Senate Bill sb1476
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Florida Senate - 2001 SB 1476
By Senator Dawson
30-1115-01 See HB
1 A bill to be entitled
2 An act relating to the Florida Kidcare Act;
3 amending ss. 409.814, 409.815, 409.8177,
4 409.818, 409.904, 624.91, F.S.; deleting
5 references to Medikids program components;
6 revising criteria for Kidcare program
7 components; deleting obsolete provisions;
8 providing for state funding of the Kidcare
9 program; requiring uniform and joint
10 administration of Kidcare program
11 implementation; requiring joint development of
12 a plan for Kidcare eligibility determinations
13 and plan implementation by a date certain;
14 creating s. 409.81753, F.S.; providing for
15 Kidcare program providers; requiring the
16 Department of Health to develop and implement
17 uniform provider standards for Kidcare
18 components; repealing s. 409.811(19), F.S.,
19 relating to a definition of Medikids; repealing
20 s. 409.813(2), F.S., relating to the Medikids
21 component of the Kidcare program; repealing s.
22 409.8132, F.S., relating to the Medikids
23 program component; providing an effective date.
24
25 Be It Enacted by the Legislature of the State of Florida:
26
27 Section 1. Section 409.814, Florida Statutes, is
28 amended to read:
29 409.814 Eligibility.--A child whose family income is
30 equal to or below 250 200 percent of the federal poverty level
31 is eligible for the Florida Kidcare program as provided in
1
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1 this section. In determining the eligibility of such a child,
2 an assets test is not required. An applicant under 19 years of
3 age who, based on a complete application, appears to be
4 eligible for the Medicaid component of the Florida Kidcare
5 program is presumed eligible for coverage under Medicaid,
6 subject to federal rules. A child who has been deemed
7 presumptively eligible for Medicaid shall not be enrolled in a
8 managed care plan until the child's full eligibility
9 determination for Medicaid has been completed. The Florida
10 Healthy Kids Corporation and other federally approved entities
11 may, subject to compliance with applicable requirements of the
12 Agency for Health Care Administration and the Department of
13 Children and Family Services, be designated as an entity to
14 conduct presumptive eligibility determinations. An applicant
15 under 19 years of age who, based on a complete application,
16 appears to be eligible for the Medikids, Florida Healthy Kids,
17 or Children's Medical Services network program component, who
18 is screened as ineligible for Medicaid and prior to the
19 monthly verification of the applicant's enrollment in Medicaid
20 or of eligibility for coverage under the state employee health
21 benefit plan, may be enrolled in and begin receiving coverage
22 from the appropriate program component on the first day of the
23 month following the receipt of a completed application. For
24 enrollment in the Children's Medical Services network, a
25 complete application includes the medical or behavioral health
26 screening. If, after verification, an individual is determined
27 to be ineligible for coverage, he or she must be disenrolled
28 from the respective Title XXI-funded Kidcare program
29 component.
30 (1) A child who is eligible for Medicaid coverage
31 under s. 409.903 or s. 409.904 must be enrolled in Medicaid
2
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Florida Senate - 2001 SB 1476
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1 and is not eligible to receive health benefits under any other
2 health benefits coverage authorized under ss. 409.810-409.820.
3 (2) A child who is not eligible for Medicaid, but who
4 is eligible for the Florida Kidcare program, may obtain
5 coverage under any of the other types of health benefits
6 coverage authorized in ss. 409.810-409.820 if such coverage is
7 approved and available in the county in which the child
8 resides. However, a child who is eligible for Medikids may
9 participate in the Florida Healthy Kids program only if the
10 child has a sibling participating in the Florida Healthy Kids
11 program and the child's county of residence permits such
12 enrollment.
13 (3) A child who is eligible for the Florida Kidcare
14 program who is a child with special health care needs, as
15 determined through a medical or behavioral screening
16 instrument, is eligible for health benefits coverage from and
17 shall be referred to the Children's Medical Services network.
18 (4) The following children are not eligible to receive
19 premium assistance for health benefits coverage under ss.
20 409.810-409.820, except under Medicaid if the child would have
21 been eligible for Medicaid under s. 409.903 or s. 409.904 as
22 of June 1, 1997:
23 (a) A child who is eligible for coverage under a state
24 health benefit plan on the basis of a family member's
25 employment with a public agency in the state.
