| 1 | The Future of Florida's Families Committee recommends the |
| 2 | following: |
| 3 |
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| 4 | Council/Committee Substitute |
| 5 | Remove the entire bill and insert: |
| 6 | A bill to be entitled |
| 7 | An act relating to the Florida KidCare program; amending |
| 8 | s. 409.811, F.S.; defining the terms "Healthy Kids" and |
| 9 | "maximum income threshold"; amending s. 409.8132, F.S.; |
| 10 | providing that eligibility for the Florida KidCare program |
| 11 | be at or below the maximum income threshold rather than a |
| 12 | specified percentage of the federal poverty level; |
| 13 | conforming and updating references; amending s. 409.8134, |
| 14 | F.S.; conforming provisions to changes made by the act; |
| 15 | amending s. 409.814, F.S.; requiring that eligibility for |
| 16 | the Florida KidCare program be at or below the maximum |
| 17 | income threshold rather than a specified percentage of the |
| 18 | federal poverty level; providing that certain specified |
| 19 | children are eligible for nonfederal premium assistance |
| 20 | for health insurance; providing that a child whose family |
| 21 | income is above the maximum income threshold may |
| 22 | participate in the Florida KidCare program but is subject |
| 23 | to certain conditions; amending s. 409.816, F.S.; |
| 24 | conforming a cross-reference; amending s. 409.818, F.S.; |
| 25 | requiring the Agency for Health Care Administration to |
| 26 | seek approval from the federal Centers for Medicare and |
| 27 | Medicaid Services to use the highest maximum income |
| 28 | threshold allowed by federal law or regulation, which is |
| 29 | up to 300 percent of the most recently stated federal |
| 30 | poverty limit; providing an alternative eligibility |
| 31 | standard pending approval of the request; amending s. |
| 32 | 409.821, F.S., relating to a public-records exemption; |
| 33 | specifying that such provision does not prohibit an |
| 34 | enrollee's parent or legal guardian from obtaining |
| 35 | confirmation of coverage and dates of coverage; amending |
| 36 | s. 624.91, F.S.; conforming provisions to changes made by |
| 37 | the act; revising the powers of the Florida Healthy Kids |
| 38 | Corporation; authorizing participating health and dental |
| 39 | plans to develop marketing and other promotional materials |
| 40 | and to participate in activities to promote the Florida |
| 41 | Healthy Kids Corporation; providing an effective date. |
| 42 |
|
| 43 | Be It Enacted by the Legislature of the State of Florida: |
| 44 |
|
| 45 | Section 1. Section 409.811, Florida Statutes, is amended |
| 46 | to read: |
| 47 | 409.811 Definitions relating to Florida KidCare Act.--As |
| 48 | used in ss. 409.810-409.820, the term: |
| 49 | (1) "Actuarially equivalent" means that: |
| 50 | (a) The aggregate value of the benefits included in health |
| 51 | benefits coverage is equal to the value of the benefits in the |
| 52 | benchmark benefit plan; and |
| 53 | (b) The benefits included in health benefits coverage are |
| 54 | substantially similar to the benefits included in the benchmark |
| 55 | benefit plan, except that preventive health services must be the |
| 56 | same as in the benchmark benefit plan. |
| 57 | (2) "Agency" means the Agency for Health Care |
| 58 | Administration. |
| 59 | (3) "Applicant" means a parent or guardian of a child or a |
| 60 | child whose disability of nonage has been removed under chapter |
| 61 | 743, who applies for determination of eligibility for health |
| 62 | benefits coverage under ss. 409.810-409.820. |
| 63 | (4) "Benchmark benefit plan" means the form and level of |
| 64 | health benefits coverage established in s. 409.815. |
| 65 | (5) "Child" means any person under 19 years of age. |
| 66 | (6) "Child with special health care needs" means a child |
| 67 | whose serious or chronic physical or developmental condition |
| 68 | requires extensive preventive and maintenance care beyond that |
| 69 | required by typically healthy children. Health care utilization |
| 70 | by such a child exceeds the statistically expected usage of the |
| 71 | normal child adjusted for chronological age, and such a child |
| 72 | often needs complex care requiring multiple providers, |
| 73 | rehabilitation services, and specialized equipment in a number |
| 74 | of different settings. |
| 75 | (7) "Children's Medical Services Network" or "network" |
| 76 | means a statewide managed care service system as defined in s. |
| 77 | 391.021(1). |
| 78 | (8) "Community rate" means a method used to develop |
| 79 | premiums for a health insurance plan that spreads financial risk |
| 80 | across a large population and allows adjustments only for age, |
| 81 | gender, family composition, and geographic area. |
| 82 | (9) "Department" means the Department of Health. |
| 83 | (10) "Enrollee" means a child who has been determined |
| 84 | eligible for and is receiving coverage under ss. 409.810- |
| 85 | 409.820. |
| 86 | (11) "Enrollment ceiling" means the maximum number of |
| 87 | children receiving premium assistance payments, excluding |
| 88 | children enrolled in Medicaid, that may be enrolled at any time |
| 89 | in the Florida KidCare program. The maximum number shall be |
| 90 | established annually in the General Appropriations Act or by |
| 91 | general law. |
| 92 | (12) "Family" means the group or the individuals whose |
| 93 | income is considered in determining eligibility for the Florida |
| 94 | KidCare program. The family includes a child with a custodial |
| 95 | parent or caretaker relative who resides in the same house or |
