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

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    Florida Senate - 2001                                  SB 1476
    30-1115-01                                              See HB




  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

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    Florida Senate - 2001                                  SB 1476
    30-1115-01                                              See HB




  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

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    Florida Senate - 2001                                  SB 1476
    30-1115-01                                              See HB




  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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    Florida Senate - 2001                                  SB 1476
    30-1115-01                                              See HB




  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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    Florida Senate - 2001                                  SB 1476
    30-1115-01                                              See HB




  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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    Florida Senate - 2001                                  SB 1476
    30-1115-01                                              See HB




  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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    Florida Senate - 2001                                  SB 1476
    30-1115-01                                              See HB




  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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    Florida Senate - 2001                                  SB 1476
    30-1115-01                                              See HB




  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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    Florida Senate - 2001                                  SB 1476
    30-1115-01                                              See HB




  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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    Florida Senate - 2001                                  SB 1476
    30-1115-01                                              See HB




  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,

31

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    Florida Senate - 2001                                  SB 1476
    30-1115-01                                              See HB




  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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    Florida Senate - 2001                                  SB 1476
    30-1115-01                                              See HB




  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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    Florida Senate - 2001                                  SB 1476
    30-1115-01                                              See HB




  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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    Florida Senate - 2001                                  SB 1476
    30-1115-01                                              See HB




  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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    Florida Senate - 2001                                  SB 1476
    30-1115-01                                              See HB




  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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    Florida Senate - 2001                                  SB 1476
    30-1115-01                                              See HB




  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

                                  17

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    Florida Senate - 2001                                  SB 1476
    30-1115-01                                              See HB




  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.

31

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    Florida Senate - 2001                                  SB 1476
    30-1115-01                                              See HB




  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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    Florida Senate - 2001                                  SB 1476
    30-1115-01                                              See HB




  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

                                  20

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    Florida Senate - 2001                                  SB 1476
    30-1115-01                                              See HB




  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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    Florida Senate - 2001                                  SB 1476
    30-1115-01                                              See HB




  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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    Florida Senate - 2001                                  SB 1476
    30-1115-01                                              See HB




  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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    Florida Senate - 2001                                  SB 1476
    30-1115-01                                              See HB




  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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    Florida Senate - 2001                                  SB 1476
    30-1115-01                                              See HB




  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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