26 (a)(b) A child who is covered under a group health
27 benefit plan or under other health insurance coverage,
28 excluding coverage provided under the Florida Healthy Kids
29 Corporation as established under s. 624.91.
30 (c) A child who is seeking premium assistance for
31 employer-sponsored group coverage, if the child has been
3
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1 covered by the same employer's group coverage during the 6
2 months prior to the family's submitting an application for
3 determination of eligibility under the Florida Kidcare
4 program.
5 (d) A child who is an alien, but who does not meet the
6 definition of qualified alien, in the United States.
7 (b)(e) A child who is an inmate of a public
8 institution or a patient in an institution for mental
9 diseases.
10
11 Children who are ineligible for federal funding under Title
12 XIX and Title XXI of the Social Security Act may be enrolled
13 in the Kidcare program based upon family income, and their
14 coverage shall be provided by state funds. Other funds may be
15 contributed toward the cost of the program on a voluntary
16 basis.
17 (5) A child whose family income is above 250 200
18 percent of the federal poverty level or a child who is
19 excluded under the provisions of subsection (4) may
20 participate in the Florida Kidcare program, excluding the
21 Medicaid program, but is subject to the following provisions:
22 (a) The family is not eligible for premium assistance
23 payments and must pay the full cost of the premium, including
24 any administrative costs.
25 (b) The agency is authorized to place limits on
26 enrollment in Medikids by these children in order to avoid
27 adverse selection. The number of children participating in
28 Medikids whose family income exceeds 200 percent of the
29 federal poverty level must not exceed 10 percent of total
30 enrollees in the Medikids program.
31
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1 (b)(c) The board of directors of the Florida Healthy
2 Kids Corporation is authorized to place limits on enrollment
3 of these children in order to avoid adverse selection. In
4 addition, the board is authorized to offer a reduced benefit
5 package to these children in order to limit program costs for
6 such families. The number of children participating in the
7 Florida Healthy Kids program whose family income exceeds 250
8 200 percent of the federal poverty level must not exceed 10
9 percent of total enrollees in the Florida Healthy Kids
10 program.
11 (c)(d) Children described in this subsection are not
12 counted in the annual enrollment ceiling for the Florida
13 Kidcare program.
14 (6) Once a child is enrolled in the Florida Kidcare
15 program, the child is eligible for coverage under the program
16 for 6 months without a redetermination or reverification of
17 eligibility, if the family continues to pay the applicable
18 premium. Effective January 1, 1999, a child who has not
19 attained the age of 5 and who has been determined eligible for
20 the Medicaid program is eligible for coverage for 12 months
21 without a redetermination or reverification of eligibility.
22 (7) When determining or reviewing a child's
23 eligibility under the program, the applicant shall be provided
24 with reasonable notice of changes in eligibility which may
25 affect enrollment in one or more of the program components.
26 In order to promote continuity of health care coverage when a
27 transition from one program component to another is
28 appropriate, the transition shall occur without any gaps in
29 coverage, provided that all required premiums are paid there
30 shall be cooperation between the program components and the
31
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1 affected family which promotes continuity of health care
2 coverage.
3 Section 2. Subsections (1) and (2) of section 409.815,
4 Florida Statutes, are amended to read:
5 409.815 Health benefits coverage; limitations.--
6 (1) MEDICAID BENEFITS.--For purposes of the Florida
7 Kidcare program, benefits available under Medicaid and
8 Medikids include those goods and services provided under the
9 medical assistance program authorized by Title XIX of the
10 Social Security Act, and regulations thereunder, as
11 administered in this state by the agency. This includes those
12 mandatory Medicaid services authorized under s. 409.905 and
13 optional Medicaid services authorized under s. 409.906,
14 rendered on behalf of eligible individuals by qualified
15 providers, in accordance with federal requirements for Title
16 XIX, subject to any limitations or directions provided for in
17 the General Appropriations Act or chapter 216, and according
18 to methodologies and limitations set forth in agency rules and
19 policy manuals and handbooks incorporated by reference
20 thereto.
21 (2) BENCHMARK BENEFITS.--In order for health benefits
22 coverage to qualify for premium assistance payments for an
23 eligible child under ss. 409.810-409.820, the health benefits
24 coverage, except for coverage under Medicaid and Medikids,
25 must include the following minimum benefits, as medically
26 necessary.
27 (a) Preventive health services.--Covered services
28 include:
29 1. Well-child care, including services recommended in
30 the Guidelines for Health Supervision of Children and Youth as
31 developed by the American Academy of Pediatrics;
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1 2. Immunizations and injections;
2 3. Health education counseling and clinical services;
3 4. Vision screening; and
4 5. Hearing screening.