| 96 | living unit or, in the case of a child whose disability of |
| 97 | nonage has been removed under chapter 743, the child. The family |
| 98 | may also include other individuals whose income and resources |
| 99 | are considered in whole or in part in determining eligibility of |
| 100 | the child. |
| 101 | (13) "Family income" means cash received at periodic |
| 102 | intervals from any source, such as wages, benefits, |
| 103 | contributions, or rental property. Income also may include any |
| 104 | money that would have been counted as income under the Aid to |
| 105 | Families with Dependent Children (AFDC) state plan in effect |
| 106 | prior to August 22, 1996. |
| 107 | (14) "Florida KidCare program," "KidCare program," or |
| 108 | "program" means the health benefits program administered through |
| 109 | ss. 409.810-409.820. |
| 110 | (15) "Guarantee issue" means that health benefits coverage |
| 111 | must be offered to an individual regardless of the individual's |
| 112 | health status, preexisting condition, or claims history. |
| 113 | (16) "Health benefits coverage" means protection that |
| 114 | provides payment of benefits for covered health care services or |
| 115 | that otherwise provides, either directly or through arrangements |
| 116 | with other persons, covered health care services on a prepaid |
| 117 | per capita basis or on a prepaid aggregate fixed-sum basis. |
| 118 | (17) "Health insurance plan" means health benefits |
| 119 | coverage under the following: |
| 120 | (a) A health plan offered by any certified health |
| 121 | maintenance organization or authorized health insurer, except a |
| 122 | plan that is limited to the following: a limited benefit, |
| 123 | specified disease, or specified accident; hospital indemnity; |
| 124 | accident only; limited benefit convalescent care; Medicare |
| 125 | supplement; credit disability; dental; vision; long-term care; |
| 126 | disability income; coverage issued as a supplement to another |
| 127 | health plan; workers' compensation liability or other insurance; |
| 128 | or motor vehicle medical payment only; or |
| 129 | (b) An employee welfare benefit plan that includes health |
| 130 | benefits established under the Employee Retirement Income |
| 131 | Security Act of 1974, as amended. |
| 132 | (18) "Healthy Kids" means a component of the Florida |
| 133 | KidCare program of medical assistance for children 5 through 18 |
| 134 | years of age as authorized under s. 624.91 and administered by |
| 135 | the Florida Healthy Kids Corporation. |
| 136 | (19) "Maximum income threshold" means a percentage of the |
| 137 | current federal poverty level used to determine eligibility for |
| 138 | certain program components, as approved by federal waiver or an |
| 139 | amendment to the state plan. |
| 140 | (20)(18) "Medicaid" means the medical assistance program |
| 141 | authorized by Title XIX of the Social Security Act, and |
| 142 | regulations thereunder, and ss. 409.901-409.920, as administered |
| 143 | in this state by the agency. |
| 144 | (21)(19) "Medically necessary" means the use of any |
| 145 | medical treatment, service, equipment, or supply necessary to |
| 146 | palliate the effects of a terminal condition, or to prevent, |
| 147 | diagnose, correct, cure, alleviate, or preclude deterioration of |
| 148 | a condition that threatens life, causes pain or suffering, or |
| 149 | results in illness or infirmity and which is: |
| 150 | (a) Consistent with the symptom, diagnosis, and treatment |
| 151 | of the enrollee's condition; |
| 152 | (b) Provided in accordance with generally accepted |
| 153 | standards of medical practice; |
| 154 | (c) Not primarily intended for the convenience of the |
| 155 | enrollee, the enrollee's family, or the health care provider; |
| 156 | (d) The most appropriate level of supply or service for |
| 157 | the diagnosis and treatment of the enrollee's condition; and |
| 158 | (e) Approved by the appropriate medical body or health |
| 159 | care specialty involved as effective, appropriate, and essential |
| 160 | for the care and treatment of the enrollee's condition. |
| 161 | (22)(20) "Medikids" means a component of the Florida |
| 162 | KidCare program of medical assistance authorized by Title XXI of |
| 163 | the Social Security Act, and regulations thereunder, and s. |
| 164 | 409.8132, as administered in the state by the agency. |
| 165 | (23)(21) "Preexisting condition exclusion" means, with |
| 166 | respect to coverage, a limitation or exclusion of benefits |
| 167 | relating to a condition based on the fact that the condition was |
| 168 | present before the date of enrollment for such coverage, whether |
| 169 | or not any medical advice, diagnosis, care, or treatment was |
| 170 | recommended or received before such date. |
| 171 | (24)(22) "Premium" means the entire cost of a health |
| 172 | insurance plan, including the administration fee or the risk |
| 173 | assumption charge. |
| 174 | (25)(23) "Premium assistance payment" means the monthly |
| 175 | consideration paid by the agency per enrollee in the Florida |
| 176 | KidCare program towards health insurance premiums. |
| 177 | (26)(24) "Qualified alien" means an alien as defined in s. |
| 178 | 431 of the Personal Responsibility and Work Opportunity |
| 179 | Reconciliation Act of 1996, as amended, Pub. L. No. 104-193. |
| 180 | (27)(25) "Resident" means a United States citizen, or |
| 181 | qualified alien, who is domiciled in this state. |
| 182 | (28)(26) "Rural county" means a county having a population |
| 183 | density of less than 100 persons per square mile, or a county |
