HOUSE AMENDMENT Bill No. SB 390
1	CHAMBER ACTION
2	Senate House
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12	Representative Green offered the following:
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14	Amendment (with title amendment)
15	Remove everything after the enacting clause, and insert:
16	Section 1. Paragraph (e) of subsection (2) of section
17	154.503, Florida Statutes, is amended to read:
18	154.503 Primary Care for Children and Families Challenge
19	Grant Program; creation; administration.--
20	(2) The department shall:
21	(e) Coordinate with the primary care program developed
22	pursuant to s. 154.011, the Agency for Health Care
23	AdministrationFlorida Healthy Kids Corporation program created
24	in s. 624.91, the school health services program created in ss.
25	381.0056 and 381.0057, the Healthy Communities, Healthy People
26	Program created in s. 381.734, and the volunteer health care
27	provider program developed pursuant to s. 766.1115.
28	Section 2. Subsection (3) of section 381.90, Florida
29	Statutes, is amended to read:
30	381.90 Health Information Systems Council; legislative
31	intent; creation, appointment, duties.--
32	(3) The council shall be composed of the following members
33	or their senior executive-level designees:
34	(a) The secretary of the Department of Health;
35	(b) The secretary of the Department of Business and
36	Professional Regulation;
37	(c) The secretary of the Department of Children and Family
38	Services;
39	(d) The Secretary of Health Care Administration;
40	(e) The secretary of the Department of Corrections;
41	(f) The Attorney General;
42	(g) The executive director of the Correctional Medical
43	Authority;
44	(h) Two members representing county health departments,
45	one from a small county and one from a large county, appointed
46	by the Governor;
47	(i) A representative from the Florida Association of
48	Counties;
49	(j) The State Treasurer and Insurance Commissioner;
50	(k) A representative from the Florida Healthy Kids
51	Corporation;
52	(k)(l)A representative from a school of public health
53	chosen by the Board of Regents;
54	(l)(m)The Commissioner of Education;
55	(m)(n)The secretary of the Department of Elderly Affairs;
56	and
57	(n)(o)The secretary of the Department of Juvenile
58	Justice.
59
60	Representatives of the Federal Government may serve without
61	voting rights.
62	Section 3. Effective upon this act becoming a law,
63	subsection (5) of section 400.179, Florida Statutes, is amended
64	to read:
65	400.179 Sale or transfer of ownership of a nursing
66	facility; liability for Medicaid underpayments and
67	overpayments.--
68	(5) Because any transfer of a nursing facility may expose
69	the fact that Medicaid may have underpaid or overpaid the
70	transferor, and because in most instances, any such underpayment
71	or overpayment can only be determined following a formal field
72	audit, the liabilities for any such underpayments or
73	overpayments shall be as follows:
74	(a) The Medicaid program shall be liable to the transferor
75	for any underpayments owed during the transferor's period of
76	operation of the facility.
77	(b) Without regard to whether the transferor had leased or
78	owned the nursing facility, the transferor shall remain liable
79	to the Medicaid program for all Medicaid overpayments received
80	during the transferor's period of operation of the facility,
81	regardless of when determined.
82	(c) Where the facility transfer takes any form of a sale
83	of assets, in addition to the transferor's continuing liability
84	for any such overpayments, if the transferor fails to meet these
85	obligations, the transferee shall be liable for all liabilities
86	that can be readily identifiable 90 days in advance of the
87	transfer. Such liability shall continue in succession until the
88	debt is ultimately paid or otherwise resolved. It shall be the
89	burden of the transferee to determine the amount of all such
90	readily identifiable overpayments from the Agency for Health
91	Care Administration, and the agency shall cooperate in every way
92	with the identification of such amounts. Readily identifiable
93	overpayments shall include overpayments that will result from,
94	but not be limited to:
95	1. Medicaid rate changes or adjustments;
96	2. Any depreciation recapture;
97	3. Any recapture of fair rental value system indexing; or
98	4. Audits completed by the agency.
99
100	The transferor shall remain liable for any such Medicaid
101	overpayments that were not readily identifiable 90 days in
102	advance of the nursing facility transfer.
103	(d) Where the transfer involves a facility that has been
104	leased by the transferor:
105	1. The transferee shall, as a condition to being issued a
106	license by the agency, acquire, maintain, and provide proof to
107	the agency of a bond with a term of 30 months, renewable
108	annually, in an amount not less than the total of 3 months
109	Medicaid payments to the facility computed on the basis of the
110	preceding 12-month average Medicaid payments to the facility.
111	2. A leasehold licensee may meet the requirements of
112	subparagraph 1. by payment of a nonrefundable fee, paid at
113	initial licensure, paid at the time of any subsequent change of
114	ownership, and paid at the time of any subsequent annual license
115	renewal, in the amount of 2 percent of the total of 3 months'
116	Medicaid payments to the facility computed on the basis of the
117	preceding 12-month average Medicaid payments to the facility. If
118	a preceding 12-month average is not available, projected
119	Medicaid payments may be used. The fee shall be deposited into
120	the Health Care Trust Fund and shall be accounted for separately
121	as a Medicaid nursing home overpayment account. These fees shall
122	be used at the sole discretion of the agency to repay nursing
123	home Medicaid overpayments. Payment of this fee shall not
124	release the licensee from any liability for any Medicaid
125	overpayments, nor shall payment bar the agency from seeking to
126	recoup overpayments from the licensee and any other liable
127	party. As a condition of exercising this lease bond alternative,
128	licensees paying this fee must maintain an existing lease bond
129	through the end of the 30-month term period of that bond. The
130	agency is herein granted specific authority to promulgate all
131	rules pertaining to the administration and management of this
132	account, including withdrawals from the account, subject to
133	federal review and approval. This subparagraph is repealed on
134	June 30, 2003.This provision shall take effect upon becoming
135	law and shall apply to any leasehold license application.
136	a. The financial viability of the Medicaid nursing home
137	overpayment account shall be determined by the agency through
138	annual review of the account balance and the amount of total
139	outstanding, unpaid Medicaid overpayments owing from leasehold
140	licensees to the agency as determined by final agency audits.
141	b. The agency, in consultation with the Florida Health
142	Care Association and the Florida Association of Homes for the
143	Aging, shall study and make recommendations on the minimum
144	amount to be held in reserve to protect against Medicaid
145	overpayments to leasehold licensees and on the issue of
146	successor liability for Medicaid overpayments upon sale or
147	transfer of ownership of a nursing facility. The agency shall
148	submit the findings and recommendations of the study to the
149	Governor, the President of the Senate, and the Speaker of the
150	House of Representatives by January 1, 2003.
151	3. The leasehold licensee may meet the bond requirement
152	through other arrangements acceptable to the agency. The agency
153	is herein granted specific authority to promulgate rules
154	pertaining to lease bond arrangements.
155	4. All existing nursing facility licensees, operating the
156	facility as a leasehold, shall acquire, maintain, and provide
157	proof to the agency of the 30-month bond required in
158	subparagraph 1., above, on and after July 1, 1993, for each
159	license renewal.
160	5. It shall be the responsibility of all nursing facility
161	operators, operating the facility as a leasehold, to renew the
162	30-month bond and to provide proof of such renewal to the agency
163	annually at the time of application for license renewal.
164	6. Any failure of the nursing facility operator to
165	acquire, maintain, renew annually, or provide proof to the
166	agency shall be grounds for the agency to deny, cancel, revoke,
167	or suspend the facility license to operate such facility and to
168	take any further action, including, but not limited to,
169	enjoining the facility, asserting a moratorium, or applying for
170	a receiver, deemed necessary to ensure compliance with this
171	section and to safeguard and protect the health, safety, and
172	welfare of the facility's residents. A lease agreement required
173	as a condition of bond financing or refinancing under s. 154.213
174	by a health facilities authority or required under s. 159.30 by
175	a county or municipality is not a leasehold for purposes of this
176	paragraph and is not subject to the bond requirement of this
177	paragraph.
178	Section 4. Paragraph (c) of subsection (4) of section
179	408.915, Florida Statutes, is amended to read:
180	408.915 Eligibility pilot project.--The Agency for Health
181	Care Administration, in consultation with the steering committee
182	established in s. 408.916, shall develop and implement a pilot
183	project to integrate the determination of eligibility for health
184	care services with information and referral services.
185	(4) The pilot project shall include eligibility
186	determinations for the following programs:
187	(c) Florida Healthy Kids as described in s. 409.8133
188	624.91and within eligibility guidelines provided in s. 409.814.
189	Section 5. Section 409.810, Florida Statutes, is amended
190	to read:
191	409.810 Short title.--Sections 409.810-409.822409.810-
192	409.820may be cited as the "Florida Kidcare Act."
193	Section 6. Section 409.811, Florida Statutes, is amended
194	to read:
195	409.811 Definitions relating to Florida Kidcare Act.--As
196	used in ss. 409.810-409.822409.810-409.820, the term:
197	(1) "Actuarially equivalent" means that:
198	(a) The aggregate value of the benefits included in health
199	benefits coverage is equal to the value of the benefits in the
200	benchmark benefit plan; and
201	(b) The benefits included in health benefits coverage are
202	substantially similar to the benefits included in the benchmark
203	benefit plan, except that preventive health services must be the
204	same as in the benchmark benefit plan.
205	(2) "Agency" means the Agency for Health Care
206	Administration.
207	(3) "Applicant" means a parent or guardian of a child or a
208	child whose disability of nonage has been removed under chapter
209	743, who applies for determination of eligibility for health
210	benefits coverage under ss. 409.810-409.822409.810-409.820.
211	(4) "Benchmark benefit plan" means the form and level of
212	health benefits coverage established in s. 409.815.
213	(5) "Child" means any person under 19 years of age.
214	(6) "Child with special health care needs" means a child
215	whose serious or chronic physical or developmental condition
216	requires extensive preventive and maintenance care beyond that
217	required by typically healthy children. Health care utilization
218	by such a child exceeds the statistically expected usage of the
219	normal child adjusted for chronological age, and such a child
220	often needs complex care requiring multiple providers,
221	rehabilitation services, and specialized equipment in a number
222	of different settings.
223	(7) "Children's Medical Services network" or "network"
224	means a statewide managed care service system as defined in s.
225	391.021(1).
226	(8) "Community rate" means a method used to develop
227	premiums for a health insurance plan that spreads financial risk
228	across a large population and allows adjustments only for age,
229	gender, family composition, and geographic area.
230	(9) "Department" means the Department of Health.
231	(10) "Enrollee" means a child who has been determined
232	eligible for and is receiving coverage under ss. 409.810-409.822
233	409.810-409.820.
234	(11) "Enrollment ceiling" means the maximum number of
235	children receiving premium assistance payments, excluding
236	children enrolled in Medicaid, that may be enrolled at any time
237	in the Florida Kidcare program. The maximum number shall be
238	established annually in the General Appropriations Act or by
239	general law.
240	(12) "Family" means the group or the individuals whose
241	income is considered in determining eligibility for the Florida
242	Kidcare program. The family includes a child with a custodial
243	parent or caretaker relative who resides in the same house or
244	living unit or, in the case of a child whose disability of
245	nonage has been removed under chapter 743, the child. The family
246	may also include other individuals whose income and resources
247	are considered in whole or in part in determining eligibility of
248	the child.
249	(13) "Family income" means cash received at periodic
250	intervals from any source, such as wages, benefits,
251	contributions, or rental property. Income also may include any
252	money that would have been counted as income under the Aid to
253	Families with Dependent Children (AFDC) state plan in effect
254	prior to August 22, 1996.
255	(14) "Florida Healthy Kids" means a component of the
256	Florida Kidcare program of medical assistance authorized by
257	Title XXI of the Social Security Act, and regulations
258	thereunder, and s. 409.8133, as administered in the state by the
259	agency.
260	(15)(14)"Guarantee issue" means that health benefits
261	coverage must be offered to an individual regardless of the
262	individual's health status, preexisting condition, or claims
263	history.
264	(16)(15)"Health benefits coverage" means protection that
265	provides payment of benefits for covered health care services or
266	that otherwise provides, either directly or through arrangements
267	with other persons, covered health care services on a prepaid
268	per capita basis or on a prepaid aggregate fixed-sum basis.
269	(17)(16)"Health insurance plan" means health benefits
270	coverage under the following:
271	(a) A health plan offered by any certified health
272	maintenance organization or authorized health insurer, except a
273	plan that is limited to the following: a limited benefit,
274	specified disease, or specified accident; hospital indemnity;
275	accident only; limited benefit convalescent care; Medicare
276	supplement; credit disability; dental; vision; long-term care;
277	disability income; coverage issued as a supplement to another
278	health plan; workers' compensation liability or other insurance;
279	or motor vehicle medical payment only; or
280	(b) An employee welfare benefit plan that includes health
281	benefits established under the Employee Retirement Income
282	Security Act of 1974, as amended.
283	(18) "Managed care plan" means a health maintenance
284	organization authorized pursuant to chapter 641 or a prepaid
285	health plan authorized pursuant to s. 409.912.
286	(19)(17)"Medicaid" means the medical assistance program
287	authorized by Title XIX of the Social Security Act, and
288	regulations thereunder, and ss. 409.901-409.920, as administered
289	in this state by the agency.
290	(20)(18)"Medically necessary" means the use of any
291	medical treatment, service, equipment, or supply necessary to
292	palliate the effects of a terminal condition, or to prevent,
293	diagnose, correct, cure, alleviate, or preclude deterioration of
294	a condition that threatens life, causes pain or suffering, or
295	results in illness or infirmity and which is:
296	(a) Consistent with the symptom, diagnosis, and treatment
297	of the enrollee's condition;
298	(b) Provided in accordance with generally accepted
299	standards of medical practice;
300	(c) Not primarily intended for the convenience of the
301	enrollee, the enrollee's family, or the health care provider;
302	(d) The most appropriate level of supply or service for
303	the diagnosis and treatment of the enrollee's condition; and
304	(e) Approved by the appropriate medical body or health
305	care specialty involved as effective, appropriate, and essential
306	for the care and treatment of the enrollee's condition.
307	(21)(19)"Medikids" means a component of the Florida
308	Kidcare program of medical assistance authorized by Title XXI of
309	the Social Security Act, and regulations thereunder, and s.
310	409.8132, as administered in the state by the agency.
311	(22)(20)"Preexisting condition exclusion" means, with
312	respect to coverage, a limitation or exclusion of benefits
313	relating to a condition based on the fact that the condition was
314	present before the date of enrollment for such coverage, whether
315	or not any medical advice, diagnosis, care, or treatment was
316	recommended or received before such date.
317	(23)(21)"Premium" means the entire cost of a health
318	insurance plan, including the administration fee or the risk
319	assumption charge.
320	(24)(22)"Premium assistance payment" means the monthly
321	consideration paid by the agency per enrollee in the Florida
322	Kidcare program towards health insurance premiums.
323	(25)(23)"Program" means the Florida Kidcare program, the
324	medical assistance program authorized by Title XXI of the Social
325	Security Act as part of the federal Balanced Budget Act of 1997.
326	(26)(24)"Qualified alien" means an alien as defined in s.
327	431 of the Personal Responsibility and Work Opportunity
328	Reconciliation Act of 1996, as amended, Pub. L. No. 104-193.
329	(27)(25)"Resident" means a United States citizen, or
330	qualified alien, who is domiciled in this state.
