.--The
13 agency may make payments for medical assistance and related
14 services on behalf of the following persons who are determined
15 to be eligible subject to the income, assets, and categorical
16 eligibility tests set forth in federal and state law. Payment
17 on behalf of these Medicaid eligible persons is subject to the
18 availability of moneys and any limitations established by the
19 General Appropriations Act or chapter 216.
20 (6) A child born before October 1, 1983, living in a
21 family that has an income which is at or below 100 percent of
22 the current federal poverty level, who has attained the age of
23 6, but has not attained the age of 19, and who would be
24 eligible in s. 409.903(6), if the child had been born on or
25 after such date. In determining the eligibility of such a
26 child, an assets test is not required.
27 (7) A child who has not attained the age of 19 who has
28 been determined eligible for the Medicaid program is deemed to
29 be eligible for a total of 6 months, regardless of changes in
30 circumstances other than attainment of the maximum age.
31
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1 Section 51. Section 409.9126, Florida Statutes, is
2 amended to read:
3 409.9126 Children with special health care needs.--
4 (1) As used in this section:
5 (a) "Children's Medical Services network" means an
6 alternative service network that includes health care
7 providers and health care facilities specified in chapter 391
8 and ss. 383.15-383.21, 383.216, and 415.5055.
9 (b) "Children with special health care needs" means
10 those children whose serious or chronic physical or
11 developmental conditions require extensive preventive and
12 maintenance care beyond that required by typically healthy
13 children. Health care utilization by these children exceeds
14 the statistically expected usage of the normal child matched
15 for chronological age and often needs complex care requiring
16 multiple providers, rehabilitation services, and specialized
17 equipment in a number of different settings.
18 (2) The Legislature finds that Medicaid-eligible
19 children with special health care needs require a
20 comprehensive, continuous, and coordinated system of health
21 care that links community-based health care with
22 multidisciplinary, regional, and tertiary care. The
23 Legislature finds that Florida's Children's Medical Services
24 program provides a full continuum of coordinated,
25 comprehensive services for children with special health care
26 needs.
27 (1)(3) Except as provided in subsection (4)
28 subsections (8) and (9), children eligible for Children's
29 Medical Services who receive Medicaid benefits, and other
30 Medicaid-eligible children with special health care needs,
31 shall be exempt from the provisions of s. 409.9122 and shall
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1 be served through the Children's Medical Services network
2 established in chapter 391.
3 (2)(4) The Legislature directs the agency to apply to
4 the federal Health Care Financing Administration for a waiver
5 to assign to the Children's Medical Services network all
6 Medicaid-eligible children who meet the criteria for
7 participation in the Children's Medical Services program as
8 specified in s. 391.021(2), and other Medicaid-eligible
9 children with special health care needs.
10 (5) The Children's Medical Services program shall
11 assign a qualified MediPass primary care provider from the
12 Children's Medical Services network who shall serve as the
13 gatekeeper and who shall be responsible for the provision or
14 authorization of all health services to a child who has been
15 assigned to the Children's Medical Services network by the
16 Medicaid program.
17 (3)(6) Services provided through the Children's
18 Medical Services network shall be reimbursed on a
19 fee-for-service basis and shall utilize a primary care case
20 management process. However, effective July 1, 1999,
21 reimbursement to the Children's Medical Services program for
22 services provided to Medicaid-eligible children with special
23 health care needs through the Children's Medical Services
24 network shall be on a capitated basis.
25 (7) The agency, in consultation with the Children's
26 Medical Services program, shall develop by rule
27 quality-of-care and service integration standards.
28 (8) The agency may issue a request for proposals,
29 based on the quality-of-care and service integration
30 standards, to allow managed care plans that have contracts
31
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1 with the Medicaid program to provide services to
2 Medicaid-eligible children with special health care needs.
3 (4)(9) The agency may shall approve requests to
4 provide services to Medicaid-eligible children with special
5 health care needs from managed care plans that meet access,
6 quality-of-care, network, and service integration standards
7 and are in good standing with the agency. The agency shall
8 monitor on a quarterly basis managed care plans which have
9 been approved to provide services to Medicaid-eligible
10 children with special health care needs. The agency may
11 determine the number of enrollment slots approved for a
12 managed care plan based on the managed care plan's network
13 capacity to serve children with special health care needs.
14 (5)(10) The agency, in consultation with the
15 Department of Health and Rehabilitative Services, shall adopt
16 rules that address Medicaid requirements for referral,
17 enrollment, and disenrollment of children with special health
18 care needs who are enrolled in Medicaid managed care plans and
19 who may benefit from the Children's Medical Services network.