| 184 | defined by the most recent United States Census as rural, in |
| 185 | which there is no prepaid health plan participating in the |
| 186 | Medicaid program as of July 1, 1998. |
| 187 | (29)(27) "Substantially similar" means that, with respect |
| 188 | to additional services as defined in s. 2103(c)(2) of Title XXI |
| 189 | of the Social Security Act, these services must have an |
| 190 | actuarial value equal to at least 75 percent of the actuarial |
| 191 | value of the coverage for that service in the benchmark benefit |
| 192 | plan and, with respect to the basic services as defined in s. |
| 193 | 2103(c)(1) of Title XXI of the Social Security Act, these |
| 194 | services must be the same as the services in the benchmark |
| 195 | benefit plan. |
| 196 | Section 2. Subsections (6) and (7) of section 409.8132, |
| 197 | Florida Statutes, are amended to read: |
| 198 | 409.8132 Medikids program component.-- |
| 199 | (6) ELIGIBILITY.-- |
| 200 | (a) A child who has attained the age of 1 year but who is |
| 201 | under the age of 5 years is eligible to enroll in the Medikids |
| 202 | program component of the Florida KidCare program, if the child |
| 203 | is a member of a family that has a family income which exceeds |
| 204 | the Medicaid applicable income level as specified in s. 409.903, |
| 205 | but which is equal to or below the maximum income threshold 200 |
| 206 | percent of the current federal poverty level. In determining |
| 207 | the eligibility of such a child, an assets test is not required. |
| 208 | A child who is eligible for Medikids may elect to enroll in |
| 209 | Florida Healthy Kids coverage or employer-sponsored group |
| 210 | coverage. However, a child who is eligible for Medikids may |
| 211 | participate in the Florida Healthy Kids program only if the |
| 212 | child has a sibling participating in the Florida Healthy Kids |
| 213 | program and the child's county of residence permits such |
| 214 | enrollment. |
| 215 | (b) The provisions of s. 409.814(3), (4), and (5), and (6) |
| 216 | are shall be applicable to the Medikids program. |
| 217 | (7) ENROLLMENT.--Enrollment in the Medikids program |
| 218 | component may occur at any time throughout the year. A child may |
| 219 | not receive services under the Medikids program until the child |
| 220 | is enrolled in a managed care plan or MediPass. Once determined |
| 221 | eligible, an applicant may receive choice counseling and select |
| 222 | a managed care plan or MediPass. The agency may initiate |
| 223 | mandatory assignment for a Medikids applicant who has not chosen |
| 224 | a managed care plan or MediPass provider after the applicant's |
| 225 | voluntary choice period ends. An applicant may select MediPass |
| 226 | under the Medikids program component only in counties that have |
| 227 | fewer than two managed care plans available to serve Medicaid |
| 228 | recipients and only if the federal Centers for Medicare and |
| 229 | Medicaid Services Health Care Financing Administration |
| 230 | determines that MediPass constitutes "health insurance coverage" |
| 231 | as defined in Title XXI of the Social Security Act. |
| 232 | Section 3. Subsection (2) of section 409.8134, Florida |
| 233 | Statutes, is amended to read: |
| 234 | 409.8134 Program enrollment and expenditure ceilings.-- |
| 235 | (2) The Florida KidCare program may conduct enrollment at |
| 236 | any time throughout the year for the purpose of enrolling |
| 237 | children eligible for all program components listed in s. |
| 238 | 409.813 except Medicaid. The four Florida KidCare administrators |
| 239 | shall work together to ensure that the year-round enrollment |
| 240 | period is announced statewide. Eligible children shall be |
| 241 | enrolled on a first-come, first-served basis using the date the |
| 242 | enrollment application is received. Enrollment shall immediately |
| 243 | cease when the enrollment ceiling is reached. Year-round |
| 244 | enrollment shall only be held if the Social Services Estimating |
| 245 | Conference determines that sufficient federal and state funds |
| 246 | will be available to finance the increased enrollment through |
| 247 | federal fiscal year 2007. Any individual who is not enrolled |
| 248 | must reapply by submitting a new application. The application |
| 249 | for the Florida KidCare program is shall be valid for a period |
| 250 | of 120 days after the date it was received. At the end of the |
| 251 | 120-day period, if the applicant has not been enrolled in the |
| 252 | program, the application is shall be invalid and the applicant |
| 253 | shall be notified of the action. The applicant may resubmit the |
| 254 | application after notification of the action taken by the |
| 255 | program. Except for the Medicaid program, whenever the Social |
| 256 | Services Estimating Conference determines that there are |
| 257 | presently, or will be by the end of the current fiscal year, |
| 258 | insufficient funds to finance the current or projected |
| 259 | enrollment in the Florida KidCare program, all additional |
| 260 | enrollment must cease and additional enrollment may not resume |
| 261 | until sufficient funds are available to finance the such |
| 262 | enrollment. |
| 263 | Section 4. Section 409.814, Florida Statutes, is amended |
| 264 | to read: |
| 265 | 409.814 Eligibility.--A child who has not reached 19 years |
| 266 | of age whose family income is equal to or below the maximum |
| 267 | income threshold 200 percent of the federal poverty level is |
| 268 | eligible for the Florida KidCare program as provided in this |
| 269 | section. For enrollment in the Children's Medical Services |