331	(28)(26)"Rural county" means a county having a population
332	density of less than 100 persons per square mile, or a county
333	defined by the most recent United States Census as rural, in
334	which there is no prepaid health plan participating in the
335	Medicaid program as of July 1, 1998.
336	(29)(27)"Substantially similar" means that, with respect
337	to additional services as defined in s. 2103(c)(2) of Title XXI
338	of the Social Security Act, these services must have an
339	actuarial value equal to at least 75 percent of the actuarial
340	value of the coverage for that service in the benchmark benefit
341	plan and, with respect to the basic services as defined in s.
342	2103(c)(1) of Title XXI of the Social Security Act, these
343	services must be the same as the services in the benchmark
344	benefit plan.
345	Section 7. Section 409.813, Florida Statutes, is amended
346	to read:
347	409.813 Program components; entitlement and
348	nonentitlement.--The Florida Kidcare program includes health
349	benefits coverage provided to children through:
350	(1) Medicaid;
351	(2) Medikids as created in s. 409.8132;
352	(3) The Florida Healthy Kids ProgramCorporationas
353	created in s. 409.8133624.91;
354	(4) Employer-sponsored group health insurance plans
355	approved under ss. 409.810-409.822409.810-409.820; and
356	(5) The Children's Medical Services network established in
357	chapter 391.
358
359	Except for coverage under the Medicaid program, coverage under
360	the Florida Kidcare program is not an entitlement. No cause of
361	action shall arise against the state, the department, the
362	Department of Children and Family Services, or the agency for
363	failure to make health services available to any person under
364	ss. 409.810-409.822409.810-409.820.
365	Section 8. Subsection (7) of section 409.8132, Florida
366	Statutes, is amended to read:
367	409.8132 Medikids program component.--
368	(7) ENROLLMENT.--Enrollment in the Medikids program
369	component may only occur during periodic open enrollment periods
370	as specified by the agency. An applicant may apply for
371	enrollment in the Medikids program component and proceed through
372	the eligibility determination process at any time throughout the
373	year. However, enrollment in Medikids shall not begin until the
374	next open enrollment period; and a child may not receive
375	services under the Medikids program until the child is enrolled
376	in a managed care plan as defined in s. 409.811 or inMediPass.
377	In addition, once determined eligible, an applicant may receive
378	choice counseling and select a managed care plan or MediPass.
379	The agency may initiate mandatory assignment for a Medikids
380	applicant who has not chosen a managed care plan or MediPass
381	provider after the applicant's voluntary choice period ends. An
382	applicant may select MediPass under the Medikids program
383	component only in counties that have fewer than two managed care
384	plans available to serve Medicaid recipients and only if the
385	federal Health Care Financing Administration determines that
386	MediPass constitutes "health insurance coverage" as defined in
387	Title XXI of the Social Security Act.
388	Section 9. Section 403.8133, Florida Statutes, is created
389	to read:
390	409.8133 Florida Healthy Kids program component.--
391	(1) PROGRAM COMPONENT CREATED; PURPOSE.--The Florida
392	Healthy Kids program component is created in the Agency for
393	Health Care Administration to provide health care services under
394	the Florida Kidcare program to eligible children using the
395	administrative structure and provider network of the Medicaid
396	program.
397	(2) ADMINISTRATION.--The secretary of the agency shall
398	appoint an administrator of the Florida Healthy Kids program
399	component. The Agency for Health Care Administration is
400	designated as the state agency authorized to make payments for
401	medical assistance and related services for the Florida Healthy
402	Kids program component of the Florida Kidcare program. Payments
403	shall be made, subject to any limitations or directions in the
404	General Appropriations Act, only for covered services provided
405	to eligible children by qualified health care providers under
406	the Florida Kidcare program.
407	(3) INSURANCE LICENSURE NOT REQUIRED.--The Florida Healthy
408	Kids program component shall not be subject to the licensing
409	requirements of the Florida Insurance Code or rules of the
410	Department of Insurance.
411	(4) APPLICABILITY OF LAWS RELATING TO MEDICAID.--The
412	provisions of ss. 409.902, 409.905, 409.906, 409.907, 409.908,
413	409.912, 409.9121, 409.9122, 409.9123, 409.9124, 409.9127,
414	409.9128, 409.913, 409.916, 409.919, 409.920, and 409.9205 apply
415	to the administration of the Florida Healthy Kids program
416	component of the Florida Kidcare program, except that s.
417	409.9122 applies to Florida Healthy Kids as modified by the
418	provisions of subsection (7).
419	(5) BENEFITS.--Benefits provided under the Florida Healthy
420	Kids program component shall be the same benefits provided to
421	children as specified in ss. 409.905 and 409.906.
422	(6) ELIGIBILITY.--
423	(a) A child who has attained the age of 5 years but who is
424	under the age of 19 years is eligible to enroll in the Florida
425	Healthy Kids program component of the Florida Kidcare program if
426	the child is a member of a family that has a family income which
427	exceeds the Medicaid applicable income level as specified in s.
428	409.903, but which is equal to or below 200 percent of the
429	current federal poverty level. In determining the eligibility of
430	such a child, an assets test is not required. A child who is
431	eligible for Florida Healthy Kids may elect to enroll in
432	employer-sponsored group coverage.
433	(b) The provisions of s. 409.814(3), (4), and (5) shall be
434	applicable to the Florida Healthy Kids program.
435	(7) ENROLLMENT.--Enrollment in the Florida Healthy Kids
436	program component may only occur during periodic open enrollment
437	periods as specified by the agency. An applicant may apply for
438	enrollment in the Florida Healthy Kids program component and
439	proceed through the eligibility determination process at any
440	time throughout the year. However, enrollment in Florida Healthy
441	Kids shall not begin until the next open enrollment period; and
442	a child may not receive services under the Florida Healthy Kids
443	program until the child is enrolled in a managed care plan or
444	MediPass. In addition, once determined eligible, an applicant
445	may receive choice counseling and select a managed care plan or
446	MediPass. The agency may initiate mandatory assignment for a
447	Florida Healthy Kids applicant who has not chosen a managed care
448	plan or MediPass provider after the applicant's voluntary choice
449	period ends. An applicant may select MediPass under the Florida
450	Healthy Kids program component only in counties that have fewer
451	than two managed care plans available to serve Medicaid
452	recipients and only if the federal Health Care Financing
453	Administration determines that MediPass constitutes "health
454	insurance coverage" as defined in Title XXI of the Social
455	Security Act.
456	(8) SPECIAL ENROLLMENT PERIODS.--The agency shall
457	establish a special enrollment period of 30 days' duration for
458	any child who is enrolled in Medicaid if such child loses
459	Medicaid eligibility and becomes eligible for Florida Healthy
460	Kids, or for any child who is enrolled in Florida Healthy Kids
461	if such child moves to another county that is not within the
462	coverage area of the child's Florida Healthy Kids managed care
463	plan or MediPass provider.
464	(9) PENALTIES FOR VOLUNTARY CANCELLATION.--The agency
465	shall establish enrollment criteria that must include penalties
466	or waiting periods of not fewer than 60 days for reinstatement
467	of coverage upon voluntary cancellation for nonpayment of
468	premiums.
469	Section 10. Section 409.814, Florida Statutes, is amended
470	to read:
471	409.814 Eligibility.--A child whose family income is equal
472	to or below 200 percent of the federal poverty level is eligible
473	for the Florida Kidcare program as provided in this section. In
474	determining the eligibility of such a child, an assets test is
475	not required. An applicant under 19 years of age who, based on a
476	complete application, appears to be eligible for the Medicaid
477	component of the Florida Kidcare program is presumed eligible
478	for coverage under Medicaid, subject to federal rules. A child
479	who has been deemed presumptively eligible for Medicaid shall
480	not be enrolled in a managed care plan until the child's full
481	eligibility determination for Medicaid has been completed. The
482	Florida Healthy Kids Corporation may, subject to compliance with
483	applicable requirements of the Agency for Health Care
484	Administration and the Department of Children and Family
485	Services, be designated as an entity to conduct presumptive
486	eligibility determinations. An applicant under 19 years of age
487	who, based on a complete application, appears to be eligible for
488	the Medikids, Florida Healthy Kids, or Children's Medical
489	Services network program component, who is screened as
490	ineligible for Medicaid and prior to the monthly verification of
491	the applicant's enrollment in Medicaid or of eligibility for
492	coverage under the state employee health benefit plan, may be
493	enrolled in and begin receiving coverage from the appropriate
494	program component on the first day of the month following the
495	receipt of a completed application. For enrollment in the
496	Children's Medical Services network, a complete application
497	includes the medical or behavioral health screening. If, after
498	verification, an individual is determined to be ineligible for
499	coverage, he or she must be disenrolled from the respective
500	Title XXI-funded Kidcare program component.
501	(1) A child who is eligible for Medicaid coverage under s.
502	409.903 or s. 409.904 must be enrolled in Medicaid and is not
503	eligible to receive health benefits under any other health
504	benefits coverage authorized under ss. 409.810-409.822409.810-
505	409.820.
506	(2) A child who is not eligible for Medicaid, but who is
507	eligible for the Florida Kidcare program, may obtain coverage
508	under any of the other types of health benefits coverage
509	authorized in ss. 409.810-409.822409.810-409.820if such
510	coverage is approved and available in the county in which the
511	child resides. However, a child who is eligible for Medikids may
512	participate in the Florida Healthy Kids program only if the
513	child has a sibling participating in the Florida Healthy Kids
514	program and the child's county of residence permits such
515	enrollment.
516	(3) A child who is eligible for the Florida Kidcare
517	program who is a child with special health care needs, as
518	determined through a medical or behavioral screening instrument,
519	is eligible for health benefits coverage from and shall be
520	referred to the Children's Medical Services network.
521	(4) The following children are not eligible to receive
522	premium assistance for health benefits coverage under ss.
523	409.810-409.822409.810-409.820, except under Medicaid if the
524	child would have been eligible for Medicaid under s. 409.903 or
525	s. 409.904 as of June 1, 1997:
526	(a) A child who is eligible for coverage under a state
527	health benefit plan on the basis of a family member's employment
528	with a public agency in the state.
529	(b) A child who is covered under a group health benefit
530	plan or under other health insurance coverage, excluding
531	coverage provided under the Florida Healthy Kids Program
532	Corporation as established under s. 409.8133624.91.
533	(c) A child who is seeking premium assistance for
534	employer-sponsored group coverage, if the child has been covered
535	by the same employer's group coverage during the 6 months prior
536	to the family's submitting an application for determination of
537	eligibility under the Florida Kidcare program.
538	(d) A child who is an alien, but who does not meet the
539	definition of qualified alien, in the United States.
540	(e) A child who is an inmate of a public institution or a
541	patient in an institution for mental diseases.
542	(5) A child whose family income is above 200 percent of
543	the federal poverty level or a child who is excluded under the
544	provisions of subsection (4) may participate in the Florida
545	Kidcare program, excluding the Medicaid program, but is subject
546	to the following provisions:
547	(a) The family is not eligible for premium assistance
548	payments and must pay the full cost of the premium, including
549	any administrative costs.
550	(b) The agency is authorized to place limits on enrollment
551	in Medikids by these children in order to avoid adverse
552	selection. The number of children participating in Medikids
553	whose family income exceeds 200 percent of the federal poverty
554	level must not exceed 10 percent of total enrollees in the
555	Medikids program.
556	(c) The board of directors of the Florida Healthy Kids
557	Corporation is authorized to place limits on enrollment in
558	Florida Health Kids byofthese children in order to avoid
559	adverse selection. In addition, the board is authorized to offer
560	a reduced benefit package to these children in order to limit
561	program costs for such families. The number of children
562	participating in the Florida Healthy Kids program whose family
563	income exceeds 200 percent of the federal poverty level must not
564	exceed 10 percent of total enrollees in the Florida Healthy Kids
565	program.
566	(d) Children described in this subsection are not counted
567	in the annual enrollment ceiling for the Florida Kidcare
568	program.
569	(6) Once a child is enrolled in the Florida Kidcare
570	program, the child is eligible for coverage under the program
571	for 6 months without a redetermination or reverification of
572	eligibility, if the family continues to pay the applicable
573	premium. Effective January 1, 1999, a child who has not attained
574	the age of 5 and who has been determined eligible for the
575	Medicaid program is eligible for coverage for 12 months without
576	a redetermination or reverification of eligibility.
577	(7) When determining or reviewing a child's eligibility
578	under the program, the applicant shall be provided with
579	reasonable notice of changes in eligibility which may affect
580	enrollment in one or more of the program components. When a
581	transition from one program component to another is appropriate,
582	there shall be cooperation between the program components and
583	the affected family which promotes continuity of health care
584	coverage.
585	Section 11. Subsection (2) of section 409.815, Florida
586	Statutes, is amended to read:
587	409.815 Health benefits coverage; limitations.--
588	(2) BENCHMARK BENEFITS.--In order for health benefits
589	coverage to qualify for premium assistance payments for an
590	eligible child under ss. 409.810-409.822409.810-409.820, the
591	health benefits coverage, except for coverage under Medicaid,
592	Florida Healthy Kids,and Medikids, must include the following
593	minimum benefits, as medically necessary.
594	(a) Preventive health services.--Covered services include:
595	1. Well-child care, including services recommended in the
596	Guidelines for Health Supervision of Children and Youth as
597	developed by the American Academy of Pediatrics;
598	2. Immunizations and injections;
599	3. Health education counseling and clinical services;
600	4. Vision screening; and
601	5. Hearing screening.
602	(b) Inpatient hospital services.--All covered services
603	provided for the medical care and treatment of an enrollee who
604	is admitted as an inpatient to a hospital licensed under part I
605	of chapter 395, with the following exceptions:
606	1. All admissions must be authorized by the enrollee's
607	health benefits coverage provider.
608	2. The length of the patient stay shall be determined
609	based on the medical condition of the enrollee in relation to
610	the necessary and appropriate level of care.
611	3. Room and board may be limited to semiprivate
612	accommodations, unless a private room is considered medically
613	necessary or semiprivate accommodations are not available.
614	4. Admissions for rehabilitation and physical therapy are
615	limited to 15 days per contract year.
616	(c) Emergency services.--Covered services include visits
617	to an emergency room or other licensed facility if needed
618	immediately due to an injury or illness and delay means risk of
619	permanent damage to the enrollee's health. Health maintenance
620	organizations shall comply with the provisions of s. 641.513.
621	(d) Maternity services.--Covered services include
622	maternity and newborn care, including prenatal and postnatal
623	care, with the following limitations:
624	1. Coverage may be limited to the fee for vaginal
625	deliveries; and
626	2. Initial inpatient care for newborn infants of enrolled
627	adolescents shall be covered, including normal newborn care,
628	nursery charges, and the initial pediatric or neonatal
629	examination, and the infant may be covered for up to 3 days
630	following birth.
631	(e) Organ transplantation services.--Covered services
632	include pretransplant, transplant, and postdischarge services
633	and treatment of complications after transplantation for
634	transplants deemed necessary and appropriate within the
635	guidelines set by the Organ Transplant Advisory Council under s.
636	381.0602 or the Bone Marrow Transplant Advisory Panel under s.
637	627.4236.
638	(f) Outpatient services.--Covered services include
639	preventive, diagnostic, therapeutic, palliative care, and other
640	services provided to an enrollee in the outpatient portion of a
641	health facility licensed under chapter 395, except for the
642	following limitations:
643	1. Services must be authorized by the enrollee's health
644	benefits coverage provider; and
645	2. Treatment for temporomandibular joint disease (TMJ) is
646	specifically excluded.