20 (11) The Children's Medical Services network may
21 contract with school districts participating in the certified
22 school match program pursuant to ss. 236.0812 and 409.908(21)
23 for the provision of school-based services, as provided for in
24 s. 409.9071, for Medicaid-eligible children who are enrolled
25 in the Children's Medical Services network.
26 (12) After 1 complete year of operation, the agency
27 shall conduct an evaluation of the Children's Medical Services
28 network. The evaluation shall include, but not be limited to,
29 an assessment of whether the use of the Children's Medical
30 Services network is less costly than the provision of the
31 services would have been in the Medicaid fee-for-service
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1 program. The evaluation also shall include an assessment of
2 patient satisfaction with the Children's Medical Services
3 network, an assessment of the quality of care delivered
4 through the network, and recommendations for further improving
5 the performance of the network. The agency shall report the
6 evaluation findings to the Governor and the chairpersons of
7 the appropriations and health care committees of each chamber
8 of the Legislature.
9 Section 52. Section 624.91, Florida Statutes, is
10 amended to read:
11 624.91 The Florida Healthy Kids Corporation Act.--
12 (1) SHORT TITLE.--This section may be cited as the
13 "William G. 'Doc' Myers Healthy Kids Corporation Act."
14 (2) LEGISLATIVE INTENT.--
15 (a) The Legislature finds that increased access to
16 health care services could improve children's health and
17 reduce the incidence and costs of childhood illness and
18 disabilities among children in this state. Many children do
19 not have comprehensive, affordable health care preventive
20 services available or funded, and for those who do, lack of
21 access is a restriction to getting service. It is the intent
22 of the Legislature that the Florida Healthy Kids a nonprofit
23 Corporation be organized to facilitate a program to bring
24 preventive health care services to children, if necessary
25 through the use of school facilities in this state when more
26 appropriate sites are unavailable, and to provide
27 comprehensive health insurance coverage to such children. A
28 goal for The corporation is encouraged to cooperate with any
29 existing health preventive service programs funded by the
30 public or the private sector.
31
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1 (b) It is the intent of the Legislature that the
2 Florida Healthy Kids Corporation serve as one of several
3 providers of services to children eligible for medical
4 assistance under Title XXI of the Social Security Act.
5 Although the corporation may serve other children, the
6 Legislature intends the primary recipients of services
7 provided through the corporation be school-age children with a
8 family income below 200 percent of the federal poverty level,
9 who do not qualify for Medicaid. It is also the intent of the
10 Legislature that state and local government Florida Healthy
11 Kids funds, to the extent permissible under federal law, be
12 used to obtain matching federal dollars.
13 (3) NONENTITLEMENT.--Nothing in this section shall be
14 construed as providing an individual with an entitlement to
15 health care services. No cause of action shall arise against
16 the state, the Florida Healthy Kids Corporation, or a unit of
17 local government for failure to make health services available
18 under this section.
19 (4)(3) CORPORATION AUTHORIZATION, DUTIES, POWERS.--
20 (a) There is created The Legislature hereby creates
21 the Florida Healthy Kids Corporation, a not-for-profit
22 corporation which operates shall operate on sites to be
23 designated by the corporation.
24 (b) The Florida Healthy Kids Corporation shall phase
25 in a program to:
26 1. Organize school children groups to facilitate the
27 provision of preventive health care services to children and
28 to provide comprehensive health insurance coverage to
29 children;
30 2. Arrange for the collection of any family, local
31 government, or employer payment or premium, in an amount to be
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1 determined by the board of directors, from all participant
2 families or employers to provide for payment of for preventive
3 health care services or premiums for comprehensive insurance
4 coverage and for the actual or estimated administrative
5 expenses incurred during the period for which family or
6 employer payments are made;
7 3. Establish the administrative and accounting
8 procedures for the operation of the corporation;
9 4. Establish, with consultation from appropriate
10 professional organizations, standards for preventive health
11 services and providers and comprehensive insurance benefits
12 appropriate to children; provided that such standards for
13 rural areas shall not limit primary care providers to
14 board-certified pediatricians;
15 5. Establish eligibility criteria which children must
16 meet in order to participate in the program;
17 6. Establish procedures under which applicants to and
18 participants in the program may have grievances reviewed by an
19 impartial body and reported to the board of directors of the
20 corporation;
21 7. Establish participation criteria and, if
22 appropriate, contract with an authorized insurer, health
23 maintenance organization, or insurance administrator to
24 provide administrative services to the corporation;
25 8. Establish enrollment criteria which shall include
26 penalties or waiting periods of not fewer than 60 days for
27 reinstatement of coverage upon voluntary cancellation for
28 nonpayment of family premiums.