| 270 | Network, a complete application includes the medical or |
| 271 | behavioral health screening. If, subsequently, an individual is |
| 272 | determined to be ineligible for coverage, he or she must |
| 273 | immediately be disenrolled from the respective Florida KidCare |
| 274 | program component. |
| 275 | (1) A child who is eligible for Medicaid coverage under s. |
| 276 | 409.903 or s. 409.904 must be enrolled in Medicaid and is not |
| 277 | eligible to receive health benefits under any other health |
| 278 | benefits coverage authorized under the Florida KidCare program. |
| 279 | (2) A child who is not eligible for Medicaid, but who is |
| 280 | eligible for the Florida KidCare program, may obtain health |
| 281 | benefits coverage under any of the other components listed in s. |
| 282 | 409.813 if such coverage is approved and available in the county |
| 283 | in which the child resides. However, a child who is eligible for |
| 284 | Medikids may participate in the Florida Healthy Kids program |
| 285 | only if the child has a sibling participating in the Florida |
| 286 | Healthy Kids program and the child's county of residence permits |
| 287 | such enrollment. |
| 288 | (3) A child who is eligible for the Florida KidCare |
| 289 | program who is a child with special health care needs, as |
| 290 | determined through a medical or behavioral screening instrument, |
| 291 | is eligible for health benefits coverage from and shall be |
| 292 | referred to the Children's Medical Services Network. |
| 293 | (4) The following children are not eligible to receive |
| 294 | federal premium assistance for health benefits coverage under |
| 295 | the Florida KidCare program, except under Medicaid if the child |
| 296 | would have been eligible for Medicaid under s. 409.903 or s. |
| 297 | 409.904 as of June 1, 1997: |
| 298 | (a) A child who is eligible for coverage under a state |
| 299 | health benefit plan on the basis of a family member's employment |
| 300 | with a public agency in the state. |
| 301 | (b) A child who is currently eligible for or covered under |
| 302 | a family member's group health benefit plan or under other |
| 303 | employer health insurance coverage, excluding coverage provided |
| 304 | under the Florida Healthy Kids Corporation as established under |
| 305 | s. 624.91, provided that the cost of the child's participation |
| 306 | is not greater than 5 percent of the family's income. This |
| 307 | provision shall be applied during redetermination for children |
| 308 | who were enrolled prior to July 1, 2004. These enrollees shall |
| 309 | have 6 months of eligibility following redetermination to allow |
| 310 | for a transition to the other health benefit plan. |
| 311 | (c) A child who is seeking premium assistance for the |
| 312 | Florida KidCare program through employer-sponsored group |
| 313 | coverage, if the child has been covered by the same employer's |
| 314 | group coverage during the 6 months prior to the family's |
| 315 | submitting an application for determination of eligibility under |
| 316 | the program. |
| 317 | (d) A child who is an alien, but who does not meet the |
| 318 | definition of qualified alien, in the United States. |
| 319 | (e) A child who is an inmate of a public institution or a |
| 320 | patient in an institution for mental diseases. |
| 321 | (f) A child who has had his or her coverage in an |
| 322 | employer-sponsored health benefit plan voluntarily canceled in |
| 323 | the last 6 months, except those children who were on the waiting |
| 324 | list prior to March 12, 2004. |
| 325 | (g) A child who is otherwise eligible for KidCare and who |
| 326 | has a preexisting condition that prevents coverage under another |
| 327 | insurance plan as described in paragraph (b) which would have |
| 328 | disqualified the child for KidCare if the child were able to |
| 329 | enroll in the plan shall be eligible for KidCare coverage when |
| 330 | enrollment is possible. |
| 331 | (5) Subject to a specific appropriation for this purpose, |
| 332 | the following children are eligible to receive nonfederal |
| 333 | premium assistance for health benefits coverage under the |
| 334 | Florida KidCare program, except under Medicaid if the child |
| 335 | would have been eligible for Medicaid under s. 409.903 or s. |
| 336 | 409.904 as of June 1, 1997: |
| 337 | (a) A child who is eligible for coverage under a state |
| 338 | health benefit plan on the basis of a family member's employment |
| 339 | with a public agency in the state. |
| 340 | (b) A child who is an alien in the United States but who |
| 341 | does not meet the definition of qualified alien. |
| 342 | (6)(5) A child whose family income is above the maximum |
| 343 | income threshold 200 percent of the federal poverty level or a |
| 344 | child who is excluded under the provisions of subsection (4) may |
| 345 | participate in the Florida KidCare program, excluding the |
| 346 | Medicaid program, but is subject to the following provisions: |
| 347 | (a) The family is not eligible for premium assistance |
| 348 | payments and must pay the full cost of the premium, including |
| 349 | any administrative costs. |
| 350 | (b) The agency is authorized to place limits on enrollment |
| 351 | in Medikids by these children in order to avoid adverse |
| 352 | selection. The number of children participating in Medikids |
| 353 | whose family income exceeds the maximum income threshold 200 |
| 354 | percent of the federal poverty level must not exceed 10 percent |
| 355 | of total enrollees in the Medikids program. |
| 356 | (c) The board of directors of the Florida Healthy Kids |