647	(g) Behavioral health services.--
648	1. Mental health benefits include:
649	a. Inpatient services, limited to not more than 30
650	inpatient days per contract year for psychiatric admissions, or
651	residential services in facilities licensed under s. 394.875(8)
652	or s. 395.003 in lieu of inpatient psychiatric admissions;
653	however, a minimum of 10 of the 30 days shall be available only
654	for inpatient psychiatric services when authorized by a
655	physician; and
656	b. Outpatient services, including outpatient visits for
657	psychological or psychiatric evaluation, diagnosis, and
658	treatment by a licensed mental health professional, limited to a
659	maximum of 40 outpatient visits each contract year.
660	2. Substance abuse services include:
661	a. Inpatient services, limited to not more than 7
662	inpatient days per contract year for medical detoxification only
663	and 30 days of residential services; and
664	b. Outpatient services, including evaluation, diagnosis,
665	and treatment by a licensed practitioner, limited to a maximum
666	of 40 outpatient visits per contract year.
667	(h) Durable medical equipment.--Covered services include
668	equipment and devices that are medically indicated to assist in
669	the treatment of a medical condition and specifically prescribed
670	as medically necessary, with the following limitations:
671	1. Low-vision and telescopic aides are not included.
672	2. Corrective lenses and frames may be limited to one pair
673	every 2 years, unless the prescription or head size of the
674	enrollee changes.
675	3. Hearing aids shall be covered only when medically
676	indicated to assist in the treatment of a medical condition.
677	4. Covered prosthetic devices include artificial eyes and
678	limbs, braces, and other artificial aids.
679	(i) Health practitioner services.--Covered services
680	include services and procedures rendered to an enrollee when
681	performed to diagnose and treat diseases, injuries, or other
682	conditions, including care rendered by health practitioners
683	acting within the scope of their practice, with the following
684	exceptions:
685	1. Chiropractic services shall be provided in the same
686	manner as in the Florida Medicaid program.
687	2. Podiatric services may be limited to one visit per day
688	totaling two visits per month for specific foot disorders.
689	(j) Home health services.--Covered services include
690	prescribed home visits by both registered and licensed practical
691	nurses to provide skilled nursing services on a part-time
692	intermittent basis, subject to the following limitations:
693	1. Coverage may be limited to include skilled nursing
694	services only;
695	2. Meals, housekeeping, and personal comfort items may be
696	excluded; and
697	3. Private duty nursing is limited to circumstances where
698	such care is medically necessary.
699	(k) Hospice services.--Covered services include reasonable
700	and necessary services for palliation or management of an
701	enrollee's terminal illness, with the following exceptions:
702	1. Once a family elects to receive hospice care for an
703	enrollee, other services that treat the terminal condition will
704	not be covered; and
705	2. Services required for conditions totally unrelated to
706	the terminal condition are covered to the extent that the
707	services are included in this section.
708	(l) Laboratory and X-ray services.--Covered services
709	include diagnostic testing, including clinical radiologic,
710	laboratory, and other diagnostic tests.
711	(m) Nursing facility services.--Covered services include
712	regular nursing services, rehabilitation services, drugs and
713	biologicals, medical supplies, and the use of appliances and
714	equipment furnished by the facility, with the following
715	limitations:
716	1. All admissions must be authorized by the health
717	benefits coverage provider.
718	2. The length of the patient stay shall be determined
719	based on the medical condition of the enrollee in relation to
720	the necessary and appropriate level of care, but is limited to
721	not more than 100 days per contract year.
722	3. Room and board may be limited to semiprivate
723	accommodations, unless a private room is considered medically
724	necessary or semiprivate accommodations are not available.
725	4. Specialized treatment centers and independent kidney
726	disease treatment centers are excluded.
727	5. Private duty nurses, television, and custodial care are
728	excluded.
729	6. Admissions for rehabilitation and physical therapy are
730	limited to 15 days per contract year.
731	(n) Prescribed drugs.--
732	1. Coverage shall include drugs prescribed for the
733	treatment of illness or injury when prescribed by a licensed
734	health practitioner acting within the scope of his or her
735	practice.
736	2. Prescribed drugs may be limited to generics if
737	available and brand name products if a generic substitution is
738	not available, unless the prescribing licensed health
739	practitioner indicates that a brand name is medically necessary.
740	3. Prescribed drugs covered under this section shall
741	include all prescribed drugs covered under the Florida Medicaid
742	program.
743	(o) Therapy services.--Covered services include
744	rehabilitative services, including occupational, physical,
745	respiratory, and speech therapies, with the following
746	limitations:
747	1. Services must be for short-term rehabilitation where
748	significant improvement in the enrollee's condition will result;
749	and
750	2. Services shall be limited to not more than 24 treatment
751	sessions within a 60-day period per episode or injury, with the
752	60-day period beginning with the first treatment.
753	(p) Transportation services.--Covered services include
754	emergency transportation required in response to an emergency
755	situation.
756	(q) Dental services.--Subject to a specific appropriation
757	for this benefit, covered services include those dental services
758	provided to children by the Florida Medicaid program under s.
759	409.906(5).
760	(r) Lifetime maximum.--Health benefits coverage obtained
761	under ss. 409.810-409.822409.810-409.820shall pay an
762	enrollee's covered expenses at a lifetime maximum of $1 million
763	per covered child.
764	(s) Cost-sharing.--Cost-sharing provisions must comply
765	with s. 409.816.
766	(t) Exclusions.--
767	1. Experimental or investigational procedures that have
768	not been clinically proven by reliable evidence are excluded;
769	2. Services performed for cosmetic purposes only or for
770	the convenience of the enrollee are excluded; and
771	3. Abortion may be covered only if necessary to save the
772	life of the mother or if the pregnancy is the result of an act
773	of rape or incest.
774	(u) Enhancements to minimum requirements.--
775	1. This section sets the minimum benefits that must be
776	included in any health benefits coverage, other than Medicaid or
777	Medikids coverage, offered under ss. 409.810-409.822409.810-
778	409.820. Health benefits coverage may include additional
779	benefits not included under this subsection, but may not include
780	benefits excluded under paragraph (s).
781	2. Health benefits coverage may extend any limitations
782	beyond the minimum benefits described in this section.
783
784	Except for the Children's Medical Services network, the agency
785	may not increase the premium assistance payment for either
786	additional benefits provided beyond the minimum benefits
787	described in this section or the imposition of less restrictive
788	service limitations.
789	(v) Applicability of other state laws.--Health insurers,
790	health maintenance organizations, and their agents are subject
791	to the provisions of the Florida Insurance Code, except for any
792	such provisions waived in this section.
793	1. Except as expressly provided in this section, a law
794	requiring coverage for a specific health care service or
795	benefit, or a law requiring reimbursement, utilization, or
796	consideration of a specific category of licensed health care
797	practitioner, does not apply to a health insurance plan policy
798	or contract offered or delivered under ss. 409.810-409.822
799	409.810-409.820unless that law is made expressly applicable to
800	such policies or contracts.
801	2. Notwithstanding chapter 641, a health maintenance
802	organization may issue contracts providing benefits equal to,
803	exceeding, or actuarially equivalent to the benchmark benefit
804	plan authorized by this section and may pay providers located in
805	a rural county negotiated fees or Medicaid reimbursement rates
806	for services provided to enrollees who are residents of the
807	rural county.
808	Section 12. Section 409.817, Florida Statutes, is amended
809	to read:
810	409.817 Approval of health benefits coverage; financial
811	assistance.--In order for health insurance coverage to qualify
812	for premium assistance payments for an eligible child under ss.
813	409.810-409.822409.810-409.820, the health benefits coverage
814	must:
815	(1) Be certified by the Department of Insurance under s.
816	409.818 as meeting, exceeding, or being actuarially equivalent
817	to the benchmark benefit plan;
818	(2) Be guarantee issued;
819	(3) Be community rated;
820	(4) Not impose any preexisting condition exclusion for
821	covered benefits; however, group health insurance plans may
822	permit the imposition of a preexisting condition exclusion, but
823	only insofar as it is permitted under s. 627.6561;
824	(5) Comply with the applicable limitations on premiums and
825	cost-sharing in s. 409.816;
826	(6) Comply with the quality assurance and access standards
827	developed under s. 409.820; and
828	(7) Establish periodic open enrollment periods, which may
829	not occur more frequently than quarterly.
830	Section 13. Section 409.818, Florida Statutes, is amended
831	to read:
832	409.818 Administration.--In order to implement ss.
833	409.810-409.822409.810-409.820, the following agencies shall
834	have the following duties:
835	(1) The Department of Children and Family Services shall:
836	(a) Develop a simplified eligibility application mail-in
837	form to be used for determining the eligibility of children for
838	coverage under the Florida Kidcare program, in consultation with
839	the agency, the Department of Health, and the Florida Healthy
840	Kids Corporation. The simplified eligibility application form
841	must include an item that provides an opportunity for the
842	applicant to indicate whether coverage is being sought for a
843	child with special health care needs. Families applying for
844	children's Medicaid coverage must also be able to use the
845	simplified application form without having to pay a premium.
846	(b) Establish and maintain the eligibility determination
847	process under the program except as specified in subsection (5).
848	The department shall directly, or through the services of a
849	contracted third-party administrator, establish and maintain a
850	process for determining eligibility of children for coverage
851	under the program. The eligibility determination process must be
852	used solely for determining eligibility of applicants for health
853	benefits coverage under the program. The eligibility
854	determination process must include an initial determination of
855	eligibility for any coverage offered under the program, as well
856	as a redetermination or reverification of eligibility each
857	subsequent 6 months. Effective January 1, 1999, a child who has
858	not attained the age of 5 and who has been determined eligible
859	for the Medicaid program is eligible for coverage for 12 months
860	without a redetermination or reverification of eligibility. In
861	conducting an eligibility determination, the department shall
862	determine if the child has special health care needs. The
863	department, in consultation with the Agency for Health Care
864	Administration and the Florida Healthy Kids Corporation, shall
865	develop procedures for redetermining eligibility which enable a
866	family to easily update any change in circumstances which could
867	affect eligibility. The department may accept changes in a
868	family's status as reported to the department by the Florida
869	Healthy Kids Corporation without requiring a new application
870	from the family. Redetermination of a child's eligibility for
871	Medicaid may not be linked to a child's eligibility
872	determination for other programs.
873	(c) Inform program applicants about eligibility
874	determinations and provide information about eligibility of
875	applicants to Medicaid, Medikids, the Children's Medical
876	Services network, and the Florida Healthy Kids Program
877	Corporation, and to insurers and their agents, through a
878	centralized coordinating office.
879	(d) Adopt rules necessary for conducting program
880	eligibility functions.
881	(2) The Department of Health shall:
882	(a) Design an eligibility intake process for the program,
883	in coordination with the Department of Children and Family
884	Services, the agency, and the Florida Healthy Kids Corporation.
885	The eligibility intake process may include local intake points
886	that are determined by the Department of Health in coordination
887	with the Department of Children and Family Services.
888	(b) Design and implement program outreach activities under
889	s. 409.819.
890	(c) Chair a state-level coordinating council to review and
891	make recommendations concerning the implementation and operation
892	of the program. The coordinating council shall include
893	representatives from the department, the Department of Children
894	and Family Services, the agency, the Florida Healthy Kids
895	Corporation, the Department of Insurance, local government,
896	health insurers, health maintenance organizations, health care
897	providers, families participating in the program, and
898	organizations representing low-income families.
899	(d) In consultation with the Florida Healthy Kids
900	Corporation and the Department of Children and Family Services,
901	establishing a toll-free telephone line to assist families with
902	questions about the program.
903	(e) Adopt rules necessary to implement outreach
904	activities.
905	(3) The Agency for Health Care Administration, under the
906	authority granted in s. 409.914(1), shall:
907	(a) Calculate the premium assistance payment necessary to
908	comply with the premium and cost-sharing limitations specified
909	in s. 409.816. The premium assistance payment for each enrollee
910	in a health insurance plan participating in the Florida Healthy
911	Kids Corporation shall equal the premium approved by the Florida
912	Healthy Kids Corporation and the Department of Insurance
913	pursuant to ss. 627.410 and 641.31, less any enrollee's share of
914	the premium established within the limitations specified in s.
915	409.816.The premium assistance payment for each enrollee in an
916	employer-sponsored health insurance plan approved under ss.
917	409.810-409.822409.810-409.820shall equal the premium for the
918	plan adjusted for any benchmark benefit plan actuarial
919	equivalent benefit rider approved by the Department of Insurance
920	pursuant to ss. 627.410 and 641.31, less any enrollee's share of
921	the premium established within the limitations specified in s.
922	409.816. In calculating the premium assistance payment levels
923	for children with family coverage, the agency shall set the
924	premium assistance payment levels for each child proportionately
925	to the total cost of family coverage.
926	(b) Annually calculate the program enrollment ceiling
927	based on estimated per child premium assistance payments and the
928	estimated appropriation available for the program.
929	(c) Make premium assistance payments to health insurance
930	plans on a periodic basis. The agency may use its Medicaid
931	fiscal agent or a contracted third-party administrator in making
932	these payments. The agency may require health insurance plans
933	that participate in the Medikids program, the Florida Healthy
934	Kids program,or employer-sponsored group health insurance to
935	collect premium payments from an enrollee's family.
936	Participating health insurance plans shall report premium
937	payments collected on behalf of enrollees in the program to the
938	agency in accordance with a schedule established by the agency.
939	(d) Monitor compliance with quality assurance and access
940	standards developed under s. 409.820.
941	(e) Establish a mechanism for investigating and resolving
942	complaints and grievances from program applicants, enrollees,
943	and health benefits coverage providers, and maintain a record of
944	complaints and confirmed problems. In the case of a child who is
945	enrolled in a health maintenance organization, the agency must
946	use the provisions of s. 641.511 to address grievance reporting
947	and resolution requirements.
948	(f) Approve health benefits coverage for participation in
949	the program, following certification by the Department of
950	Insurance under subsection (4).
951	(g) Adopt rules necessary for calculating premium
952	assistance payment levels, calculating the program enrollment
953	ceiling, making premium assistance payments, monitoring access
954	and quality assurance standards, investigating and resolving
955	complaints and grievances, administering the Medikids program
956	and the Florida Healthy Kids program, and approving health
957	benefits coverage.
958
959	The agency is designated the lead state agency for Title XXI of
960	the Social Security Act for purposes of receipt of federal
961	funds, for reporting purposes, and for ensuring compliance with
962	federal and state regulations and rules.
963	(4) The Department of Insurance shall certify that health
964	benefits coverage plans that seek to provide services under the
965	Florida Kidcare program, except those offered through the
966	Florida Healthy Kids Corporation or theChildren's Medical
967	Services network, meet, exceed, or are actuarially equivalent to
968	the benchmark benefit plan and that health insurance plans will
969	be offered at an approved rate. In determining actuarial
970	equivalence of benefits coverage, the Department of Insurance
971	and health insurance plans must comply with the requirements of
972	s. 2103 of Title XXI of the Social Security Act. The department
973	shall adopt rules necessary for certifying health benefits
974	coverage plans.
975	(5) The Florida Healthy Kids Corporation shall retain its
976	functions as authorized in s. 624.91, including eligibility
977	determination for participation in the Healthy Kids program.