5 (b) Inpatient hospital services.--All covered services
6 provided for the medical care and treatment of an enrollee who
7 is admitted as an inpatient to a hospital licensed under part
8 I of chapter 395, with the following exceptions:
9 1. All admissions must be authorized by the enrollee's
10 health benefits coverage provider.
11 2. The length of the patient stay shall be determined
12 based on the medical condition of the enrollee in relation to
13 the necessary and appropriate level of care.
14 3. Room and board may be limited to semiprivate
15 accommodations, unless a private room is considered medically
16 necessary or semiprivate accommodations are not available.
17 4. Admissions for rehabilitation and physical therapy
18 are limited to 15 days per contract year.
19 (c) Emergency services.--Covered services include
20 visits to an emergency room or other licensed facility if
21 needed immediately due to an injury or illness and delay means
22 risk of permanent damage to the enrollee's health. Health
23 maintenance organizations shall comply with the provisions of
24 s. 641.513.
25 (d) Maternity services.--Covered services include
26 maternity and newborn care, including prenatal and postnatal
27 care, with the following limitations:
28 1. Coverage may be limited to the fee for vaginal
29 deliveries; and
30 2. Initial inpatient care for newborn infants of
31 enrolled adolescents shall be covered, including normal
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1 newborn care, nursery charges, and the initial pediatric or
2 neonatal examination, and the infant may be covered for up to
3 3 days following birth.
4 (e) Organ transplantation services.--Covered services
5 include pretransplant, transplant, and postdischarge services
6 and treatment of complications after transplantation for
7 transplants deemed necessary and appropriate within the
8 guidelines set by the Organ Transplant Advisory Council under
9 s. 381.0602 or the Bone Marrow Transplant Advisory Panel under
10 s. 627.4236.
11 (f) Outpatient services.--Covered services include
12 preventive, diagnostic, therapeutic, palliative care, and
13 other services provided to an enrollee in the outpatient
14 portion of a health facility licensed under chapter 395,
15 except for the following limitations:
16 1. Services must be authorized by the enrollee's
17 health benefits coverage provider; and
18 2. Treatment for temporomandibular joint disease (TMJ)
19 is specifically excluded.
20 (g) Behavioral health services.--
21 1. Mental health benefits include:
22 a. Inpatient services, limited to not more than 30
23 inpatient days per contract year for psychiatric admissions,
24 or residential services in facilities licensed under s.
25 394.875(8) or s. 395.003 in lieu of inpatient psychiatric
26 admissions; however, a minimum of 10 of the 30 days shall be
27 available only for inpatient psychiatric services when
28 authorized by a physician; and
29 b. Outpatient services, including outpatient visits
30 for psychological or psychiatric evaluation, diagnosis, and
31
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1 treatment by a licensed mental health professional, limited to
2 a maximum of 40 outpatient visits each contract year.
3 2. Substance abuse services include:
4 a. Inpatient services, limited to not more than 7
5 inpatient days per contract year for medical detoxification
6 only and 30 days of residential services; and
7 b. Outpatient services, including evaluation,
8 diagnosis, and treatment by a licensed practitioner, limited
9 to a maximum of 40 outpatient visits per contract year.
10 (h) Durable medical equipment.--Covered services
11 include equipment and devices that are medically indicated to
12 assist in the treatment of a medical condition and
13 specifically prescribed as medically necessary, with the
14 following limitations:
15 1. Low-vision and telescopic aides are not included.
16 2. Corrective lenses and frames may be limited to one
17 pair every 2 years, unless the prescription or head size of
18 the enrollee changes.
19 3. Hearing aids shall be covered only when medically
20 indicated to assist in the treatment of a medical condition.
21 4. Covered prosthetic devices include artificial eyes
22 and limbs, braces, and other artificial aids.
23 (i) Health practitioner services.--Covered services
24 include services and procedures rendered to an enrollee when
25 performed to diagnose and treat diseases, injuries, or other
26 conditions, including care rendered by health practitioners
27 acting within the scope of their practice, with the following
28 exceptions:
29 1. Chiropractic services shall be provided in the same
30 manner as in the Florida Medicaid program.
31
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1 2. Podiatric services may be limited to one visit per
2 day totaling two visits per month for specific foot disorders.
3 (j) Home health services.--Covered services include
4 prescribed home visits by both registered and licensed
5 practical nurses to provide skilled nursing services on a
6 part-time intermittent basis, subject to the following
7 limitations:
8 1. Coverage may be limited to include skilled nursing
9 services only;
10 2. Meals, housekeeping, and personal comfort items may
11 be excluded; and
12 3. Private duty nursing is limited to circumstances
13 where such care is medically necessary.