| 357 | Corporation is authorized to place limits on enrollment of these |
| 358 | children in order to avoid adverse selection. In addition, the |
| 359 | board is authorized to offer a reduced benefit package to these |
| 360 | children in order to limit program costs for such families. The |
| 361 | number of children participating in the Florida Healthy Kids |
| 362 | program whose family income exceeds the maximum income threshold |
| 363 | 200 percent of the federal poverty level must not exceed 10 |
| 364 | percent of total enrollees in the Florida Healthy Kids program. |
| 365 | (d) Children described in this subsection are not counted |
| 366 | in the annual enrollment ceiling for the Florida KidCare |
| 367 | program. |
| 368 | (7)(6) Once a child is enrolled in the Florida KidCare |
| 369 | program, the child is eligible for coverage under the program |
| 370 | for 12 months without a redetermination or reverification of |
| 371 | eligibility, if the family continues to pay the applicable |
| 372 | premium. Eligibility for program components funded through Title |
| 373 | XXI of the Social Security Act shall terminate when a child |
| 374 | attains the age of 19. Effective January 1, 1999, a child who |
| 375 | has not attained the age of 5 and who has been determined |
| 376 | eligible for the Medicaid program is eligible for coverage for |
| 377 | 12 months without a redetermination or reverification of |
| 378 | eligibility. |
| 379 | (8)(7) When determining or reviewing a child's eligibility |
| 380 | under the Florida KidCare program, the applicant shall be |
| 381 | provided with reasonable notice of changes in eligibility which |
| 382 | may affect enrollment in one or more of the program components. |
| 383 | When a transition from one program component to another is |
| 384 | authorized, there shall be cooperation between the program |
| 385 | components and the affected family which promotes continuity of |
| 386 | health care coverage. Any authorized transfers must be managed |
| 387 | within the program's overall appropriated or authorized levels |
| 388 | of funding. Each component of the program shall establish a |
| 389 | reserve to ensure that transfers between components will be |
| 390 | accomplished within current year appropriations. These reserves |
| 391 | shall be reviewed by each convening of the Social Services |
| 392 | Estimating Conference to determine the adequacy of such reserves |
| 393 | to meet actual experience. |
| 394 | (9)(8) In determining the eligibility of a child, an |
| 395 | assets test is not required. Each applicant shall provide |
| 396 | written documentation during the application process and the |
| 397 | redetermination process, including, but not limited to, the |
| 398 | following: |
| 399 | (a) Proof of family income, which must include a copy of |
| 400 | the applicant's most recent federal income tax return. In the |
| 401 | absence of a federal income tax return, an applicant may submit |
| 402 | wages and earnings statements (pay stubs), W-2 forms, or other |
| 403 | appropriate documents. |
| 404 | (b) A statement from all family members that: |
| 405 | 1. Their employer does not sponsor a health benefit plan |
| 406 | for employees; or |
| 407 | 2. The potential enrollee is not covered by the employer- |
| 408 | sponsored health benefit plan because the potential enrollee is |
| 409 | not eligible for coverage, or, if the potential enrollee is |
| 410 | eligible but not covered, a statement of the cost to enroll the |
| 411 | potential enrollee in the employer-sponsored health benefit |
| 412 | plan. |
| 413 | (10)(9) Subject to paragraph (4)(b) and s. 624.91(3), the |
| 414 | Florida KidCare program shall withhold benefits from an enrollee |
| 415 | if the program obtains evidence that the enrollee is no longer |
| 416 | eligible, submitted incorrect or fraudulent information in order |
| 417 | to establish eligibility, or failed to provide verification of |
| 418 | eligibility. The applicant or enrollee shall be notified that |
| 419 | because of such evidence program benefits will be withheld |
| 420 | unless the applicant or enrollee contacts a designated |
| 421 | representative of the program by a specified date, which must be |
| 422 | within 10 days after the date of notice, to discuss and resolve |
| 423 | the matter. The program shall make every effort to resolve the |
| 424 | matter within a timeframe that will not cause benefits to be |
| 425 | withheld from an eligible enrollee. |
| 426 | (11)(10) The following individuals may be subject to |
| 427 | prosecution in accordance with s. 414.39: |
| 428 | (a) An applicant obtaining or attempting to obtain |
| 429 | benefits for a potential enrollee under the Florida KidCare |
| 430 | program when the applicant knows or should have known the |
| 431 | potential enrollee does not qualify for the Florida KidCare |
| 432 | program. |
| 433 | (b) An individual who assists an applicant in obtaining or |
| 434 | attempting to obtain benefits for a potential enrollee under the |
| 435 | Florida KidCare program when the individual knows or should have |
| 436 | known the potential enrollee does not qualify for the Florida |
| 437 | KidCare program. |
| 438 | Section 5. Subsection (3) of section 409.816, Florida |
| 439 | Statutes, is amended to read: |
| 440 | 409.816 Limitations on premiums and cost-sharing.--The |
| 441 | following limitations on premiums and cost-sharing are |
| 442 | established for the program. |
| 443 | (3) Enrollees in families with a family income above 150 |
| 444 | percent of the federal poverty level, who are not receiving |