978	(5)(6)The agency, the Department of Health, the
979	Department of Children and Family Services, the Florida Healthy
980	Kids Corporation, and the Department of Insurance, after
981	consultation with and approval of the Speaker of the House of
982	Representatives and the President of the Senate, are authorized
983	to make program modifications that are necessary to overcome any
984	objections of the United States Department of Health and Human
985	Services to obtain approval of the state's child health
986	insurance plan under Title XXI of the Social Security Act.
987	Section 14. Section 624.91, Florida Statutes, is
988	renumbered as section 409.821, Florida Statutes, and amended to
989	read:
990	409.821624.91The Florida Healthy Kids Corporation Act.--
991	(1) SHORT TITLE.--This section may be cited as the
992	"William G. 'Doc' Myers Healthy Kids Corporation Act."
993	(2) LEGISLATIVE INTENT.--
994	(a) The Legislature finds that increased access to health
995	care services could improve children's health and reduce the
996	incidence and costs of childhood illness and disabilities among
997	children in this state. Many children do not have comprehensive,
998	affordable health care services available. It is the intent of
999	the Legislature that the Florida Healthy Kids Corporation
1000	provide comprehensive health insurance coverage to such
1001	children. The corporation is encouraged to cooperate with any
1002	existing health service programs funded by the public or the
1003	private sector and to work cooperatively with the Florida
1004	Partnership for School Readiness.
1005	(b) It is the intent of the Legislature that the Florida
1006	Healthy Kids Corporation serve as one of several providers of
1007	services to children eligible for medical assistance under Title
1008	XXI of the Social Security Act. Although the corporation may
1009	serve other children, the Legislature intends the primary
1010	recipients of services provided through the corporation be
1011	school-age children with a family income below 200 percent of
1012	the federal poverty level, who do not qualify for Medicaid. It
1013	is also the intent of the Legislature that state and local
1014	government Florida Healthy Kids funds be used to continue and
1015	expand coverage, within available appropriations, to children
1016	not eligible for federal matching funds under Title XXI.
1017	(3) NONENTITLEMENT.--Nothing in this section shall be
1018	construed as providing an individual with an entitlement to
1019	health care services. No cause of action shall arise against the
1020	state, the Florida Healthy Kids Corporation, or a unit of local
1021	government for failure to make health services available under
1022	this section.
1023	(2)(4)CORPORATION AUTHORIZATION, DUTIES, POWERS.--
1024	(a) There is created the Florida Healthy Kids Corporation,
1025	a not-for-profit corporation.
1026	(b) The Florida Healthy Kids Corporation shall:
1027	1. Organize school children groups to facilitate the
1028	provision of comprehensive health insurance coverage to
1029	children;
1030	1.2. Arrange for the collection for the Agency for Health
1031	Care Administrationof any family, local contributions, or
1032	employer payment or premium, in an amount to be determined by
1033	the board of directors,to provide for payment of premiums for
1034	comprehensive insurance coverage and for the actual or estimated
1035	administrative expenses;
1036	2.3.Arrange for the collection of any voluntary
1037	contributions to provide for payment of premiums for coverage
1038	under the Florida Kidcare program forchildren who are not
1039	eligible for medical assistance under Title XXI of the Social
1040	Security Act for the Agency for Health Care Administration. Each
1041	fiscal year, the corporation shall establish a local match
1042	policy for the enrollment of non-Title-XXI-eligible children in
1043	the Healthy Kids program. By May 1 of each year, the corporation
1044	shall provide written notification of the amount to be remitted
1045	to the Agency for Health Care Administrationcorporationfor the
1046	following fiscal year under that policy. Local match sources may
1047	include, but are not limited to, funds provided by
1048	municipalities, counties, school boards, hospitals, health care
1049	providers, charitable organizations, special taxing districts,
1050	and private organizations. The minimum local match cash
1051	contributions required each fiscal year and local match credits
1052	shall be determined by the General Appropriations Act. The
1053	corporation shall calculate a county's local match rate based
1054	upon that county's percentage of the state's total non-Title-XXI
1055	expenditures as reported in the corporation's most recently
1056	audited financial statement. In awarding the local match
1057	credits, the corporation may consider factors including, but not
1058	limited to, population density, per capita income, and existing
1059	child-health-related expenditures and services;
1060	3.4. Accept for the Agency for Health Care Administration
1061	voluntary supplemental local match contributions that comply
1062	with the requirements of Title XXI of the Social Security Act
1063	for the purpose of providing additional coverage in contributing
1064	counties under Title XXI that shall be remitted to the Agency
1065	for Health Care Administration within 1 week after receipt;
1066	4.5.Establish the administrative and accounting
1067	procedures for the operation of the corporation;
1068	6. Establish, with consultation from appropriate
1069	professional organizations, standards for preventive health
1070	services and providers and comprehensive insurance benefits
1071	appropriate to children; provided that such standards for rural
1072	areas shall not limit primary care providers to board-certified
1073	pediatricians;
1074	7. Establish eligibility criteria which children must meet
1075	in order to participate in the program;
1076	8. Establish procedures under which providers of local
1077	match to, applicants to and participants in the program may have
1078	grievances reviewed by an impartial body and reported to the
1079	board of directors of the corporation;
1080	9. Establish participation criteria and, if appropriate,
1081	contract with an authorized insurer, health maintenance
1082	organization, or insurance administrator to provide
1083	administrative services to the corporation;
1084	10. Establish enrollment criteria which shall include
1085	penalties or waiting periods of not fewer than 60 days for
1086	reinstatement of coverage upon voluntary cancellation for
1087	nonpayment of family premiums;
1088	5.11.If a space is available, establish a special open
1089	enrollment period of 30 days' duration for any child who is
1090	enrolled in Medicaid or Medikids if such child loses Medicaid or
1091	Medikids eligibility and becomes eligible for the Florida
1092	Healthy Kids program;
1093	12. Contract with authorized insurers or any provider of
1094	health care services, meeting standards established by the
1095	corporation, for the provision of comprehensive insurance
1096	coverage to participants. Such standards shall include criteria
1097	under which the corporation may contract with more than one
1098	provider of health care services in program sites. Health plans
1099	shall be selected through a competitive bid process. The
1100	selection of health plans shall be based primarily on quality
1101	criteria established by the board. The health plan selection
1102	criteria and scoring system, and the scoring results, shall be
1103	available upon request for inspection after the bids have been
1104	awarded;
1105	13. Establish disenrollment criteria in the event local
1106	matching funds are insufficient to cover enrollments;
1107	6.14.Develop and implement a plan to publicize the
1108	Florida Healthy Kids Corporation, the eligibility requirements
1109	of the program, and the procedures for enrollment in the program
1110	and to maintain public awareness of the corporation and the
1111	program;
1112	7.15.Secure staff necessary to properly administer the
1113	corporation. Staff costs shall be funded from state and local
1114	matching funds and such other private or public funds as become
1115	available. The board of directors shall determine the number of
1116	staff members necessary to administer the corporation;
1117	8.16.As appropriate, enter into contracts with local
1118	school boards or other agencies to provide onsite information,
1119	enrollment, and other services necessary to the operation of the
1120	corporation;
1121	17. Provide a report annually to the Governor, Chief
1122	Financial Officer, Commissioner of Education, Senate President,
1123	Speaker of the House of Representatives, and Minority Leaders of
1124	the Senate and the House of Representatives;
1125	18. Each fiscal year, establish a maximum number of
1126	participants, on a statewide basis, who may enroll in the
1127	program; and
1128	19. Establish eligibility criteria, premium and cost-
1129	sharing requirements, and benefit packages which conform to the
1130	provisions of the Florida Kidcare program, as created in ss.
1131	409.810-409.820.
1132	(c) Coverage under the corporation's program is secondary
1133	to any other available private coverage held by the participant
1134	child or family member. The corporation may establish procedures
1135	for coordinating benefits under this program with benefits under
1136	other public and private coverage.
1137	(c)(d)The Florida Healthy Kids Corporation shall be a
1138	private corporation not for profit, organized pursuant to
1139	chapter 617, and shall have all powers necessary to carry out
1140	the purposes of this act, including, but not limited to, the
1141	power to receive and accept grants, loans, or advances of funds
1142	from any public or private agency and to receive and accept from
1143	any source contributions of money, property, labor, or any other
1144	thing of value, to be held, used, and applied for the purposes
1145	of this act.
1146	(5) BOARD OF DIRECTORS.--
1147	(a) The Florida Healthy Kids Corporation shall operate
1148	subject to the supervision and approval of a board of directors
1149	chaired by the Secretary of the Agency for Health Care
1150	AdministrationChief Financial Officeror her or his designee,
1151	and composed of 1014other members selected for 3-year terms of
1152	office as follows:
1153	1. The Chief Financial Officer or his or her designee.One
1154	member appointed by the Commissioner of Education from among
1155	three persons nominated by the Florida Association of School
1156	Administrators;
1157	2. One member appointed by the Commissioner of Education
1158	from among three persons nominated by the Florida Association of
1159	School Boards;
1160	2.3.One member appointed by the Commissioner of Education
1161	from the Office of School Health Programs of the Florida
1162	Department of Education.;
1163	3.4.One member appointed by the Governor from among three
1164	members nominated by the Florida Pediatric Society.;
1165	4.5.One member, appointed by the Governor, who represents
1166	the Children's Medical Services Program.;
1167	5.6. One member appointed by the GovernorChief Financial
1168	Officerfrom among three members nominated by the Florida
1169	Hospital Association.;
1170	7. Two members, appointed by the Chief Financial Officer,
1171	who are representatives of authorized health care insurers or
1172	health maintenance organizations;
1173	6.8. One member, appointed by the Board of GovernorsChief
1174	Financial Officer, who is knowledgeable aboutrepresents the
1175	Institute for child health policy.;
1176	7.9.One member, appointed by the Governor, from among
1177	three members nominated by the Florida Academy of Family
1178	Physicians.;
1179	8.10.One member, appointed by the Governor, who
1180	represents the state Medicaid program.Agency for Health Care
1181	Administration;
1182	11. One member, appointed by the Chief Financial Officer,
1183	from among three members nominated by the Florida Association of
1184	Counties, representing rural counties;
1185	9.12.One member, appointed by the Governor, from among
1186	three members nominated by the Florida Association of Counties.,
1187	representing urban counties; and
1188	10.13.The State Health Officer or her or his designee.
1189	(b) A member of the board of directors may be removed by
1190	the official who appointed that member. The board shall appoint
1191	an executive director, who is responsible for other staff
1192	authorized by the board.
1193	(c) Board members are entitled to receive, from funds of
1194	the corporation, reimbursement for per diem and travel expenses
1195	as provided by s. 112.061.
1196	(d) There shall be no liability on the part of, and no
1197	cause of action shall arise against, any member of the board of
1198	directors, or its employees or agents, for any action they take
1199	in the performance of their powers and duties under this act.
1200	(6) LICENSING NOT REQUIRED; FISCAL OPERATION.--
1201	(a) The corporation shall not be deemed an insurer. The
1202	officers, directors, and employees of the corporation shall not
1203	be deemed to be agents of an insurer. Neither the corporation
1204	nor any officer, director, or employee of the corporation is
1205	subject to the licensing requirements of the insurance code or
1206	the rules of the Department of Financial Services. However, any
1207	marketing representative utilized and compensated by the
1208	corporation must be appointed as a representative of the
1209	insurers or health services providers with which the corporation
1210	contracts.
1211	(b) The board has complete fiscal control over the
1212	corporation and is responsible for all corporate operations.
1213	(c) The Department of Financial Services shall supervise
1214	any liquidation or dissolution of the corporation and shall
1215	have, with respect to such liquidation or dissolution, all power
1216	granted to it pursuant to the insurance code.
1217	(7) ACCESS TO RECORDS; CONFIDENTIALITY;
1218	PENALTIES.--Notwithstanding any other laws to the contrary, the
1219	Florida Healthy Kids Corporation shall have access to the
1220	medical records of a student upon receipt of permission from a
1221	parent or guardian of the student. Such medical records may be
1222	maintained by state and local agencies. Any identifying
1223	information, including medical records and family financial
1224	information, obtained by the corporation pursuant to this
1225	subsection is confidential and is exempt from the provisions of
1226	s. 119.07(1). Neither the corporation nor the staff or agents of
1227	the corporation may release, without the written consent of the
1228	participant or the parent or guardian of the participant, to any
1229	state or federal agency, to any private business or person, or
1230	to any other entity, any confidential information received
1231	pursuant to this subsection. A violation of this subsection is a
1232	misdemeanor of the second degree, punishable as provided in s.
1233	775.082 or s. 775.083.
1234	Section 15. Section 624.915, Florida Statutes, is
1235	renumbered as section 409.822, Florida Statutes, and amended to
1236	read:
1237	409.822624.915Florida Healthy Kids Corporation;
1238	operating fund.--The Florida Healthy Kids Corporation may
1239	establish and manage an operating fund for the purposes of
1240	addressing the corporation's unique cash-flow needs and
1241	facilitating the fiscal management of the corporation. The
1242	corporation may accumulate and maintain in the operating fund at
1243	any given time a cash balance reserve equal to no more than 25
1244	percent of its annualized operating expenses. Effective July 15,
1245	2003, the operating fund shall be terminated and all remaining
1246	cash balance shall be remitted to the Agency for Health Care
1247	Administration for use in funding the Florida Kidcare program.
1248	Upon dissolution of the corporation, any remaining cash balances
1249	of state funds shall revert to the General Revenue Fund, or such
1250	other state funds consistent with the appropriated funding, as
1251	provided by law.
1252	Section 16. Section 409.821, Florida Statutes, is
1253	renumbered as section 409.823, Florida Statutes, and amended to
1254	read:
1255	409.823409.821 Sections 409.810-409.822409.810-409.820;
1256	confidential information.--Notwithstanding any other law to the
1257	contrary, any information contained in an application for
1258	determination of eligibility for the Florida Kidcare program
1259	which identifies applicants, including medical information and
1260	family financial information, and any information obtained
1261	through quality assurance activities and patient satisfaction
1262	surveys which identifies program participants, obtained by the
1263	Florida Kidcare program under ss. 409.810-409.822409.810-
1264	409.820, is confidential and is exempt from s. 119.07(1) and s.
1265	24(a), Art. I of the State Constitution. Except as otherwise
1266	provided by law, program staff or staff or agents affiliated
1267	with the program may not release, without the written consent of
1268	the applicant or the parent or guardian of the applicant, to any
1269	state or federal agency, to any private business or person, or
1270	to any other entity, any confidential information received under
1271	ss. 409.810-409.822409.810-409.820. This section is subject to
1272	the Open Government Sunset Review Act of 1995 in accordance with
1273	s. 119.15, and shall stand repealed on October 2, 2003, unless
1274	reviewed and saved from repeal through reenactment by the
1275	Legislature.
1276	Section 17. Subsection (2) of section 409.904, Florida
1277	Statutes, is amended to read:
1278	409.904 Optional payments for eligible persons.--The
1279	agency may make payments for medical assistance and related
1280	services on behalf of the following persons who are determined
1281	to be eligible subject to the income, assets, and categorical
1282	eligibility tests set forth in federal and state law. Payment on
1283	behalf of these Medicaid eligible persons is subject to the
1284	availability of moneys and any limitations established by the
1285	General Appropriations Act or chapter 216.
1286	(2) A caretaker relative or parent, a pregnant woman, a
1287	child under age 19 who would otherwise qualify for Florida
1288	Kidcare Medicaid, a child up to age 21 who would otherwise
1289	qualify under s. 409.903(1), a person age 65 or over, or a blind
1290	or disabled person, who would otherwise be eligible for Florida
1291	Medicaid, except that the income or assets of such family or
1292	person exceed established limitations. For a family or person in
1293	one of these coverage groups, medical expenses are deductible
1294	from income in accordance with federal requirements in order to
1295	make a determination of eligibility. Expenses used to meet
1296	spend-down liability are not reimbursable by Medicaid. Effective
1297	May 1, 2003, When determining the eligibility of ana pregnant
1298	woman, a child, or an aged, blind, or disabledindividual, $270
1299	shall be deducted from the countable income of the filing unit.