14 (k) Hospice services.--Covered services include
15 reasonable and necessary services for palliation or management
16 of an enrollee's terminal illness, with the following
17 exceptions:
18 1. Once a family elects to receive hospice care for an
19 enrollee, other services that treat the terminal condition
20 will not be covered; and
21 2. Services required for conditions totally unrelated
22 to the terminal condition are covered to the extent that the
23 services are included in this section.
24 (l) Laboratory and X-ray services.--Covered services
25 include diagnostic testing, including clinical radiologic,
26 laboratory, and other diagnostic tests.
27 (m) Nursing facility services.--Covered services
28 include regular nursing services, rehabilitation services,
29 drugs and biologicals, medical supplies, and the use of
30 appliances and equipment furnished by the facility, with the
31 following limitations:
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1 1. All admissions must be authorized by the health
2 benefits coverage provider.
3 2. The length of the patient stay shall be determined
4 based on the medical condition of the enrollee in relation to
5 the necessary and appropriate level of care, but is limited to
6 not more than 100 days per contract year.
7 3. Room and board may be limited to semiprivate
8 accommodations, unless a private room is considered medically
9 necessary or semiprivate accommodations are not available.
10 4. Specialized treatment centers and independent
11 kidney disease treatment centers are excluded.
12 5. Private duty nurses, television, and custodial care
13 are excluded.
14 6. Admissions for rehabilitation and physical therapy
15 are limited to 15 days per contract year.
16 (n) Prescribed drugs.--
17 1. Coverage shall include drugs prescribed for the
18 treatment of illness or injury when prescribed by a licensed
19 health practitioner acting within the scope of his or her
20 practice.
21 2. Prescribed drugs may be limited to generics if
22 available and brand name products if a generic substitution is
23 not available, unless the prescribing licensed health
24 practitioner indicates that a brand name is medically
25 necessary.
26 3. Prescribed drugs covered under this section shall
27 include all prescribed drugs covered under the Florida
28 Medicaid program.
29 (o) Therapy services.--Covered services include
30 rehabilitative services, including occupational, physical,
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1 respiratory, and speech therapies, with the following
2 limitations:
3 1. Services must be for short-term rehabilitation
4 where significant improvement in the enrollee's condition will
5 result; and
6 2. Services shall be limited to not more than 24
7 treatment sessions within a 60-day period per episode or
8 injury, with the 60-day period beginning with the first
9 treatment.
10 (p) Transportation services.--Covered services include
11 emergency transportation required in response to an emergency
12 situation.
13 (q) Dental services.--Subject to a specific
14 appropriation for this benefit, covered services include those
15 dental services provided to children by the Florida Medicaid
16 program under s. 409.906(6).
17 (r) Lifetime maximum.--Health benefits coverage
18 obtained under ss. 409.810-409.820 shall pay an enrollee's
19 covered expenses at a lifetime maximum of $1 million per
20 covered child.
21 (s) Cost-sharing.--Cost-sharing provisions must comply
22 with s. 409.816.
23 (t) Exclusions.--
24 1. Experimental or investigational procedures that
25 have not been clinically proven by reliable evidence are
26 excluded;
27 2. Services performed for cosmetic purposes only or
28 for the convenience of the enrollee are excluded; and
29 3. Abortion may be covered only if necessary to save
30 the life of the mother or if the pregnancy is the result of an
31 act of rape or incest.
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1 (u) Enhancements to minimum requirements.--
2 1. This section sets the minimum benefits that must be
3 included in any health benefits coverage, other than Medicaid
4 or Medikids coverage, offered under ss. 409.810-409.820.
5 Health benefits coverage may include additional benefits not
6 included under this subsection, but may not include benefits
7 excluded under paragraph (s).
8 2. Health benefits coverage may extend any limitations
9 beyond the minimum benefits described in this section.
10
11 Except for the Children's Medical Services network, the agency
12 may not increase the premium assistance payment for either
13 additional benefits provided beyond the minimum benefits
14 described in this section or the imposition of less
15 restrictive service limitations.
16 (v) Applicability of other state laws.--Health
17 insurers, health maintenance organizations, and their agents
18 are subject to the provisions of the Florida Insurance Code,
19 except for any such provisions waived in this section.