29 9. If a space is available, establish a special open
30 enrollment period of 30 days' duration for any child who is
31 enrolled in Medicaid or Medikids if such child loses Medicaid
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1 or Medikids eligibility and becomes eligible for the Florida
2 Healthy Kids program.
3 10.8. Contract with authorized insurers or any
4 provider of health care services, meeting standards
5 established by the corporation, for the provision of
6 comprehensive insurance coverage and preventive health care
7 services to participants. Such standards shall include
8 criteria under which the corporation may contract with more
9 than one provider of health care services in program sites;
10 11.9. Develop and implement a plan to publicize the
11 Florida Healthy Kids Corporation, the eligibility requirements
12 of the program, and the procedures for enrollment in the
13 program and to maintain public awareness of the corporation
14 and the program;
15 12.10. Secure staff necessary to properly administer
16 the corporation. Staff costs shall be funded from state and
17 local matching funds and such other private or public funds as
18 become available. The board of directors shall determine the
19 number of staff members necessary to administer the
20 corporation;
21 13.11. As appropriate, enter into contracts with local
22 school boards or other agencies to provide onsite information,
23 enrollment, and other services necessary to the operation of
24 the corporation; and
25 14.12. Provide a report on an annual basis to the
26 Governor, Insurance Commissioner, Commissioner of Education,
27 Senate President, Speaker of the House of Representatives, and
28 Minority Leaders of the Senate and the House of
29 Representatives;.
30 15.13. Each fiscal year, establish a maximum number of
31 participants by county, on a statewide basis, who may enroll
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1 in the program without the benefit of local matching funds.
2 Thereafter, the corporation may establish local government
3 matching requirements for supplemental participation in the
4 program. The corporation may vary local matching requirements
5 and enrollment by county depending on factors which may
6 influence the local government's ability to provide local
7 match, including, but not limited to, population density, per
8 capita income, existing local tax effort, and other factors.
9 The corporation also may accept in-kind match in lieu of cash
10 for the local match requirement to the extent allowed by Title
11 XXI of the Social Security Act; and For the 1996-1997 fiscal
12 year only, funds may be appropriated to the Florida Healthy
13 Kids Corporation to organize school children groups to
14 facilitate the provision of preventive health care services to
15 children at sites in addition to those allowed in subparagraph
16 1. This subparagraph is repealed on July 1, 1997.
17 15. Establish eligibility criteria, premium and
18 cost-sharing requirements, and benefit packages which conform
19 to the provisions of this act when serving children eligible
20 for the Florida Children's Healthy Bodies program, as created
21 in this act.
22 (c) Contracts in existence on June 30, 1998, that
23 comply with cost-sharing provisions approved by the federal
24 Health Care Financing Administration as conforming with Title
25 XXI of the Social Security Act shall be deemed to conform with
26 the Florida Children's Healthy Bodies program until renewal of
27 the contract but no later than 2 years after the effective
28 date of the contract.
29 (d)(c) Coverage under the corporation's program is
30 secondary to any other available private coverage held by the
31 participant child or family member. The corporation may
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1 establish procedures for coordinating benefits under this
2 program with benefits under other public and private coverage.
3 (e)(d) The Florida Healthy Kids Corporation shall be a
4 private corporation not for profit, organized pursuant to
5 chapter 617, and shall have all powers necessary to carry out
6 the purposes of this act, including, but not limited to, the
7 power to receive and accept grants, loans, or advances of
8 funds from any public or private agency and to receive and
9 accept from any source contributions of money, property,
10 labor, or any other thing of value, to be held, used, and
11 applied for the purposes of this act.
12 (5)(4) BOARD OF DIRECTORS.--
13 (a) The Florida Healthy Kids Corporation shall operate
14 subject to the supervision and approval of a board of
15 directors chaired by the Insurance Commissioner or her or his
16 designee, and composed of 12 other members selected for 3-year
17 terms of office as follows:
18 1. One member appointed by the Commissioner of
19 Education from among three persons nominated by the Florida
20 Association of School Administrators;
21 2. One member appointed by the Commissioner of
22 Education from among three persons nominated by the Florida
23 Association of School Boards;
24 3. One member appointed by the Commissioner of
25 Education from the Office of School Health Programs of the
26 Florida Department of Education;
27 4. One member appointed by the Governor from among
28 three members nominated by the Florida Pediatric Society;
29 5. One member, appointed by the Governor, who
30 represents the Children's Medical Services Program;
31
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1 6. One member appointed by the Insurance Commissioner
2 from among three members nominated by the Florida Hospital
3 Association;
4 7. Two members, appointed by the Insurance
5 Commissioner, who are representatives of authorized health
6 care insurers or health maintenance organizations;
7 8. One member, appointed by the Insurance
8 Commissioner, who represents the Institute for Child Health
9 Policy;
10 9. One member, appointed by the Governor, from among
11 three members nominated by the Florida Academy of Family
12 Physicians;
13 10. One member, appointed by the Governor, who
14 represents the Agency for Health Care Administration; and
15 11. The State Health Officer or her or his designee.