1300	When determining the eligibility of the parent or caretaker
1301	relative as defined by Title XIX of the Social Security Act, the
1302	additional income disregard of $270 does not apply.A family or
1303	person eligible under the coverage known as the "medically
1304	needy," is eligible to receive the same services as other
1305	Medicaid recipients, with the exception of services in skilled
1306	nursing facilities and intermediate care facilities for the
1307	developmentally disabled.
1308	Section 18. Subsections (1), (12), and (23) of section
1309	409.906, Florida Statutes, are amended to read:
1310	409.906 Optional Medicaid services.--Subject to specific
1311	appropriations, the agency may make payments for services which
1312	are optional to the state under Title XIX of the Social Security
1313	Act and are furnished by Medicaid providers to recipients who
1314	are determined to be eligible on the dates on which the services
1315	were provided. Any optional service that is provided shall be
1316	provided only when medically necessary and in accordance with
1317	state and federal law. Optional services rendered by providers
1318	in mobile units to Medicaid recipients may be restricted or
1319	prohibited by the agency. Nothing in this section shall be
1320	construed to prevent or limit the agency from adjusting fees,
1321	reimbursement rates, lengths of stay, number of visits, or
1322	number of services, or making any other adjustments necessary to
1323	comply with the availability of moneys and any limitations or
1324	directions provided for in the General Appropriations Act or
1325	chapter 216. If necessary to safeguard the state's systems of
1326	providing services to elderly and disabled persons and subject
1327	to the notice and review provisions of s. 216.177, the Governor
1328	may direct the Agency for Health Care Administration to amend
1329	the Medicaid state plan to delete the optional Medicaid service
1330	known as "Intermediate Care Facilities for the Developmentally
1331	Disabled." Optional services may include:
1332	(1) ADULT DENTAL SERVICES.--The agency may pay for
1333	dentures, the procedures required to seat dentures, and the
1334	repair and reline of dentures, provided by or under the
1335	direction of a licensed dentist, for a recipient who is age 65
1336	or oldermedically necessary, emergency dental procedures to
1337	alleviate pain or infection. Emergency dental care shall be
1338	limited to emergency oral examinations, necessary radiographs,
1339	extractions, and incision and drainage of abscess, for a
1340	recipient who is age 21 or older. However, Medicaid will not
1341	provide reimbursement for dental services provided in a mobile
1342	dental unit, except for a mobile dental unit:
1343	(a) Owned by, operated by, or having a contractual
1344	agreement with the Department of Health and complying with
1345	Medicaid's county health department clinic services program
1346	specifications as a county health department clinic services
1347	provider.
1348	(b) Owned by, operated by, or having a contractual
1349	arrangement with a federally qualified health center and
1350	complying with Medicaid's federally qualified health center
1351	specifications as a federally qualified health center provider.
1352	(c) Rendering dental services to Medicaid recipients, 21
1353	years of age and older, at nursing facilities.
1354	(d) Owned by, operated by, or having a contractual
1355	agreement with a state-approved dental educational institution.
1356	(12) CHILDREN'SHEARING SERVICES.--The agency may pay for
1357	hearing and related services, including hearing evaluations,
1358	hearing aid devices, dispensing of the hearing aid, and related
1359	repairs, if provided to a recipient younger than 21 years of age
1360	by a licensed hearing aid specialist, otolaryngologist,
1361	otologist, audiologist, or physician.
1362	(23) CHILDREN'SVISUAL SERVICES.--The agency may pay for
1363	visual examinations, eyeglasses, and eyeglass repairs for a
1364	recipient younger than 21 years of age, if they are prescribed
1365	by a licensed physician specializing in diseases of the eye or
1366	by a licensed optometrist.
1367	Section 19. Subsection (1) of section 409.9081, Florida
1368	Statutes, is amended to read:
1369	409.9081 Copayments.--
1370	(1) The agency shall require, subject to federal
1371	regulations and limitations, each Medicaid recipient to pay at
1372	the time of service a nominal copayment for the following
1373	Medicaid services:
1374	(a) Hospital outpatient services: up to $3 for each
1375	hospital outpatient visit.
1376	(b) Physician services: up to $2 copayment for each visit
1377	with a physician licensed under chapter 458, chapter 459,
1378	chapter 460, chapter 461, or chapter 463.
1379	(c) Prescribed drug services: a $2 copayment for each
1380	generic drug, $5 for each Medicaid preferred drug list product,
1381	and $15 for each non-Medicaid preferred drug list brand name
1382	drug.
1383	(d) Hospital outpatient services, emergency department: up
1384	to $15 for each hospital outpatient emergency department
1385	encounter that is for nonemergency purposes.
1386	Section 20. Section 409.911, Florida Statutes, is amended
1387	to read:
1388	409.911 Disproportionate share program.--Subject to
1389	specific allocations established within the General
1390	Appropriations Act and any limitations established pursuant to
1391	chapter 216, the agency shall distribute, pursuant to this
1392	section, moneys to hospitals providing a disproportionate share
1393	of Medicaid or charity care services by making quarterly
1394	Medicaid payments as required. Notwithstanding the provisions of
1395	s. 409.915, counties are exempt from contributing toward the
1396	cost of this special reimbursement for hospitals serving a
1397	disproportionate share of low-income patients.
1398	(1) Definitions.--As used in this section, s. 409.9112,
1399	and the Florida Hospital Uniform Reporting System manual:
1400	(a) "Adjusted patient days" means the sum of acute care
1401	patient days and intensive care patient days as reported to the
1402	Agency for Health Care Administration, divided by the ratio of
1403	inpatient revenues generated from acute, intensive, ambulatory,
1404	and ancillary patient services to gross revenues.
1405	(b) "Actual audited data" or "actual audited experience"
1406	means data reported to the Agency for Health Care Administration
1407	which has been audited in accordance with generally accepted
1408	auditing standards by the agency or representatives under
1409	contract with the agency.
1410	(c) "Base Medicaid per diem" means the hospital's Medicaid
1411	per diem rate initially established by the Agency for Health
1412	Care Administration on January 1, 1999. The base Medicaid per
1413	diem rate shall not include any additional per diem increases
1414	received as a result of the disproportionate share distribution.
1415	(c)(d)"Charity care" or "uncompensated charity care"
1416	means that portion of hospital charges reported to the Agency
1417	for Health Care Administration for which there is no
1418	compensation, other than restricted or unrestricted revenues
1419	provided to a hospital by local governments or tax districts
1420	regardless of the method of payment, for care provided to a
1421	patient whose family income for the 12 months preceding the
1422	determination is less than or equal to 200 percent of the
1423	federal poverty level, unless the amount of hospital charges due
1424	from the patient exceeds 25 percent of the annual family income.
1425	However, in no case shall the hospital charges for a patient
1426	whose family income exceeds four times the federal poverty level
1427	for a family of four be considered charity.
1428	(d)(e)"Charity care days" means the sum of the deductions
1429	from revenues for charity care minus 50 percent of restricted
1430	and unrestricted revenues provided to a hospital by local
1431	governments or tax districts, divided by gross revenues per
1432	adjusted patient day.
1433	(f) "Disproportionate share percentage" means a rate of
1434	increase in the Medicaid per diem rate as calculated under this
1435	section.
1436	(e)(g)"Hospital" means a health care institution licensed
1437	as a hospital pursuant to chapter 395, but does not include
1438	ambulatory surgical centers.
1439	(f)(h)"Medicaid days" means the number of actual days
1440	attributable to Medicaid patients as determined by the Agency
1441	for Health Care Administration.
1442	(2) The Agency for Health Care Administration shall
1443	utilize the following actual audited datacriteria to determine
1444	the Medicaid days and charity care to be used in the calculation
1445	of theif a hospital qualifies for adisproportionate share
1446	payment:
1447	(a) The Agency for Health Care Administration shall use
1448	the average of the 1997, 1998, and 1999 audited data to
1449	determine each hospital's Medicaid days and charity careA
1450	hospital's total Medicaid days when combined with its total
1451	charity care days must equal or exceed 7 percent of its total
1452	adjusted patient days.
1453	(b) In the event the Agency for Health Care Administration
1454	does not have the prescribed 3 years of audited disproportionate
1455	share data for a hospital, the Agency for Health Care
1456	Administration shall use the average of the audited
1457	disproportionate share data for the years availableA hospital's
1458	total charity care days weighted by a factor of 4.5, plus its
1459	total Medicaid days weighted by a factor of 1, shall be equal to
1460	or greater than 10 percent of its total adjusted patient days.
1461	(c) Additionally, In accordance with Section 1923(b) of
1462	the Social Security Actthe seventh federal Omnibus Budget
1463	Reconciliation Act, a hospital with a Medicaid inpatient
1464	utilization rate greater than one standard deviation above the
1465	statewide mean or a hospital with a low-income utilization rate
1466	of 25 percent or greater shall qualify for reimbursement.
1467	(3) In computing the disproportionate share rate:
1468	(a) Per diem increases earned from disproportionate share
1469	shall be applied to each hospital's base Medicaid per diem rate
1470	and shall be capped at 170 percent.
1471	(b) The agency shall use 1994 audited financial data for
1472	the calculation of disproportionate share payments under this
1473	section.
1474	(c) If the total amount earned by all hospitals under this
1475	section exceeds the amount appropriated, each hospital's share
1476	shall be reduced on a pro rata basis so that the total dollars
1477	distributed from the trust fund do not exceed the total amount
1478	appropriated.
1479	(d) The total amount calculated to be distributed under
1480	this section shall be made in quarterly payments subsequent to
1481	each quarter during the fiscal year.
1482	(3)(4)Hospitals that qualify for a disproportionate share
1483	payment solely under paragraph (2)(c) shall have their payment
1484	calculated in accordance with the following formulas:
1485
1486	DSHP = (HMD/TSMD) x $1 million
1487	TAA = TA x (1/5.5)
1488	DSHP = (HMD/TSMD) x TAA
1489
1490	Where:
1491	TAA = total amount available.
1492	TA = total appropriation.
1493	DSHP = disproportionate share hospital payment.
1494	HMD = hospital Medicaid days.
1495	TSMD = total state Medicaid days.
1496
1497	(4) The following formulas shall be used to pay
1498	disproportionate share dollars to public hospitals:
1499	(a) For state mental health hospitals:
1500
1501	DSHP = (HMD/TMDMH) x TAAMH
1502
1503	The total amount available for the state mental health hospitals
1504	shall be the difference between the federal cap for Institutions
1505	for Mental Diseases and the amounts paid under the mental health
1506	disproportionate share program.
1507
1508	Where:
1509	DSHP = disproportionate share hospital payment.
1510	HMD = hospital Medicaid days.
1511	TMDHH = total Medicaid days for state mental health
1512	hospitals.
1513	TAAMH = total amount available for mental health hospitals.
1514
1515	(b) For nonstate government owned or operated hospitals
1516	with 3,200 or more Medicaid days:
1517
1518	DSHP = [.(.82 x HCCD/TCCD) + (.18 x HMD/TMD)] x TAAPH
1519	TAAPh = TAA – TAAMH
1520
1521	Where:
1522	TAA = total available appropriation.
1523	TAAPH = total amount available for public hospitals.
1524	DSHP = disproportionate share hospital payments.
1525	TMD = total Medicaid days for public nonstate hospitals.
1526	HCCD = hospital charity care dollars.
1527	TCCD = total charity care dollars for public nonstate
1528	hospitals.
1529
1530	(c) For nonstate government owned or operated hospitals
1531	with 3,200 or more Medicaid days, a total of $400,000 shall be
1532	distributed equally among these hospitals.
1533	(5) The following formula shall be utilized by the agency
1534	to determine the maximum disproportionate share rate to be used
1535	to increase the Medicaid per diem rate for hospitals that
1536	qualify pursuant to paragraphs (2)(a) and (b):
1537	DSR = CCD MD
1538	@_@1@_@
1539	@_@2@_@
1540	Where:
1541	APD = adjusted patient days.
1542	CCD = charity care days.
1543	DSR = disproportionate share rate.
1544	MD = Medicaid days.
1545
1546	(6)(a) To calculate the total amount earned by all
1547	hospitals under this section, hospitals with a disproportionate
1548	share rate less than 50 percent shall divide their Medicaid days
1549	by four, and hospitals with a disproportionate share rate
1550	greater than or equal to 50 percent and with greater than 40,000
1551	Medicaid days shall multiply their Medicaid days by 1.5, and the
1552	following formula shall be used by the agency to calculate the
1553	total amount earned by all hospitals under this section:
1554
1555	TAE = BMPD x MD x DSP
1556
1557	Where:
1558	TAE = total amount earned.
1559	BMPD = base Medicaid per diem.
1560	MD = Medicaid days.
1561	DSP = disproportionate share percentage.
1562
1563	(5)(b)In no case shall total payments to a hospital under
1564	this section, with the exception of public nonstate facilities
1565	orstate facilities, exceed the total amount of uncompensated
1566	charity care of the hospital, as determined by the agency
1567	according to the most recent calendar year audited data
1568	available at the beginning of each state fiscal year.
1569	(7) The following criteria shall be used in determining
1570	the disproportionate share percentage:
1571	(a) If the disproportionate share rate is less than 10
1572	percent, the disproportionate share percentage is zero and there
1573	is no additional payment.
1574	(b) If the disproportionate share rate is greater than or
1575	equal to 10 percent, but less than 20 percent, then the
1576	disproportionate share percentage is 1.8478498.
1577	(c) If the disproportionate share rate is greater than or
1578	equal to 20 percent, but less than 30 percent, then the
1579	disproportionate share percentage is 3.4145488.
1580	(d) If the disproportionate share rate is greater than or
1581	equal to 30 percent, but less than 40 percent, then the
1582	disproportionate share percentage is 6.3095734.
1583	(e) If the disproportionate share rate is greater than or
1584	equal to 40 percent, but less than 50 percent, then the
1585	disproportionate share percentage is 11.6591440.
1586	(f) If the disproportionate share rate is greater than or
1587	equal to 50 percent, but less than 60 percent, then the
1588	disproportionate share percentage is 73.5642254.
1589	(g) If the disproportionate share rate is greater than or
1590	equal to 60 percent but less than 72.5 percent, then the
1591	disproportionate share percentage is 135.9356391.
1592	(h) If the disproportionate share rate is greater than or
1593	equal to 72.5 percent, then the disproportionate share
1594	percentage is 170.