| 445 | coverage under the Medicaid program or who are not eligible |
| 446 | under s. 409.814(6) s. 409.814(5), may be required to pay |
| 447 | enrollment fees, premiums, copayments, deductibles, coinsurance, |
| 448 | or similar charges on a sliding scale related to income, except |
| 449 | that the total annual aggregate cost-sharing with respect to all |
| 450 | children in a family may not exceed 5 percent of the family's |
| 451 | income. However, copayments, deductibles, coinsurance, or |
| 452 | similar charges may not be imposed for preventive services, |
| 453 | including well-baby and well-child care, age-appropriate |
| 454 | immunizations, and routine hearing and vision screenings. |
| 455 | Section 6. Subsection (3) of section 409.818, Florida |
| 456 | Statutes, is amended to read: |
| 457 | 409.818 Administration.--In order to implement ss. |
| 458 | 409.810-409.820, the following agencies shall have the following |
| 459 | duties: |
| 460 | (3) The Agency for Health Care Administration, under the |
| 461 | authority granted in s. 409.914(1), shall: |
| 462 | (a) Calculate the premium assistance payment necessary to |
| 463 | comply with the premium and cost-sharing limitations specified |
| 464 | in s. 409.816. The premium assistance payment for each enrollee |
| 465 | in a health insurance plan participating in the Florida Healthy |
| 466 | Kids Corporation shall equal the premium approved by the Florida |
| 467 | Healthy Kids Corporation and the Office of Insurance Regulation |
| 468 | of the Financial Services Commission pursuant to ss. 627.410 and |
| 469 | 641.31, less any enrollee's share of the premium established |
| 470 | within the limitations specified in s. 409.816. The premium |
| 471 | assistance payment for each enrollee in an employer-sponsored |
| 472 | health insurance plan approved under ss. 409.810-409.820 shall |
| 473 | equal the premium for the plan adjusted for any benchmark |
| 474 | benefit plan actuarial equivalent benefit rider approved by the |
| 475 | Office of Insurance Regulation pursuant to ss. 627.410 and |
| 476 | 641.31, less any enrollee's share of the premium established |
| 477 | within the limitations specified in s. 409.816. In calculating |
| 478 | the premium assistance payment levels for children with family |
| 479 | coverage, the agency shall set the premium assistance payment |
| 480 | levels for each child proportionately to the total cost of |
| 481 | family coverage. |
| 482 | (b) Annually calculate the program enrollment ceiling |
| 483 | based on estimated per child premium assistance payments and the |
| 484 | estimated appropriation available for the program. |
| 485 | (c) Make premium assistance payments to health insurance |
| 486 | plans on a periodic basis. The agency may use its Medicaid |
| 487 | fiscal agent or a contracted third-party administrator in making |
| 488 | these payments. The agency may require health insurance plans |
| 489 | that participate in the Medikids program or employer-sponsored |
| 490 | group health insurance to collect premium payments from an |
| 491 | enrollee's family. Participating health insurance plans shall |
| 492 | report premium payments collected on behalf of enrollees in the |
| 493 | program to the agency in accordance with a schedule established |
| 494 | by the agency. |
| 495 | (d) Monitor compliance with quality assurance and access |
| 496 | standards developed under s. 409.820. |
| 497 | (e) Establish a mechanism for investigating and resolving |
| 498 | complaints and grievances from program applicants, enrollees, |
| 499 | and health benefits coverage providers, and maintain a record of |
| 500 | complaints and confirmed problems. In the case of a child who is |
| 501 | enrolled in a health maintenance organization, the agency must |
| 502 | use the provisions of s. 641.511 to address grievance reporting |
| 503 | and resolution requirements. |
| 504 | (f) Approve health benefits coverage for participation in |
| 505 | the program, following certification by the Office of Insurance |
| 506 | Regulation under subsection (4). |
| 507 | (g) Adopt rules necessary for calculating premium |
| 508 | assistance payment levels, calculating the program enrollment |
| 509 | ceiling, making premium assistance payments, monitoring access |
| 510 | and quality assurance standards, investigating and resolving |
| 511 | complaints and grievances, administering the Medikids program, |
| 512 | and approving health benefits coverage. |
| 513 |
|
| 514 | The agency is designated the lead state agency for Title XXI of |
| 515 | the Social Security Act for purposes of receipt of federal |
| 516 | funds, for reporting purposes, and for ensuring compliance with |
| 517 | federal and state regulations and rules. The agency shall seek |
| 518 | approval from the federal Centers for Medicare and Medicaid |
| 519 | Services for the highest maximum income threshold of up to 300 |
| 520 | percent of the most recently stated federal poverty limit. Until |
| 521 | the federal agency approves the request, the maximum income |
| 522 | threshold used for the Florida KidCare program shall be 200 |
| 523 | percent of the most recently stated federal poverty limit or the |
| 524 | highest income threshold allowed under current federal law. Any |
| 525 | such expansion under this subsection is subject to a specified |
| 526 | appropriation for such purpose. |
| 527 | Section 7. Section 409.821, Florida Statutes, is amended |
| 528 | to read: |
| 529 | 409.821 Florida KidCare program public records |
| 530 | exemption.--Notwithstanding any other law to the contrary, any |
| 531 | information identifying a Florida KidCare program applicant or |