20 1. Except as expressly provided in this section, a law
21 requiring coverage for a specific health care service or
22 benefit, or a law requiring reimbursement, utilization, or
23 consideration of a specific category of licensed health care
24 practitioner, does not apply to a health insurance plan policy
25 or contract offered or delivered under ss. 409.810-409.820
26 unless that law is made expressly applicable to such policies
27 or contracts.
28 2. Notwithstanding chapter 641, a health maintenance
29 organization may issue contracts providing benefits equal to,
30 exceeding, or actuarially equivalent to the benchmark benefit
31 plan authorized by this section and may pay providers located
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1 in a rural county negotiated fees or Medicaid reimbursement
2 rates for services provided to enrollees who are residents of
3 the rural county.
4 Section 3. Section 409.81753, Florida Statutes, is
5 created to read:
6 409.81753 Kidcare providers.--All children in the
7 Kidcare program shall be provided with a medical home. The
8 Department of Health, in consultation with the Florida Healthy
9 Kids Corporation, shall develop and implement uniform provider
10 standards to be applied to all Kidcare components.
11 Section 4. Subsection (9) of section 409.8177, Florida
12 Statutes, is amended to read:
13 409.8177 Program evaluation.--The agency, in
14 consultation with the Department of Health, the Department of
15 Children and Family Services, and the Florida Healthy Kids
16 Corporation, shall by January 1 of each year submit to the
17 Governor, the President of the Senate, and the Speaker of the
18 House of Representatives a report of the Florida Kidcare
19 program. In addition to the items specified under s. 2108 of
20 Title XXI of the Social Security Act, the report shall include
21 an assessment of crowd-out and access to health care, as well
22 as the following:
23 (9) An assessment of the effectiveness of Medikids,
24 Children's Medical Services network, and other public and
25 private programs in the state in increasing the availability
26 of affordable quality health insurance and health care for
27 children.
28 Section 5. Section 409.818, Florida Statutes, is
29 amended to read:
30 409.818 Administration.--All agencies implementing the
31 Kidcare program shall administer the program to provide a
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1 seamless system and continuity of care. All children eligible
2 for Kidcare shall be issued a uniform Kidcare Card to document
3 their eligibility. Children who become ineligible for one
4 program component shall be reviewed for eligibility for
5 coverage in another program component and, if eligible, shall
6 automatically be transferred to such program component. The
7 Department of Children and Family Services, the Department of
8 Health, the Agency for Health Care Administration, and the
9 Florida Healthy Kids Corporation shall jointly develop a plan
10 for a single entity to perform Kidcare eligibility
11 determinations and shall implement the plan no later than
12 October 1, 2001. In order to implement ss. 409.810-409.820,
13 the following agencies shall have the following duties:
14 (1) The Department of Children and Family Services
15 shall:
16 (a) Develop a simplified eligibility application
17 mail-in form to be used for determining the eligibility of
18 children for coverage under the Florida Kidcare program, in
19 consultation with the agency, the Department of Health, and
20 the Florida Healthy Kids Corporation. The simplified
21 eligibility application form must include an item that
22 provides an opportunity for the applicant to indicate whether
23 coverage is being sought for a child with special health care
24 needs. Families applying for children's Medicaid coverage must
25 also be able to use the simplified application form without
26 having to pay a premium.
27 (b) Establish and maintain the eligibility
28 determination process under the program except as specified in
29 subsection (5). The department shall directly, or through the
30 services of a contracted third-party administrator, establish
31 and maintain a process for determining eligibility of children
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1 for coverage under the program. The eligibility determination
2 process must be used solely for determining eligibility of
3 applicants for health benefits coverage under the program. The
4 eligibility determination process must include an initial
5 determination of eligibility for any coverage offered under
6 the program, as well as a redetermination or reverification of
7 eligibility each subsequent 12 6 months. Effective January 1,
8 1999, a child who has not attained the age of 5 and who has
9 been determined eligible for the Medicaid program is eligible
10 for coverage for 12 months without a redetermination or
11 reverification of eligibility. In conducting an eligibility
12 determination, the department shall determine if the child has
13 special health care needs. The department, in consultation
14 with the Agency for Health Care Administration and the Florida
15 Healthy Kids Corporation, shall develop procedures for
16 redetermining eligibility which enable a family to easily
17 update any change in circumstances which could affect
18 eligibility. The department may accept changes in a family's
19 status as reported to the department by the Florida Healthy
20 Kids Corporation without requiring a new application from the
21 family. Redetermination of a child's eligibility for Medicaid
22 may not be linked to a child's eligibility determination for
23 other programs.