1595	(8) The following formula shall be used by the agency to
1596	calculate the total amount earned by all hospitals under this
1597	section:
1598
1599	TAE = BMPD x MD x DSP
1600
1601	Where:
1602	TAE = total amount earned.
1603	BMPD = base Medicaid per diem.
1604	MD = Medicaid days.
1605	DSP = disproportionate share percentage.
1606
1607	(6)(9)The agency is authorized to receive funds from
1608	local governments and other local political subdivisions for the
1609	purpose of making payments, including federal matching funds,
1610	through the Medicaid disproportionate share program. Funds
1611	received from local governments for this purpose shall be
1612	separately accounted for and shall not be commingled with other
1613	state or local funds in any manner.
1614	(7)(10)Payments made by the agency to hospitals eligible
1615	to participate in this program shall be made in accordance with
1616	federal rules and regulations.
1617	(a) If the Federal Government prohibits, restricts, or
1618	changes in any manner the methods by which funds are distributed
1619	for this program, the agency shall not distribute any additional
1620	funds and shall return all funds to the local government from
1621	which the funds were received, except as provided in paragraph
1622	(b).
1623	(b) If the Federal Government imposes a restriction that
1624	still permits a partial or different distribution, the agency
1625	may continue to disburse funds to hospitals participating in the
1626	disproportionate share program in a federally approved manner,
1627	provided:
1628	1. Each local government which contributes to the
1629	disproportionate share program agrees to the new manner of
1630	distribution as shown by a written document signed by the
1631	governing authority of each local government; and
1632	2. The Executive Office of the Governor, the Office of
1633	Planning and Budgeting, the House of Representatives, and the
1634	Senate are provided at least 7 days' prior notice of the
1635	proposed change in the distribution, and do not disapprove such
1636	change.
1637	(c) No distribution shall be made under the alternative
1638	method specified in paragraph (b) unless all parties agree or
1639	unless all funds of those parties that disagree which are not
1640	yet disbursed have been returned to those parties.
1641	(8)(11)Notwithstanding the provisions of chapter 216, the
1642	Executive Office of the Governor is hereby authorized to
1643	establish sufficient trust fund authority to implement the
1644	disproportionate share program.
1645	Section 21. Section 409.9112, Florida Statutes, is amended
1646	to read:
1647	409.9112 Disproportionate share program for regional
1648	perinatal intensive care centers.--In addition to the payments
1649	made under s. 409.911, the Agency for Health Care Administration
1650	shall design and implement a system of making disproportionate
1651	share payments to those hospitals that participate in the
1652	regional perinatal intensive care center program established
1653	pursuant to chapter 383. This system of payments shall conform
1654	with federal requirements and shall distribute funds in each
1655	fiscal year for which an appropriation is made by making
1656	quarterly Medicaid payments. Notwithstanding the provisions of
1657	s. 409.915, counties are exempt from contributing toward the
1658	cost of this special reimbursement for hospitals serving a
1659	disproportionate share of low-income patients.
1660	(1) The following formula shall be used by the agency to
1661	calculate the total amount earned for hospitals that participate
1662	in the regional perinatal intensive care center program:
1663
1664	TAE = HDSP/THDSP
1665
1666	Where:
1667	TAE = total amount earned by a regional perinatal intensive
1668	care center.
1669	HDSP = the prior state fiscal year regional perinatal
1670	intensive care center disproportionate share payment to the
1671	individual hospital.
1672	THDSP = the prior state fiscal year total regional
1673	perinatal intensive care center disproportionate share payments
1674	to all hospitals.
1675	(2) The total additional payment for hospitals that
1676	participate in the regional perinatal intensive care center
1677	program shall be calculated by the agency as follows:
1678
1679	TAP = TAE x TA
1680
1681	Where:
1682	TAP = total additional payment for a regional perinatal
1683	intensive care center.
1684	TAE = total amount earned by a regional perinatal intensive
1685	care center.
1686	TA = total appropriation for the regional perinatal
1687	intensive care center disproportionate share program.
1688
1689	TAE = DSR x BMPD x MD
1690
1691	Where:
1692	TAE = total amount earned by a regional perinatal intensive
1693	care center.
1694	DSR = disproportionate share rate.
1695	BMPD = base Medicaid per diem.
1696	MD = Medicaid days.
1697
1698	(2) The total additional payment for hospitals that
1699	participate in the regional perinatal intensive care center
1700	program shall be calculated by the agency as follows:
1701	TAP = TAE x TA
1702	@_@4@_@
1703	@_@5@_@
1704	Where:
1705	TAP = total additional payment for a regional perinatal
1706	intensive care center.
1707	TAE = total amount earned by a regional perinatal intensive
1708	care center.
1709	STAE = sum of total amount earned by each hospital that
1710	participates in the regional perinatal intensive care center
1711	program.
1712	TA = total appropriation for the regional perinatal
1713	intensive care disproportionate share program.
1714
1715	(3) In order to receive payments under this section, a
1716	hospital must be participating in the regional perinatal
1717	intensive care center program pursuant to chapter 383 and must
1718	meet the following additional requirements:
1719	(a) Agree to conform to all departmental and agency
1720	requirements to ensure high quality in the provision of
1721	services, including criteria adopted by departmental and agency
1722	rule concerning staffing ratios, medical records, standards of
1723	care, equipment, space, and such other standards and criteria as
1724	the department and agency deem appropriate as specified by rule.
1725	(b) Agree to provide information to the department and
1726	agency, in a form and manner to be prescribed by rule of the
1727	department and agency, concerning the care provided to all
1728	patients in neonatal intensive care centers and high-risk
1729	maternity care.
1730	(c) Agree to accept all patients for neonatal intensive
1731	care and high-risk maternity care, regardless of ability to pay,
1732	on a functional space-available basis.
1733	(d) Agree to develop arrangements with other maternity and
1734	neonatal care providers in the hospital's region for the
1735	appropriate receipt and transfer of patients in need of
1736	specialized maternity and neonatal intensive care services.
1737	(e) Agree to establish and provide a developmental
1738	evaluation and services program for certain high-risk neonates,
1739	as prescribed and defined by rule of the department.
1740	(f) Agree to sponsor a program of continuing education in
1741	perinatal care for health care professionals within the region
1742	of the hospital, as specified by rule.
1743	(g) Agree to provide backup and referral services to the
1744	department's county health departments and other low-income
1745	perinatal providers within the hospital's region, including the
1746	development of written agreements between these organizations
1747	and the hospital.
1748	(h) Agree to arrange for transportation for high-risk
1749	obstetrical patients and neonates in need of transfer from the
1750	community to the hospital or from the hospital to another more
1751	appropriate facility.
1752	(4) Hospitals which fail to comply with any of the
1753	conditions in subsection (3) or the applicable rules of the
1754	department and agency shall not receive any payments under this
1755	section until full compliance is achieved. A hospital which is
1756	not in compliance in two or more consecutive quarters shall not
1757	receive its share of the funds. Any forfeited funds shall be
1758	distributed by the remaining participating regional perinatal
1759	intensive care center program hospitals.
1760	Section 22. Section 409.9117, Florida Statutes, is amended
1761	to read:
1762	409.9117 Primary care disproportionate share program.--
1763	(1) If federal funds are available for disproportionate
1764	share programs in addition to those otherwise provided by law,
1765	there shall be created a primary care disproportionate share
1766	program.
1767	(2) The following formula shall be used by the agency to
1768	calculate the total amount earned for hospitals that participate
1769	in the primary care disproportionate share program:
1770
1771	TAE = HDSP/THDSP
1772
1773	Where:
1774	TAE = total amount earned by a hospital participating in
1775	the primary care disproportionate share program.
1776	HDSP = the prior state fiscal year primary care
1777	disproportionate share payment to the individual hospital.
1778	THDSP = the prior state fiscal year to primary care
1779	disproportionate share payments to all hospitals.
1780	(3) The total additional payment for hospitals that
1781	participate in the primary care disproportionate share program
1782	shall be calculated by the agency as follows:
1783
1784	TAP = TAE x TA
1785
1786	Where:
1787	TAP = total additional payment for a primary care hospital.
1788	TAE = total amount earned by a primary care hospital.
1789	TA = total appropriation for the primary care
1790	disproportionate share program.
1791	(4)(2)In the establishment and funding of this program,
1792	the agency shall use the following criteria in addition to those
1793	specified in s. 409.911, payments may not be made to a hospital
1794	unless the hospital agrees to:
1795	(a) Cooperate with a Medicaid prepaid health plan, if one
1796	exists in the community.
1797	(b) Ensure the availability of primary and specialty care
1798	physicians to Medicaid recipients who are not enrolled in a
1799	prepaid capitated arrangement and who are in need of access to
1800	such physicians.
1801	(c) Coordinate and provide primary care services free of
1802	charge, except copayments, to all persons with incomes up to 100
1803	percent of the federal poverty level who are not otherwise
1804	covered by Medicaid or another program administered by a
1805	governmental entity, and to provide such services based on a
1806	sliding fee scale to all persons with incomes up to 200 percent
1807	of the federal poverty level who are not otherwise covered by
1808	Medicaid or another program administered by a governmental
1809	entity, except that eligibility may be limited to persons who
1810	reside within a more limited area, as agreed to by the agency
1811	and the hospital.
1812	(d) Contract with any federally qualified health center,
1813	if one exists within the agreed geopolitical boundaries,
1814	concerning the provision of primary care services, in order to
1815	guarantee delivery of services in a nonduplicative fashion, and
1816	to provide for referral arrangements, privileges, and
1817	admissions, as appropriate. The hospital shall agree to provide
1818	at an onsite or offsite facility primary care services within 24
1819	hours to which all Medicaid recipients and persons eligible
1820	under this paragraph who do not require emergency room services
1821	are referred during normal daylight hours.
1822	(e) Cooperate with the agency, the county, and other
1823	entities to ensure the provision of certain public health
1824	services, case management, referral and acceptance of patients,
1825	and sharing of epidemiological data, as the agency and the
1826	hospital find mutually necessary and desirable to promote and
1827	protect the public health within the agreed geopolitical
1828	boundaries.
1829	(f) In cooperation with the county in which the hospital
1830	resides, develop a low-cost, outpatient, prepaid health care
1831	program to persons who are not eligible for the Medicaid
1832	program, and who reside within the area.
1833	(g) Provide inpatient services to residents within the
1834	area who are not eligible for Medicaid or Medicare, and who do
1835	not have private health insurance, regardless of ability to pay,
1836	on the basis of available space, except that nothing shall
1837	prevent the hospital from establishing bill collection programs
1838	based on ability to pay.
1839	(h) Work with the Florida Healthy Kids Corporation, the
1840	Florida Health Care Purchasing Cooperative, and business health
1841	coalitions, as appropriate, to develop a feasibility study and
1842	plan to provide a low-cost comprehensive health insurance plan
1843	to persons who reside within the area and who do not have access
1844	to such a plan.
1845	(i) Work with public health officials and other experts to
1846	provide community health education and prevention activities
1847	designed to promote healthy lifestyles and appropriate use of
1848	health services.
1849	(j) Work with the local health council to develop a plan
1850	for promoting access to affordable health care services for all
1851	persons who reside within the area, including, but not limited
1852	to, public health services, primary care services, inpatient
1853	services, and affordable health insurance generally.
1854
1855	Any hospital that fails to comply with any of the provisions of
1856	this subsection, or any other contractual condition, may not
1857	receive payments under this section until full compliance is
1858	achieved.
1859	Section 23. Section 409.9119, Florida Statutes, is amended
1860	to read:
1861	409.9119 Disproportionate share program for specialty
1862	hospitals for children.--In addition to the payments made under
1863	s. 409.911, the Agency for Health Care Administration shall
1864	develop and implement a system under which disproportionate
1865	share payments are made to those hospitals that are licensed by
1866	the state as specialty hospitals for children and were licensed
1867	on January 1, 2000, as specialty hospitals for children. This
1868	system of payments must conform to federal requirements and must
1869	distribute funds in each fiscal year for which an appropriation
1870	is made by making quarterly Medicaid payments. Notwithstanding
1871	s. 409.915, counties are exempt from contributing toward the
1872	cost of this special reimbursement for hospitals that serve a
1873	disproportionate share of low-income patients. Payments are
1874	subject to specific appropriations in the General Appropriations
1875	Act.
1876	(1) The agency shall use the following formula to
1877	calculate the total amount earned for hospitals that participate
1878	in the specialty hospital for children disproportionate share
1879	program:
1880
1881	TAE = DSR x BMPD x MD
1882
1883	Where:
1884	TAE = total amount earned by a specialty hospital for
1885	children.
1886	DSR = disproportionate share rate.
1887	BMPD = base Medicaid per diem.
1888	MD = Medicaid days.
1889	(2) The agency shall calculate the total additional
1890	payment for hospitals that participate in the specialty hospital
1891	for children disproportionate share program as follows:
1892	TAP = TAE x TA
1893	(---------------)
1894	STAE
1895	Where:
1896	TAP = total additional payment for a specialty hospital for
1897	children.
1898	TAE = total amount earned by a specialty hospital for
1899	children.
1900	TA = total appropriation for the specialty hospital for
1901	children disproportionate share program.
1902	STAE = sum of total amount earned by each hospital that
1903	participates in the specialty hospital for children
1904	disproportionate share program.
1905
1906	(3) A hospital may not receive any payments under this
1907	section until it achieves full compliance with the applicable
1908	rules of the agency. A hospital that is not in compliance for
1909	two or more consecutive quarters may not receive its share of
1910	the funds. Any forfeited funds must be distributed to the
1911	remaining participating specialty hospitals for children that
1912	are in compliance.
1913	Section 24. Subsection (3) of section 409.912, Florida
1914	Statutes, is amended, and subsection (41) is added to said
1915	section, to read:
1916	409.912 Cost-effective purchasing of health care.--The
1917	agency shall purchase goods and services for Medicaid recipients
1918	in the most cost-effective manner consistent with the delivery
1919	of quality medical care. The agency shall maximize the use of
1920	prepaid per capita and prepaid aggregate fixed-sum basis
1921	services when appropriate and other alternative service delivery
1922	and reimbursement methodologies, including competitive bidding
1923	pursuant to s. 287.057, designed to facilitate the cost-
1924	effective purchase of a case-managed continuum of care. The
1925	agency shall also require providers to minimize the exposure of
1926	recipients to the need for acute inpatient, custodial, and other
1927	institutional care and the inappropriate or unnecessary use of
1928	high-cost services. The agency may establish prior authorization
1929	requirements for certain populations of Medicaid beneficiaries,
1930	certain drug classes, or particular drugs to prevent fraud,
1931	abuse, overuse, and possible dangerous drug interactions. The
1932	Pharmaceutical and Therapeutics Committee shall make
1933	recommendations to the agency on drugs for which prior
1934	authorization is required. The agency shall inform the
1935	Pharmaceutical and Therapeutics Committee of its decisions
1936	regarding drugs subject to prior authorization.
1937	(3) The agency may contract with:
1938	(a) An entity that provides no prepaid health care
1939	services other than Medicaid services under contract with the
1940	agency and which is owned and operated by a county, county
1941	health department, or county-owned and operated hospital to
1942	provide health care services on a prepaid or fixed-sum basis to
1943	recipients, which entity may provide such prepaid services
1944	either directly or through arrangements with other providers.
1945	Such prepaid health care services entities must be licensed
1946	under parts I and III by January 1, 1998, and until then are
1947	exempt from the provisions of part I of chapter 641. An entity
1948	recognized under this paragraph which demonstrates to the
1949	satisfaction of the Department of Insurance that it is backed by
1950	the full faith and credit of the county in which it is located
1951	may be exempted from s. 641.225.