| 532 | enrollee, as defined in s. 409.811, held by the Agency for |
| 533 | Health Care Administration, the Department of Children and |
| 534 | Family Services, the Department of Health, or the Florida |
| 535 | Healthy Kids Corporation is confidential and exempt from s. |
| 536 | 119.07(1) and s. 24(a), Art. I of the State Constitution. Such |
| 537 | information may be disclosed to another governmental entity only |
| 538 | if disclosure is necessary for the entity to perform its duties |
| 539 | and responsibilities under the Florida KidCare program and shall |
| 540 | be disclosed to the Department of Revenue for purposes of |
| 541 | administering the state Title IV-D program. The receiving |
| 542 | governmental entity must maintain the confidential and exempt |
| 543 | status of such information. Furthermore, such information may |
| 544 | not be released to any person without the written consent of the |
| 545 | program applicant. This exemption applies to any information |
| 546 | identifying a Florida KidCare program applicant or enrollee held |
| 547 | by the Agency for Health Care Administration, the Department of |
| 548 | Children and Family Services, the Department of Health, or the |
| 549 | Florida Healthy Kids Corporation before, on, or after the |
| 550 | effective date of this exemption. A violation of this section is |
| 551 | a misdemeanor of the second degree, punishable as provided in s. |
| 552 | 775.082 or s. 775.083. This section does not prohibit an |
| 553 | enrollee's parent or legal guardian from obtaining confirmation |
| 554 | of coverage and dates of coverage. |
| 555 | Section 8. Subsections (3) and (5) of section 624.91, |
| 556 | Florida Statutes, are amended to read: |
| 557 | 624.91 The Florida Healthy Kids Corporation Act.-- |
| 558 | (3) ELIGIBILITY FOR NONFEDERAL STATE-FUNDED |
| 559 | ASSISTANCE.--Only residents of this state between 5 and 18 years |
| 560 | of age who meet the qualifications for the Florida KidCare |
| 561 | program under s. 409.814 are eligible for nonfederal assistance |
| 562 | in the Florida Healthy Kids program. the following individuals |
| 563 | are eligible for state-funded assistance in paying Florida |
| 564 | Healthy Kids premiums: |
| 565 | (a) Residents of this state who are eligible for the |
| 566 | Florida KidCare program pursuant to s. 409.814. |
| 567 | (b) Notwithstanding s. 409.814, legal aliens who are |
| 568 | enrolled in the Florida Healthy Kids program as of January 31, |
| 569 | 2004, who do not qualify for Title XXI federal funds because |
| 570 | they are not qualified aliens as defined in s. 409.811. |
| 571 | (c) Notwithstanding s. 409.814, individuals who have |
| 572 | attained the age of 19 as of March 31, 2004, who were receiving |
| 573 | Florida Healthy Kids benefits prior to the enactment of the |
| 574 | Florida KidCare program. This paragraph shall be repealed March |
| 575 | 31, 2005. |
| 576 | (d) Notwithstanding s. 409.814, state employee dependents |
| 577 | who were enrolled in the Florida Healthy Kids program as of |
| 578 | January 31, 2004. Such individuals shall remain eligible until |
| 579 | January 1, 2005. |
| 580 | (5) CORPORATION AUTHORIZATION, DUTIES, PROMOTION, |
| 581 | POWERS.-- |
| 582 | (a) There is created the Florida Healthy Kids Corporation, |
| 583 | a not-for-profit corporation. |
| 584 | (b) The Florida Healthy Kids Corporation shall: |
| 585 | 1. Arrange for the collection of any family, local |
| 586 | contributions, or employer payment or premium, in an amount to |
| 587 | be determined by the board of directors, to provide for payment |
| 588 | of premiums for comprehensive insurance coverage and for the |
| 589 | actual or estimated administrative expenses. |
| 590 | 2. Arrange for the collection of any voluntary |
| 591 | contributions to provide for payment of premiums for children |
| 592 | who are not eligible for medical assistance under Title XXI of |
| 593 | the Social Security Act. Each fiscal year, the corporation shall |
| 594 | establish a local match policy for the enrollment of non-Title- |
| 595 | XXI-eligible children in the Healthy Kids program. By May 1 of |
| 596 | each year, the corporation shall provide written notification of |
| 597 | the amount to be remitted to the corporation for the following |
| 598 | fiscal year under that policy. Local match sources may include, |
| 599 | but are not limited to, funds provided by municipalities, |
| 600 | counties, school boards, hospitals, health care providers, |
| 601 | charitable organizations, special taxing districts, and private |
| 602 | organizations. The minimum local match cash contributions |
| 603 | required each fiscal year and local match credits shall be |
| 604 | determined by the General Appropriations Act. The corporation |
| 605 | shall calculate a county's local match rate based upon that |
| 606 | county's percentage of the state's total non-Title-XXI |
| 607 | expenditures as reported in the corporation's most recently |
| 608 | audited financial statement. In awarding the local match |
| 609 | credits, the corporation may consider factors including, but not |
| 610 | limited to, population density, per capita income, and existing |
| 611 | child-health-related expenditures and services. |
| 612 | 2.3. Subject to the provisions of s. 409.8134, accept |
| 613 | voluntary supplemental local match contributions that comply |
| 614 | with the requirements of Title XXI of the Social Security Act |
| 615 | for the purpose of providing additional coverage in contributing |
| 616 | counties under Title XXI. |
| 617 | 3.4. Establish the administrative and accounting |