24 (c) Inform program applicants about eligibility
25 determinations and provide information about eligibility of
26 applicants to Medicaid, Medikids, the Children's Medical
27 Services network, and the Florida Healthy Kids Corporation,
28 and to insurers and their agents, through a centralized
29 coordinating office.
30 (d) Adopt rules necessary for conducting program
31 eligibility functions.
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1 (2) The Department of Health shall:
2 (a) Design an eligibility intake process for the
3 program, in coordination with the Department of Children and
4 Family Services, the agency, and the Florida Healthy Kids
5 Corporation. The eligibility intake process may include local
6 intake points that are determined by the Department of Health
7 in coordination with the Department of Children and Family
8 Services.
9 (b) Design and implement program outreach activities
10 under s. 409.819.
11 (c) Chair a state-level coordinating council to review
12 and make recommendations concerning the implementation and
13 operation of the program. The coordinating council shall
14 include representatives from the department, the Department of
15 Children and Family Services, the agency, the Florida Healthy
16 Kids Corporation, the Department of Insurance, local
17 government, health insurers, health maintenance organizations,
18 health care providers, families participating in the program,
19 and organizations representing low-income families.
20 (d) In consultation with the Florida Healthy Kids
21 Corporation and the Department of Children and Family
22 Services, establishing a toll-free telephone line to assist
23 families with questions about the program.
24 (e) Adopt rules necessary to implement outreach
25 activities.
26 (3) The Agency for Health Care Administration, under
27 the authority granted in s. 409.914(1), shall:
28 (a) Calculate the premium assistance payment necessary
29 to comply with the premium and cost-sharing limitations
30 specified in s. 409.816. The premium assistance payment for
31 each enrollee in a health insurance plan participating in the
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1 Florida Healthy Kids Corporation shall equal the premium
2 approved by the Florida Healthy Kids Corporation and the
3 Department of Insurance pursuant to ss. 627.410 and 641.31,
4 less any enrollee's share of the premium established within
5 the limitations specified in s. 409.816. The premium
6 assistance payment for each enrollee in an employer-sponsored
7 health insurance plan approved under ss. 409.810-409.820 shall
8 equal the premium for the plan adjusted for any benchmark
9 benefit plan actuarial equivalent benefit rider approved by
10 the Department of Insurance pursuant to ss. 627.410 and
11 641.31, less any enrollee's share of the premium established
12 within the limitations specified in s. 409.816. In calculating
13 the premium assistance payment levels for children with family
14 coverage, the agency shall set the premium assistance payment
15 levels for each child proportionately to the total cost of
16 family coverage.
17 (b) Annually calculate the program enrollment ceiling
18 based on estimated per child premium assistance payments and
19 the estimated appropriation available for the program.
20 (c) Make premium assistance payments to health
21 insurance plans on a periodic basis. The agency may use its
22 Medicaid fiscal agent or a contracted third-party
23 administrator in making these payments. The agency may
24 require health insurance plans that participate in the
25 Medikids program or employer-sponsored group health insurance
26 to collect premium payments from an enrollee's family.
27 Participating health insurance plans shall report premium
28 payments collected on behalf of enrollees in the program to
29 the agency in accordance with a schedule established by the
30 agency.
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1 (d) Monitor compliance with quality assurance and
2 access standards developed under s. 409.820.
3 (e) Establish a mechanism for investigating and
4 resolving complaints and grievances from program applicants,
5 enrollees, and health benefits coverage providers, and
6 maintain a record of complaints and confirmed problems. In the
7 case of a child who is enrolled in a health maintenance
8 organization, the agency must use the provisions of s. 641.511
9 to address grievance reporting and resolution requirements.
10 (f) Approve health benefits coverage for participation
11 in the program, following certification by the Department of
12 Insurance under subsection (4).
13 (g) Adopt rules that comply with Title XXI of the
14 Social Security Act necessary for calculating premium
15 assistance payment levels, calculating the program enrollment
16 ceiling, making premium assistance payments, monitoring access
17 and quality assurance standards, investigating and resolving
18 complaints and grievances, administering the Medikids program,
19 and approving health benefits coverage.
20
21 The agency is designated the lead state agency for Title XXI
22 of the Social Security Act for purposes of receipt of federal
23 funds, for reporting purposes, and for ensuring compliance
24 with federal and state regulations and rules.