1952	(b) An entity that is providing comprehensive behavioral
1953	health care services to certain Medicaid recipients through a
1954	capitated, prepaid arrangement pursuant to the federal waiver
1955	provided for by s. 409.905(5). Such an entity must be licensed
1956	under chapter 624, chapter 636, or chapter 641 and must possess
1957	the clinical systems and operational competence to manage risk
1958	and provide comprehensive behavioral health care to Medicaid
1959	recipients. As used in this paragraph, the term "comprehensive
1960	behavioral health care services" means covered mental health and
1961	substance abuse treatment services that are available to
1962	Medicaid recipients. The secretary of the Department of Children
1963	and Family Services shall approve provisions of procurements
1964	related to children in the department's care or custody prior to
1965	enrolling such children in a prepaid behavioral health plan. Any
1966	contract awarded under this paragraph must be competitively
1967	procured. In developing the behavioral health care prepaid plan
1968	procurement document, the agency shall ensure that the
1969	procurement document requires the contractor to develop and
1970	implement a plan to ensure compliance with s. 394.4574 related
1971	to services provided to residents of licensed assisted living
1972	facilities that hold a limited mental health license. The agency
1973	must ensure that Medicaid recipients are offered a choice of
1974	behavioral health care providers within the managed care plan.
1975	The agency may seek and implement federal waivers to allow the
1976	state to require certain Medicaid recipients to be assigned to a
1977	single prepaid mental health plan for comprehensive behavioral
1978	health care services with the provision that individuals will
1979	have a choice of providers and the provider network meets the
1980	agency's specificationshave available the choice of at least
1981	two managed care plans for their behavioral health care
1982	services. To ensure unimpaired access to behavioral health care
1983	services by Medicaid recipients, all contracts issued pursuant
1984	to this paragraph shall require 80 percent of the capitation
1985	paid to the managed care plan, including health maintenance
1986	organizations, to be expended for the provision of behavioral
1987	health care services. In the event the managed care plan expends
1988	less than 80 percent of the capitation paid pursuant to this
1989	paragraph for the provision of behavioral health care services,
1990	the difference shall be returned to the agency. The agency shall
1991	provide the managed care plan with a certification letter
1992	indicating the amount of capitation paid during each calendar
1993	year for the provision of behavioral health care services
1994	pursuant to this section. The agency may reimburse for
1995	substance-abuse-treatment services on a fee-for-service basis
1996	until the agency finds that adequate funds are available for
1997	capitated, prepaid arrangements.
1998	1. The agency may contract for prepaid behavioral health
1999	services anywhere in the state if it has determined, in
2000	consultation with the Department of Children and Families, that
2001	a geographic area is prepared for a prepaid, capitated
2002	behavioral health system of careBy January 1, 2001, the agency
2003	shall modify the contracts with the entities providing
2004	comprehensive inpatient and outpatient mental health care
2005	services to Medicaid recipients in Hillsborough, Highlands,
2006	Hardee, Manatee, and Polk Counties, to include substance-abuse-
2007	treatment services.
2008	2. By December 31, 2001, the agency shall contract with
2009	entities providing comprehensive behavioral health care services
2010	to Medicaid recipients through capitated, prepaid arrangements
2011	in Charlotte, Collier, DeSoto, Escambia, Glades, Hendry, Lee,
2012	Okaloosa, Pasco, Pinellas, Santa Rosa, Sarasota, and Walton
2013	Counties. The agency may contract with entities providing
2014	comprehensive behavioral health care services to Medicaid
2015	recipients through capitated, prepaid arrangements in Alachua
2016	County. The agency may determine if Sarasota County shall be
2017	included as a separate catchment area or included in any other
2018	agency geographic area.
2019	2.3.Children residing in a Department of Juvenile Justice
2020	residential program approved as a Medicaid behavioral health
2021	overlay services provider shall not be included in a behavioral
2022	health care prepaid health plan pursuant to this paragraph.
2023	3.4.In converting to a prepaid system of delivery, the
2024	agency shall in its procurement document require an entity
2025	providing comprehensive behavioral health care services to
2026	prevent the displacement of indigent care patients by enrollees
2027	in the Medicaid prepaid health plan providing behavioral health
2028	care services from facilities receiving state funding to provide
2029	indigent behavioral health care, to facilities licensed under
2030	chapter 395 which do not receive state funding for indigent
2031	behavioral health care, or reimburse the unsubsidized facility
2032	for the cost of behavioral health care provided to the displaced
2033	indigent care patient.
2034	4.5.Traditional community mental health providers under
2035	contract with the Department of Children and Family Services
2036	pursuant to part IV of chapter 394 and inpatient mental health
2037	providers licensed pursuant to chapter 395 must be offered an
2038	opportunity to accept or decline a contract to participate in
2039	any provider network for prepaid behavioral health services.
2040	(c) A federally qualified health center or an entity owned
2041	by one or more federally qualified health centers or an entity
2042	owned by other migrant and community health centers receiving
2043	non-Medicaid financial support from the Federal Government to
2044	provide health care services on a prepaid or fixed-sum basis to
2045	recipients. Such prepaid health care services entity must be
2046	licensed under parts I and III of chapter 641, but shall be
2047	prohibited from serving Medicaid recipients on a prepaid basis,
2048	until such licensure has been obtained. However, such an entity
2049	is exempt from s. 641.225 if the entity meets the requirements
2050	specified in subsections (14) and (15).
2051	(d) A provider networkNo more than four provider service
2052	networks for demonstration projects to test Medicaid direct
2053	contracting. The demonstration projectsmay be reimbursed on a
2054	fee-for-service or prepaid basis. A provider service network
2055	which is reimbursed by the agency on a prepaid basis shall be
2056	exempt from parts I and III of chapter 641, but must meet
2057	appropriate financial reserve, quality assurance, and patient
2058	rights requirements as established by the agency. The agency
2059	shall award contracts on a competitive bid basis and shall
2060	select bidders based upon price and quality of care. Medicaid
2061	recipients assigned to a demonstration project shall be chosen
2062	equally from those who would otherwise have been assigned to
2063	prepaid plans and MediPass.The agency is authorized to seek
2064	federal Medicaid waivers as necessary to implement the
2065	provisions of this section. A demonstration project awarded
2066	pursuant to this paragraph shall be for 4 years from the date of
2067	implementation.
2068	(e) An entity that provides comprehensive behavioral
2069	health care services to certain Medicaid recipients through an
2070	administrative services organization agreement. Such an entity
2071	must possess the clinical systems and operational competence to
2072	provide comprehensive health care to Medicaid recipients. As
2073	used in this paragraph, the term "comprehensive behavioral
2074	health care services" means covered mental health and substance
2075	abuse treatment services that are available to Medicaid
2076	recipients. Any contract awarded under this paragraph must be
2077	competitively procured. The agency must ensure that Medicaid
2078	recipients have available the choice of at least two managed
2079	care plans for their behavioral health care services.
2080	(f) An entity that provides in-home physician services to
2081	test the cost-effectiveness of enhanced home-based medical care
2082	to Medicaid recipients with degenerative neurological diseases
2083	and other diseases or disabling conditions associated with high
2084	costs to Medicaid. The program shall be designed to serve very
2085	disabled persons and to reduce Medicaid reimbursed costs for
2086	inpatient, outpatient, and emergency department services. The
2087	agency shall contract with vendors on a risk-sharing basis.
2088	(g) Children's or adultprovider networks that provide
2089	care coordination and care management for Medicaid-eligible
2090	pediatricpatients, primary care, authorization of specialty
2091	care, and other urgent and emergency care through organized
2092	providers designed to service Medicaid eligibles under age 18
2093	and pediatricemergency departments' diversion programs. The
2094	networks shall provide after-hour operations, including evening
2095	and weekend hours, to promote, when appropriate, the use of the
2096	children's or adultnetworks rather than hospital emergency
2097	departments.
2098	(h) An entity authorized in s. 430.205 to contract with
2099	the agency and the Department of Elderly Affairs to provide
2100	health care and social services on a prepaid or fixed-sum basis
2101	to elderly recipients. Such prepaid health care services
2102	entities are exempt from the provisions of part I of chapter 641
2103	for the first 3 years of operation. An entity recognized under
2104	this paragraph that demonstrates to the satisfaction of the
2105	Department of Insurance that it is backed by the full faith and
2106	credit of one or more counties in which it operates may be
2107	exempted from s. 641.225.
2108	(i) A Children's Medical Services network, as defined in
2109	s. 391.021.
2110	(41) The agency may contract on a prepaid or fixed-sum
2111	basis with an appropriately licensed prepaid dental health plan
2112	to provide Medicaid covered dental services to child or adult
2113	Medicaid recipients.
2114	Section 25. Subsection (2) of section 409.9122, Florida
2115	Statutes, is amended to read:
2116	409.9122 Mandatory Medicaid managed care enrollment;
2117	programs and procedures.--
2118	(2)(a) The agency shall enroll in a managed care plan or
2119	MediPass all Medicaid recipients, except those Medicaid
2120	recipients who are: in an institution; enrolled in the Medicaid
2121	medically needy program; or eligible for both Medicaid and
2122	Medicare. However, to the extent permitted by federal law, the
2123	agency may enroll in a managed care plan or MediPass a Medicaid
2124	recipient who is exempt from mandatory managed care enrollment,
2125	provided that:
2126	1. The recipient's decision to enroll in a managed care
2127	plan or MediPass is voluntary;
2128	2. If the recipient chooses to enroll in a managed care
2129	plan, the agency has determined that the managed care plan
2130	provides specific programs and services which address the
2131	special health needs of the recipient; and
2132	3. The agency receives any necessary waivers from the
2133	federal Health Care Financing Administration.
2134
2135	The agency shall develop rules to establish policies by which
2136	exceptions to the mandatory managed care enrollment requirement
2137	may be made on a case-by-case basis. The rules shall include the
2138	specific criteria to be applied when making a determination as
2139	to whether to exempt a recipient from mandatory enrollment in a
2140	managed care plan or MediPass. School districts participating in
2141	the certified school match program pursuant to ss. 409.908(21)
2142	and 1011.70 shall be reimbursed by Medicaid, subject to the
2143	limitations of s. 1011.70(1), for a Medicaid-eligible child
2144	participating in the services as authorized in s. 1011.70, as
2145	provided for in s. 409.9071, regardless of whether the child is
2146	enrolled in MediPass or a managed care plan. Managed care plans
2147	shall make a good faith effort to execute agreements with school
2148	districts regarding the coordinated provision of services
2149	authorized under s. 1011.70. County health departments
2150	delivering school-based services pursuant to ss. 381.0056 and
2151	381.0057 shall be reimbursed by Medicaid for the federal share
2152	for a Medicaid-eligible child who receives Medicaid-covered
2153	services in a school setting, regardless of whether the child is
2154	enrolled in MediPass or a managed care plan. Managed care plans
2155	shall make a good faith effort to execute agreements with county
2156	health departments regarding the coordinated provision of
2157	services to a Medicaid-eligible child. To ensure continuity of
2158	care for Medicaid patients, the agency, the Department of
2159	Health, and the Department of Education shall develop procedures
2160	for ensuring that a student's managed care plan or MediPass
2161	provider receives information relating to services provided in
2162	accordance with ss. 381.0056, 381.0057, 409.9071, and 1011.70.
2163	(b) A Medicaid recipient shall not be enrolled in or
2164	assigned to a managed care plan or MediPass unless the managed
2165	care plan or MediPass has complied with the quality-of-care
2166	standards specified in paragraphs (3)(a) and (b), respectively.
2167	(c) Medicaid recipients shall have a choice of managed
2168	care plans or MediPass. The Agency for Health Care
2169	Administration, the Department of Health, the Department of
2170	Children and Family Services, and the Department of Elderly
2171	Affairs shall cooperate to ensure that each Medicaid recipient
2172	receives clear and easily understandable information that meets
2173	the following requirements:
2174	1. Explains the concept of managed care, including
2175	MediPass.
2176	2. Provides information on the comparative performance of
2177	managed care plans and MediPass in the areas of quality,
2178	credentialing, preventive health programs, network size and
2179	availability, and patient satisfaction.
2180	3. Explains where additional information on each managed
2181	care plan and MediPass in the recipient's area can be obtained.
2182	4. Explains that recipients have the right to choose their
2183	own managed care plans or MediPass. However, if a recipient does
2184	not choose a managed care plan or MediPass, the agency will
2185	assign the recipient to a managed care plan or MediPass
2186	according to the criteria specified in this section.
2187	5. Explains the recipient's right to complain, file a
2188	grievance, or change managed care plans or MediPass providers if
2189	the recipient is not satisfied with the managed care plan or
2190	MediPass.
2191	(d) The agency shall develop a mechanism for providing
2192	information to Medicaid recipients for the purpose of making a
2193	managed care plan or MediPass selection. Examples of such
2194	mechanisms may include, but not be limited to, interactive
2195	information systems, mailings, and mass marketing materials.
2196	Managed care plans and MediPass providers are prohibited from
2197	providing inducements to Medicaid recipients to select their
2198	plans or from prejudicing Medicaid recipients against other
2199	managed care plans or MediPass providers.
2200	(e) Medicaid recipients who are already enrolled in a
2201	managed care plan or MediPass shall be offered the opportunity
2202	to change managed care plans or MediPass providers on a
2203	staggered basis, as defined by the agency. All Medicaid
2204	recipients shall have 90 days in which to make a choice of
2205	managed care plans or MediPass providers. Those Medicaid
2206	recipients who do not make a choice shall be assigned to a
2207	managed care plan or MediPass in accordance with paragraph (f).
2208	To facilitate continuity of care, for a Medicaid recipient who
2209	is also a recipient of Supplemental Security Income (SSI), prior
2210	to assigning the SSI recipient to a managed care plan or
2211	MediPass, the agency shall determine whether the SSI recipient
2212	has an ongoing relationship with a MediPass provider or managed
2213	care plan, and if so, the agency shall assign the SSI recipient
2214	to that MediPass provider or managed care plan. Those SSI
2215	recipients who do not have such a provider relationship shall be
2216	assigned to a managed care plan or MediPass provider in
2217	accordance with paragraph (f).
2218	(f) When a Medicaid recipient does not choose a managed
2219	care plan or MediPass provider, the agency shall assign the
2220	Medicaid recipient to a managed care plan or MediPass provider.
2221	Medicaid recipients who are subject to mandatory assignment but
2222	who fail to make a choice shall be assigned to managed care
2223	plans until an enrollment of 45 percent in MediPass and 55
2224	percent in managed care plans is achieved. Once this enrollment
2225	is achieved, the assignments shall be divided in order to
2226	maintain an enrollment in MediPass and managed care plans which
2227	is in a 45 percent and 55 percent proportion, respectively.