| 618 | procedures for the operation of the corporation. |
| 619 | 4.5. Establish, with consultation from appropriate |
| 620 | professional organizations, standards for preventive health |
| 621 | services and providers and comprehensive insurance benefits |
| 622 | appropriate to children, provided that the such standards for |
| 623 | rural areas do shall not limit primary care providers to board- |
| 624 | certified pediatricians. |
| 625 | 5.6. Determine eligibility for children seeking to |
| 626 | participate in the Title XXI-funded components of the Florida |
| 627 | KidCare program consistent with the requirements specified in s. |
| 628 | 409.814, as well as the non-Title-XXI-eligible children as |
| 629 | provided in subsection (3). |
| 630 | 6.7. Establish procedures under which providers of local |
| 631 | match to, applicants to and participants in the program may have |
| 632 | grievances reviewed by an impartial body and reported to the |
| 633 | board of directors of the corporation. |
| 634 | 7.8. Establish participation criteria and, if appropriate, |
| 635 | contract with an authorized insurer, health maintenance |
| 636 | organization, or third-party administrator to provide |
| 637 | administrative services to the corporation. |
| 638 | 8.9. Establish enrollment criteria that which shall |
| 639 | include penalties or waiting periods of not fewer than 60 days |
| 640 | for reinstatement of coverage upon voluntary cancellation for |
| 641 | nonpayment of family premiums. |
| 642 | 9.10. Contract with authorized insurers or any provider of |
| 643 | health care services, meeting standards established by the |
| 644 | corporation, for the provision of comprehensive insurance |
| 645 | coverage to participants. Such standards shall include criteria |
| 646 | under which the corporation may contract with more than one |
| 647 | provider of health care services in program sites. Health plans |
| 648 | shall be selected through a competitive bid process. The Florida |
| 649 | Healthy Kids Corporation shall purchase goods and services in |
| 650 | the most cost-effective manner consistent with the delivery of |
| 651 | quality medical care. The maximum administrative cost for a |
| 652 | Florida Healthy Kids Corporation contract shall be 15 percent. |
| 653 | For health care contracts, the minimum medical loss ratio for a |
| 654 | Florida Healthy Kids Corporation contract shall be 85 percent. |
| 655 | For dental contracts, the remaining compensation to be paid to |
| 656 | the authorized insurer or provider under a Florida Healthy Kids |
| 657 | Corporation contract shall be no less than an amount which is 85 |
| 658 | percent of premium; to the extent any contract provision does |
| 659 | not provide for this minimum compensation, this section shall |
| 660 | prevail. The health plan selection criteria and scoring system, |
| 661 | and the scoring results, shall be available upon request for |
| 662 | inspection after the bids have been awarded. |
| 663 | 11. Establish disenrollment criteria in the event local |
| 664 | matching funds are insufficient to cover enrollments. |
| 665 | 10.12. Develop and implement a plan to publicize the |
| 666 | Florida Healthy Kids Corporation, the eligibility requirements |
| 667 | of the program, and the procedures for enrollment in the program |
| 668 | and to maintain public awareness of the corporation and the |
| 669 | program. Participating health and dental plans may develop |
| 670 | marketing and other promotional materials and participate in |
| 671 | activities, such as health fairs and public events, as approved |
| 672 | by the corporation. The health and dental plans may also contact |
| 673 | their enrollees and former enrollees to encourage continued |
| 674 | participation in the plan. |
| 675 | 11.13. Secure staff necessary to properly administer the |
| 676 | corporation. Staff costs shall be funded from state and local |
| 677 | matching funds and such other private or public funds as become |
| 678 | available. The board of directors shall determine the number of |
| 679 | staff members necessary to administer the corporation. |
| 680 | 12.14. Provide a report annually to the Governor, Chief |
| 681 | Financial Officer, Commissioner of Education, Senate President, |
| 682 | Speaker of the House of Representatives, and Minority Leaders of |
| 683 | the Senate and the House of Representatives. |
| 684 | 13.15. Establish benefit packages which conform to the |
| 685 | provisions of the Florida KidCare program, as created in ss. |
| 686 | 409.810-409.820. |
| 687 | (c) Coverage under the corporation's program is secondary |
| 688 | to any other available private coverage held by, or applicable |
| 689 | to, the participant child or family member. Insurers under |
| 690 | contract with the corporation are the payors of last resort and |
| 691 | must coordinate benefits with any other third-party payor that |
| 692 | may be liable for the participant's medical care. |
| 693 | (d) The Florida Healthy Kids Corporation shall be a |
| 694 | private corporation not for profit, organized under pursuant to |
| 695 | chapter 617, and shall have all powers necessary to carry out |
| 696 | the purposes of this act, including, but not limited to, the |
| 697 | power to receive and accept grants, loans, or advances of funds |
| 698 | from any public or private agency and to receive and accept from |
| 699 | any source contributions of money, property, labor, or any other |
| 700 | thing of value, to be held, used, and applied for the purposes |
| 701 | of this section act. |
| 702 | Section 9. This act shall take effect July 1, 2006. |