25 (4) The Department of Insurance shall certify that
26 health benefits coverage plans that seek to provide services
27 under the Florida Kidcare program, except those offered
28 through the Florida Healthy Kids Corporation or the Children's
29 Medical Services network, meet, exceed, or are actuarially
30 equivalent to the benchmark benefit plan and that health
31 insurance plans will be offered at an approved rate. In
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1 determining actuarial equivalence of benefits coverage, the
2 Department of Insurance and health insurance plans must comply
3 with the requirements of s. 2103 of Title XXI of the Social
4 Security Act. The department shall adopt rules necessary for
5 certifying health benefits coverage plans.
6 (5) The Florida Healthy Kids Corporation shall retain
7 its functions as authorized in s. 624.91, including
8 eligibility determination for participation in the Healthy
9 Kids program.
10 (6) The agency, the Department of Health, the
11 Department of Children and Family Services, the Florida
12 Healthy Kids Corporation, and the Department of Insurance,
13 after consultation with and approval of the Speaker of the
14 House of Representatives and the President of the Senate, are
15 authorized to make program modifications that are necessary to
16 overcome any objections of the United States Department of
17 Health and Human Services to obtain approval of the state's
18 child health insurance plan under Title XXI of the Social
19 Security Act.
20 Section 6. Subsections (6), (7), and (8) of section
21 409.904, Florida Statutes, are amended to read:
22 409.904 Optional payments for eligible persons.--The
23 agency may make payments for medical assistance and related
24 services on behalf of the following persons who are determined
25 to be eligible subject to the income, assets, and categorical
26 eligibility tests set forth in federal and state law. Payment
27 on behalf of these Medicaid eligible persons is subject to the
28 availability of moneys and any limitations established by the
29 General Appropriations Act or chapter 216.
30 (6) A child born before October 1, 1983, living in a
31 family that has an income which is at or below 200 100 percent
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1 of the current federal poverty level, who has attained the age
2 of 6, but has not attained the age of 19, and who would be
3 eligible in s. 409.903(6), if the child had been born on or
4 after such date. In determining the eligibility of such a
5 child, an assets test is not required. A child who is eligible
6 for Medicaid under this subsection must be offered the
7 opportunity, subject to federal rules, to be made
8 presumptively eligible in accordance with federal law by any
9 entity authorized under federal law. A child who has been
10 deemed presumptively eligible for Medicaid shall not be
11 enrolled in a managed care plan until the child's full
12 eligibility determination for Medicaid has been completed.
13 (7) A child who has not attained the age of 19 who has
14 been determined eligible for the Medicaid program is deemed to
15 be eligible for a total of 12 6 months, regardless of changes
16 in circumstances other than attainment of the maximum age.
17 Effective January 1, 1999, a child who has not attained the
18 age of 5 and who has been determined eligible for the Medicaid
19 program is deemed to be eligible for a total of 12 months
20 regardless of changes in circumstances other than attainment
21 of the maximum age.
22 (8) A pregnant woman for the duration of her pregnancy
23 and for the postpartum period, as defined in federal law and
24 rule, A child under 1 year of age who lives in a family that
25 has an income above 185 percent of the current most recently
26 published federal poverty level, but which is at or below 200
27 percent of such poverty level. A pregnant woman who applies
28 for eligibility for the Medicaid program through a qualified
29 Medicaid provider shall be offered the opportunity to be made
30 presumptively eligible in accordance with federal law by any
31 entity authorized under federal law. In determining the
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1 eligibility of such child, an assets test is not required. A
2 child who is eligible for Medicaid under this subsection must
3 be offered the opportunity, subject to federal rules, to be
4 made presumptively eligible.
5 Section 7. Paragraph (b) of subsection (2) and
6 paragraph (b) of subsection (4) of section 624.91, Florida
7 Statutes, are amended to read:
8 624.91 The Florida Healthy Kids Corporation Act.--
9 (2) LEGISLATIVE INTENT.--
10 (b) It is the intent of the Legislature that the
11 Florida Healthy Kids Corporation serve as one of several
12 providers of services to children eligible for medical
13 assistance under Title XXI of the Social Security Act.
14 Although the corporation may serve other children, the
15 Legislature intends the primary recipients of services
16 provided through the corporation be school-age children with a
17 family income at or below 250 200 percent of the federal
18 poverty level, who do not qualify for Medicaid. It is also
19 the intent of the Legislature that state and local government
20 Florida Healthy Kids funds, to the extent permissible under
21 federal law, be used to obtain matching federal dollars.