16
17 In order to provide for staggered terms, the initial term of
18 the members appointed under subparagraphs 1., 4., and 6. shall
19 be for 2 years and the initial term of the members appointed
20 under subparagraphs 2., 5., 8., and 10. shall be for 4 years.
21 (b) A member of the board of directors may be removed
22 by the official who appointed that member. The board shall
23 appoint an executive director, who is responsible for other
24 staff authorized by the board.
25 (c) Board members are entitled to receive, from funds
26 of the corporation, reimbursement for per diem and travel
27 expenses as provided by s. 112.061.
28 (d) There shall be no liability on the part of, and no
29 cause of action shall arise against, any member of the board
30 of directors, or its employees or agents, for any action they
31
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1 take in the performance of their powers and duties under this
2 act.
3 (6)(5) LICENSING NOT REQUIRED; FISCAL OPERATION.--
4 (a) The corporation shall not be deemed an insurer.
5 The officers, directors, and employees of the corporation
6 shall not be deemed to be agents of an insurer. Neither the
7 corporation nor any officer, director, or employee of the
8 corporation is subject to the licensing requirements of the
9 insurance code or the rules of the Department of Insurance.
10 However, the Department of Insurance may require that any
11 marketing representative utilized and compensated by the
12 corporation must be appointed as a representative of the
13 insurers or health services providers with which the
14 corporation contracts.
15 (b) The board has complete fiscal control over the
16 corporation and is responsible for all corporate operations.
17 (c) The Department of Insurance shall supervise any
18 liquidation or dissolution of the corporation and shall have,
19 with respect to such liquidation or dissolution, all power
20 granted to it pursuant to the insurance code.
21 (7)(6) ACCESS TO RECORDS; CONFIDENTIALITY;
22 PENALTIES.--Notwithstanding any other laws to the contrary,
23 the Florida Healthy Kids Corporation shall have access to the
24 medical records of a student upon receipt of permission from a
25 parent or guardian of the student. Such medical records may
26 be maintained by state and local agencies. Any identifying
27 information, including medical records and family financial
28 information, obtained by the corporation pursuant to this
29 subsection is confidential and is exempt from the provisions
30 of s. 119.07(1). Neither the corporation nor the staff or
31 agents of the corporation may release, without the written
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1 consent of the participant or the parent or guardian of the
2 participant, to any state or federal agency, to any private
3 business or person, or to any other entity, any confidential
4 information received pursuant to this subsection. A violation
5 of this subsection is a misdemeanor of the second degree,
6 punishable as provided in s. 775.082 or s. 775.083.
7 Section 53. Sections 391.031, 391.056, 391.091, and
8 624.92, Florida Statutes, are hereby repealed.
9 Section 54. Subsection (3) of section 409.814, Florida
10 Statutes, as created by this act, shall stand repealed
11 effective October 1, 2000. It is the intent of the
12 Legislature that these provisions be reviewed on an annual
13 basis prior to that date.
14 Section 55. Sections 409.810 through 409.821, Florida
15 Statutes, as created by this act, shall stand repealed
16 effective October 1, 2003. It is the intent of the
17 Legislature that these sections be reviewed on an annual basis
18 prior to that date.
19 Section 56. This act shall take effect upon becoming a
20 law.
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1 *****************************************
2 HOUSE SUMMARY
3
Revises and expands the Children's Medical Services
4 program to provide for medical assistance to children
receiving Medicaid, children with special health care
5 needs, and children participating in the Florida
Children's Healthy Bodies program authorized by Title XXI
6 of the Social Security Act. Establishes a Statewide
Children's Medical Services Network Advisory Council and
7 a Cardiac Advisory Council, and authorizes technical
advisory panels, to advise on the delivery of medical
8 services to children. Establishes the Florida Children's
Healthy Bodies program to provide health benefits
9 coverage to previously uninsured children, through
Medicaid, "Medikids," which makes elements of the
10 Medicaid program applicable to children, the Florida
Healthy Kids program, an urban health insurance pilot
11 project established in the act, the Children's Medical
Services network, and certain family coverage authorized
12 by the act. Specifies duties of the Department of Health,
the Division of Children's Medical Services, the Agency
13 for Health Care Administration, the Department of
Children and Family Services, the Department of
14 Insurance, and the Florida Healthy Kids Corporation. See
bill for details.
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