2228	Thereafter, assignment of Medicaid recipients who fail to make a
2229	choice shall be based proportionally on the preferences of
2230	recipients who have made a choice in the previous period. Such
2231	proportions shall be revised at least quarterly to reflect an
2232	update of the preferences of Medicaid recipients. The agency
2233	shall disproportionately assign Medicaid-eligible recipients who
2234	are required to but have failed to make a choice of managed care
2235	plan or MediPass, including children, and who are to be assigned
2236	to the MediPass program to children's networks as described in
2237	s. 409.912(3)(g), Children's Medical Services network as defined
2238	in s. 391.021, exclusive provider organizations, provider
2239	service networks, minority physician networks, and pediatric
2240	emergency department diversion programs authorized by this
2241	chapter or the General Appropriations Act, in such manner as the
2242	agency deems appropriate, until the agency has determined that
2243	the networks and programs have sufficient numbers to be
2244	economically operated. For purposes of this paragraph, when
2245	referring to assignment, the term "managed care plans" includes
2246	health maintenance organizations, exclusive provider
2247	organizations, provider service networks, minority physician
2248	networks, Children's Medical Services network, and pediatric
2249	emergency department diversion programs authorized by this
2250	chapter or the General Appropriations Act. Beginning July 1,
2251	2002, the agency shall assign all children in families who have
2252	not made a choice of a managed care plan or MediPass in the
2253	required timeframe to a pediatric emergency room diversion
2254	program described in s. 409.912(3)(g) that, as of July 1, 2002,
2255	has executed a contract with the agency, until such network or
2256	program has reached an enrollment of 15,000 children. Once that
2257	minimum enrollment level has been reached, the agency shall
2258	assign children who have not chosen a managed care plan or
2259	MediPass to the network or program in a manner that maintains
2260	the minimum enrollment in the network or program at not less
2261	than 15,000 children. To the extent practicable, the agency
2262	shall also assign all eligible children in the same family to
2263	such network or program. When making assignments, the agency
2264	shall take into account the following criteria:
2265	1. A managed care plan has sufficient network capacity to
2266	meet the need of members.
2267	2. The managed care plan or MediPasshas previously
2268	enrolled the recipient as a member, or one of the managed care
2269	plan's primary care providers or MediPass providershas
2270	previously provided health care to the recipient.
2271	3. The agency has knowledge that the member has previously
2272	expressed a preference for a particular managed care plan or
2273	MediPass provideras indicated by Medicaid fee-for-service
2274	claims data, but has failed to make a choice.
2275	4. The managed care plan's or MediPassprimary care
2276	providers are geographically accessible to the recipient's
2277	residence.
2278	(g) When more than one managed care plan or MediPass
2279	provider meets the criteria specified in paragraph (f), the
2280	agency shall make recipient assignments consecutively by family
2281	unit.
2282	(h) The agency may not engage in practices that are
2283	designed to favor one managed care plan over another or that are
2284	designed to influence Medicaid recipients to enroll in MediPass
2285	rather than in a managed care plan or to enroll in a managed
2286	care plan rather than in MediPass. This subsection does not
2287	prohibit the agency from reporting on the performance of
2288	MediPass or any managed care plan, as measured by performance
2289	criteria developed by the agency.
2290	(i) After a recipient has made a selection or has been
2291	enrolled in a managed care plan or MediPass, the recipient shall
2292	have 90 days in which to voluntarily disenroll and select
2293	another managed care plan or MediPass provider. After 90 days,
2294	no further changes may be made except for cause. Cause shall
2295	include, but not be limited to, poor quality of care, lack of
2296	access to necessary specialty services, an unreasonable delay or
2297	denial of service, or fraudulent enrollment. The agency shall
2298	develop criteria for good cause disenrollment for chronically
2299	ill and disabled populations who are assigned to managed care
2300	plans if more appropriate care is available through the MediPass
2301	program. The agency must make a determination as to whether
2302	cause exists. However, the agency may require a recipient to use
2303	the managed care plan's or MediPass grievance process prior to
2304	the agency's determination of cause, except in cases in which
2305	immediate risk of permanent damage to the recipient's health is
2306	alleged. The grievance process, when utilized, must be completed
2307	in time to permit the recipient to disenroll no later than the
2308	first day of the second month after the month the disenrollment
2309	request was made. If the managed care plan or MediPass, as a
2310	result of the grievance process, approves an enrollee's request
2311	to disenroll, the agency is not required to make a determination
2312	in the case. The agency must make a determination and take final
2313	action on a recipient's request so that disenrollment occurs no
2314	later than the first day of the second month after the month the
2315	request was made. If the agency fails to act within the
2316	specified timeframe, the recipient's request to disenroll is
2317	deemed to be approved as of the date agency action was required.
2318	Recipients who disagree with the agency's finding that cause
2319	does not exist for disenrollment shall be advised of their right
2320	to pursue a Medicaid fair hearing to dispute the agency's
2321	finding.
2322	(j) The agency shall apply for a federal waiver from the
2323	Health Care Financing Administration to lock eligible Medicaid
2324	recipients into a managed care plan or MediPass for 12 months
2325	after an open enrollment period. After 12 months' enrollment, a
2326	recipient may select another managed care plan or MediPass
2327	provider. However, nothing shall prevent a Medicaid recipient
2328	from changing primary care providers within the managed care
2329	plan or MediPass program during the 12-month period.
2330	(k) When a Medicaid recipient does not choose a managed
2331	care plan or MediPass provider, the agency shall assign the
2332	Medicaid recipient to a managed care plan, except in those
2333	counties in which there are fewer than two managed care plans
2334	accepting Medicaid enrollees, in which case assignment shall be
2335	to a managed care plan or a MediPass provider. Medicaid
2336	recipients in counties with fewer than two managed care plans
2337	accepting Medicaid enrollees who are subject to mandatory
2338	assignment but who fail to make a choice shall be assigned to
2339	managed care plans until an enrollment of 45 percent in MediPass
2340	and 55 percent in managed care plans is achieved. Once that
2341	enrollment is achieved, the assignments shall be divided in
2342	order to maintain an enrollment in MediPass and managed care
2343	plans which is in a 45 percent and 55 percent proportion,
2344	respectively. In geographic areas where the agency is
2345	contracting for the provision of comprehensive behavioral health
2346	services through a capitated prepaid arrangement, recipients who
2347	fail to make a choice shall be assigned equally to MediPass or a
2348	managed care plan. For purposes of this paragraph, when
2349	referring to assignment, the term "managed care plans" includes
2350	exclusive provider organizations, provider service networks,
2351	Children's Medical Services network, minority physician
2352	networks, and pediatric emergency department diversion programs
2353	authorized by this chapter or the General Appropriations Act.
2354	When making assignments, the agency shall take into account the
2355	following criteria:
2356	1. A managed care plan has sufficient network capacity to
2357	meet the need of members.
2358	2. The managed care plan or MediPasshas previously
2359	enrolled the recipient as a member, or one of the managed care
2360	plan's primary care providers or MediPass providershas
2361	previously provided health care to the recipient.
2362	3. The agency has knowledge that the member has previously
2363	expressed a preference for a particular managed care plan or
2364	MediPass provideras indicated by Medicaid fee-for-service
2365	claims data, but has failed to make a choice.
2366	4. The managed care plan's or MediPassprimary care
2367	providers are geographically accessible to the recipient's
2368	residence.
2369	5. The agency has authority to make mandatory assignments
2370	based on quality of service and performance of managed care
2371	plans.
2372	(l) Notwithstanding the provisions of chapter 287, the
2373	agency may, at its discretion, renew cost-effective contracts
2374	for choice counseling services once or more for such periods as
2375	the agency may decide. However, all such renewals may not
2376	combine to exceed a total period longer than the term of the
2377	original contract.
2378	Section 26. Subsections (8) and (28) of section 409.913,
2379	Florida Statutes, are amended to read:
2380	409.913 Oversight of the integrity of the Medicaid
2381	program.--The agency shall operate a program to oversee the
2382	activities of Florida Medicaid recipients, and providers and
2383	their representatives, to ensure that fraudulent and abusive
2384	behavior and neglect of recipients occur to the minimum extent
2385	possible, and to recover overpayments and impose sanctions as
2386	appropriate. Beginning January 1, 2003, and each year
2387	thereafter, the agency and the Medicaid Fraud Control Unit of
2388	the Department of Legal Affairs shall submit a joint report to
2389	the Legislature documenting the effectiveness of the state's
2390	efforts to control Medicaid fraud and abuse and to recover
2391	Medicaid overpayments during the previous fiscal year. The
2392	report must describe the number of cases opened and investigated
2393	each year; the sources of the cases opened; the disposition of
2394	the cases closed each year; the amount of overpayments alleged
2395	in preliminary and final audit letters; the number and amount of
2396	fines or penalties imposed; any reductions in overpayment
2397	amounts negotiated in settlement agreements or by other means;
2398	the amount of final agency determinations of overpayments; the
2399	amount deducted from federal claiming as a result of
2400	overpayments; the amount of overpayments recovered each year;
2401	the amount of cost of investigation recovered each year; the
2402	average length of time to collect from the time the case was
2403	opened until the overpayment is paid in full; the amount
2404	determined as uncollectible and the portion of the uncollectible
2405	amount subsequently reclaimed from the Federal Government; the
2406	number of providers, by type, that are terminated from
2407	participation in the Medicaid program as a result of fraud and
2408	abuse; and all costs associated with discovering and prosecuting
2409	cases of Medicaid overpayments and making recoveries in such
2410	cases. The report must also document actions taken to prevent
2411	overpayments and the number of providers prevented from
2412	enrolling in or reenrolling in the Medicaid program as a result
2413	of documented Medicaid fraud and abuse and must recommend
2414	changes necessary to prevent or recover overpayments. For the
2415	2001-2002 fiscal year, the agency shall prepare a report that
2416	contains as much of this information as is available to it.
2417	(8) A Medicaid provider shall retain medical,
2418	professional, financial, and business records pertaining to
2419	services and goods furnished to a Medicaid recipient and billed
2420	to Medicaid for a period of 5 years after the date of furnishing
2421	such services or goods. The agency and its duly authorized
2422	agentsmay investigate, review, or analyze such records, which
2423	must be made available during normal business hours. However,
2424	24-hour notice must be provided if patient treatment would be
2425	disrupted. The provider is responsible for furnishing to the
2426	agency and its duly authorized agents, and keeping the agency
2427	and its duly authorized agentsinformed of the location of, the
2428	provider's Medicaid-related records. The authority of the agency
2429	and its duly authorized agentsto obtain Medicaid-related
2430	records from a provider is neither curtailed nor limited during
2431	a period of litigation between the agency and the provider.
2432	(28) Notwithstanding other provisions of law, the agency
2433	and its duly authorized agentsand the Medicaid Fraud Control
2434	Unit of the Department of Legal Affairs may review a provider's
2435	Medicaid-related records in order to determine the total output
2436	of a provider's practice to reconcile quantities of goods or
2437	services billed to Medicaid against quantities of goods or
2438	services used in the provider's total practice.
2439	Section 27. Subsection (7) is added to section 430.502,
2440	Florida Statutes, to read:
2441	430.502 Alzheimer's disease; memory disorder clinics and
2442	day care and respite care programs.--
2443	(7) The department, in collaboration with the agency, may
2444	develop and implement a program to provide home and community-
2445	based services to Medicaid eligible individuals with Alzheimer's
2446	disease or related disorders. The program will provide
2447	specialized services designed to maintain individuals with
2448	Alzheimer's disease or related disorders in the community when
2449	they would otherwise be in a nursing home due to their
2450	condition. Individuals served under this program must be
2451	Medicaid eligible, diagnosed with Alzheimer's disease or related
2452	disorders, meet nursing home level of care criteria as
2453	determined by the department, and have a capable caregiver at
2454	home. This program may be operated in designated areas of the
2455	state, as determined by the department. The department may seek
2456	any federal waivers necessary to implement this program.
2457	Section 28. Section 57 of chapter 98-288, Laws of Florida,
2458	is repealed.
2459	Section 29. Except as otherwise provided herein, this act
2460	shall take effect July 1, 2003.
2461
2462
2463	================= T I T L E A M E N D M E N T =================
2464	Remove the entire title, and insert:
2465	A bill to be entitled
2466	An act relating to health care; amending s. 154.503, F.S.;
2467	requiring the Department of Health to coordinate with the
2468	Agency for Health Care Administration with respect to the
2469	Primary Care for Children and Families Challenge Grant
2470	Program; amending s. 381.90, F.S.; revising membership of
2471	the Health Information Systems Council; amending s.
2472	400.179, F.S.; providing for retention of a provision
2473	assessing a fee against leasehold licensees of transferred
2474	nursing facilities to cover Medicaid underpayments and
2475	overpayments; amending s. 408.915, F.S.; conforming a
2476	cross reference; amending s. 409.810, F.S.; conforming a
2477	cross reference; amending s. 409.811, F.S.; providing
2478	definitions applicable to the Florida Kidcare Act;
2479	conforming cross references; amending s. 409.813, F.S.;
2480	conforming cross references; amending s. 409.8132, F.S.;
2481	providing a cross reference; creating s. 403.8133, F.S.;
2482	creating the Florida Healthy Kids program component of the
2483	Florida Kidcare program; providing for administration;
2484	providing an exemption from insurance licensure;
2485	specifying applicability of laws relating to Medicaid;
2486	providing benefits; providing eligibility requirements;
2487	providing for enrollment; providing penalties for
2488	voluntary cancellation; amending s. 409.814, F.S.;
2489	conforming references; amending s. 409.815, F.S.;
2490	conforming references; amending s. 409.817, F.S.;
2491	conforming references; amending s. 409.818, F.S.;
2492	conforming references; renumbering and amending s. 624.91,
2493	F.S.; incorporating the Florida Healthy Kids Corporation
2494	Act into the Florida Kidcare Act and making it a program
2495	component; renumbering and amending s. 624.915, F.S.;
2496	terminating the operating fund of the Florida Healthy Kids
2497	Corporation and transferring its balance to the Florida
2498	Kidcare program; renumbering and amending s. 409.821,
2499	F.S.; conforming cross references; amending s. 409.904,
2500	F.S.; revising eligibility requirements for certain
2501	optional payments for medical assistance and related
2502	services; amending s. 409.906, F.S., relating to optional
2503	Medicaid services; limiting provision of adult dental
2504	services; limiting provision of hearing and visual
2505	services; amending s. 409.9081, F.S.; providing copayment
2506	requirements for prescribed drug services and hospital
2507	outpatient emergency department services; amending s.
2508	409.911, F.S., relating to the disproportionate share
2509	program; revising disproportionate share formulas;
2510	amending s. 409.9112, F.S., relating to the
2511	disproportionate share program for regional perinatal
2512	intensive care centers; revising disproportionate share
2513	formulas; amending s. 409.9117, F.S., relating to the
2514	primary care disproportionate share program; revising
2515	disproportionate share formulas; amending s. 409.9119,
2516	F.S., relating to the disproportionate share program for
2517	specialty hospitals for children; revising
2518	disproportionate share formulas; amending s. 409.912,
2519	F.S.; providing for choice of behavioral health care
2520	providers within managed care plans; providing for
2521	contracting to provide Medicaid-covered dental services;
2522	amending s. 409.9122, F.S.; providing for assignment to a
2523	managed care plan; amending s. 409.913, F.S.; providing
2524	for oversight of Medicaid by authorized agents of the
2525	Agency for Health Care Administration; amending s.
2526	430.502, F.S.; authorizing a program for home and
2527	community-based services to Medicaid-eligible individuals
2528	with Alzheimer's disease or related disorders; repealing
2529	s. 57, ch. 98-288, Laws of Florida, relating to future
2530	review and repeal of the "Florida Kidcare Act" based on
2531	specified changes in federal policy; providing effective
2532	dates.