22 (4) CORPORATION AUTHORIZATION, DUTIES, POWERS.--
23 (b) The Florida Healthy Kids Corporation shall phase
24 in a program to:
25 1. Organize school children groups to facilitate the
26 provision of comprehensive health insurance coverage to
27 children;
28 2. Arrange for the collection of any family voluntary,
29 local contributions, or employer payment or premium, in an
30 amount to be determined by the board of directors, to provide
31
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1 for payment of premiums for comprehensive insurance coverage
2 and for the actual or estimated administrative expenses;
3 3. Establish the administrative and accounting
4 procedures for the operation of the corporation;
5 4. Establish, with consultation from appropriate
6 professional organizations, standards for preventive health
7 services and providers and comprehensive insurance benefits
8 appropriate to children; provided that such standards for
9 rural areas shall not limit primary care providers to
10 board-certified pediatricians;
11 5. Establish eligibility criteria which children must
12 meet in order to participate in the program;
13 5.6. Establish procedures under which applicants to
14 and participants in the program may have grievances reviewed
15 by an impartial body and reported to the board of directors of
16 the corporation;
17 6.7. Establish participation criteria and, if
18 appropriate, contract with an authorized insurer, health
19 maintenance organization, or insurance administrator to
20 provide administrative services to the corporation;
21 7.8. Establish enrollment criteria which shall include
22 year-round enrollment penalties or waiting periods of not
23 fewer than 60 days for reinstatement of coverage upon
24 voluntary cancellation for nonpayment of family premiums;
25 9. If a space is available, establish a special open
26 enrollment period of 30 days' duration for any child who is
27 enrolled in Medicaid or Medikids if such child loses Medicaid
28 or Medikids eligibility and becomes eligible for the Florida
29 Healthy Kids program;
30 8.10. Contract with authorized insurers or any
31 provider of health care services, meeting standards
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1 established by the corporation, for the provision of
2 comprehensive insurance coverage to participants. Such
3 standards shall include criteria under which the corporation
4 may contract with more than one provider of health care
5 services in program sites. Health plans shall be selected
6 through a competitive bid process. The selection of health
7 plans shall be based primarily on quality criteria established
8 by the board. The health plan selection criteria and scoring
9 system, and the scoring results, shall be available upon
10 request for inspection after the bids have been awarded;
11 9.11. Participate in the development and
12 implementation of Develop and implement a plan to publicize
13 the Kidcare program Florida Healthy Kids Corporation, the
14 eligibility requirements of the program, and the procedures
15 for enrollment in the program and to maintain public awareness
16 of the corporation and the program;
17 10.12. Secure staff necessary to properly administer
18 the corporation. Staff costs shall be funded from state and
19 local matching funds and such other private or public funds as
20 become available. The board of directors shall determine the
21 number of staff members necessary to administer the
22 corporation;
23 11.13. As appropriate, enter into contracts with local
24 school boards or other federally approved entities agencies to
25 provide onsite information, enrollment, and other services
26 necessary to the operation of the corporation;
27 12.14. Provide a report on an annual basis to the
28 Governor, Insurance Commissioner, Commissioner of Education,
29 Senate President, Speaker of the House of Representatives, and
30 Minority Leaders of the Senate and the House of
31 Representatives.;
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1 15. Each fiscal year, establish a maximum number of
2 participants by county, on a statewide basis, who may enroll
3 in the program without the benefit of local matching funds.
4 Thereafter, the corporation may establish local matching
5 requirements for supplemental participation in the program.
6 The corporation may vary local matching requirements and
7 enrollment by county depending on factors which may influence
8 the generation of local match, including, but not limited to,
9 population density, per capita income, existing local tax
10 effort, and other factors. The corporation also may accept
11 in-kind match in lieu of cash for the local match requirement
12 to the extent allowed by Title XXI of the Social Security Act;
13 and
14 16. Establish eligibility criteria, premium and
15 cost-sharing requirements, and benefit packages which conform
16 to the provisions of the Florida Kidcare program, as created
17 in ss. 409.810-409.820.
18 Section 8. Subsection (19) of section 409.811, Florida
19 Statutes, subsection (2) of section 409.813, Florida Statutes,
20 and section 409.8132, Florida Statutes, are repealed.
21 Section 9. This act shall take effect October 1, 2001.
22
23 *****************************************
24 LEGISLATIVE SUMMARY
25
Repeals the Medikids component of the Florida Kidcare
26 program, revises criteria for the Kidcare program,
specifies state funding for the Kidcare program, and
27 deletes obsolete provisions. (See bill for details.)
28
29
30
31
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