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Florida Senate - 2007 (PROPOSED COMMITTEE BILL) SPB 7008
FOR CONSIDERATION By the Committee on Health Policy
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1 A bill to be entitled
2 An act relating to the Florida Kidcare Program;
3 amending s. 409.811, F.S.; redefining the term
4 "child with special health care needs" and
5 defining the term "Healthy Kids" as a component
6 of the program; amending s. 409.812, F.S.;
7 deleting a provision requiring that a child be
8 uninsured in order to be eligible for the
9 program; amending s. 409.8132, F.S.; conforming
10 references; amending s. 409.8134, F.S.;
11 revising certain requirements for financing
12 increased enrollment in the program; amending
13 s. 409.814, F.S.; revising certain requirements
14 for screening applicants to the program;
15 extending for a limited period coverage for a
16 child who becomes ineligible under certain
17 circumstances; deleting obsolete provisions;
18 revising certain eligibility criteria;
19 requiring the Agency for Health Care
20 Administration to notify providers if a child
21 becomes ineligible for Medicaid or Medikids;
22 requiring that an applicant provide additional
23 documentation when applying to the program;
24 amending s. 409.816, F.S.; conforming a
25 cross-reference; amending s. 409.818, F.S.;
26 requiring that the Department of Children and
27 Family Services develop a standardized
28 application form; requiring that the Department
29 of Health develop standards for quality
30 assurance and access for program components;
31 repealing s. 409.820, F.S., relating to
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1 standards for quality assurance and access;
2 amending s. 409.821, F.S.; clarifying that an
3 exemption from the public-records law does not
4 prohibit an enrollee's parent or guardian from
5 obtaining certain information; creating s.
6 409.830, F.S.; establishing the Florida Kidcare
7 Consolidation Pilot Program within specified
8 counties of the state; providing for the pilot
9 program to be administered by the Agency for
10 Health Care Administration, in coordination
11 with the Department of Children and Family
12 Services; providing duties of the agency in
13 administering the pilot program; providing
14 requirements for benefits, eligibility, and
15 enrollment; providing a capitation rate for
16 compensating managed care plans participating
17 in the pilot program; requiring that the agency
18 enter into a contract for an evaluation of the
19 pilot program; requiring the agency to seek
20 approval of a federal waiver or amendments to
21 the Medicaid state plan; requiring that the
22 agency adopt rules to implement the pilot
23 program; amending s. 624.91, F.S.; providing
24 that the Florida Healthy Kids Corporation is an
25 agency under ch. 120, F.S., for purposes of
26 administering the Healthy Kids program;
27 authorizing health and dental plans that
28 participate in the program to distribute
29 marketing and promotional materials and
30 participate in certain activities; providing an
31 effective date.
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1 Be It Enacted by the Legislature of the State of Florida:
2
3 Section 1. Section 409.811, Florida Statutes, is
4 amended to read:
5 409.811 Definitions relating to Florida Kidcare
6 Act.--As used in ss. 409.810-409.820, the term:
7 (1) "Actuarially equivalent" means that:
8 (a) The aggregate value of the benefits included in
9 health benefits coverage is equal to the value of the benefits
10 in the benchmark benefit plan; and
11 (b) The benefits included in health benefits coverage
12 are substantially similar to the benefits included in the
13 benchmark benefit plan, except that preventive health services
14 must be the same as in the benchmark benefit plan.
15 (2) "Agency" means the Agency for Health Care
16 Administration.
17 (3) "Applicant" means a parent or guardian of a child
18 or a child whose disability of nonage has been removed under
19 chapter 743, who applies for determination of eligibility for
20 health benefits coverage under ss. 409.810-409.820.
21 (4) "Benchmark benefit plan" means the form and level
22 of health benefits coverage established in s. 409.815.
23 (5) "Child" means any person under 19 years of age.
24 (6) "Child with special health care needs" means a
25 child who has chronic physical, developmental, behavioral, or
26 emotional conditions and who also requires health care and
27 related services of a type or amount beyond that which is
28 generally required by children. whose serious or chronic
29 physical or developmental condition requires extensive
30 preventive and maintenance care beyond that required by
31 typically healthy children. Health care utilization by such a
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1 child exceeds the statistically expected usage of the normal
2 child adjusted for chronological age, and such a child often
3 needs complex care requiring multiple providers,
4 rehabilitation services, and specialized equipment in a number
5 of different settings.
6 (7) "Children's Medical Services Network" or "network"
7 means a statewide managed care service system as defined in s.
8 391.021(1).
9 (8) "Community rate" means a method used to develop
10 premiums for a health insurance plan that spreads financial
11 risk across a large population and allows adjustments only for
12 age, gender, family composition, and geographic area.
13 (9) "Department" means the Department of Health.
14 (10) "Enrollee" means a child who has been determined
15 eligible for and is receiving coverage under ss.
16 409.810-409.820.
17 (11) "Family" means the group or the individuals whose
18 income is considered in determining eligibility for the
19 Florida Kidcare program. The family includes a child with a
20 custodial parent or caretaker relative who resides in the same
21 house or living unit or, in the case of a child whose
22 disability of nonage has been removed under chapter 743, the
23 child. The family may also include other individuals whose
24 income and resources are considered in whole or in part in
25 determining eligibility of the child.
26 (12) "Family income" means cash received at periodic
27 intervals from any source, such as wages, benefits,
28 contributions, or rental property. Income also may include any
29 money that would have been counted as income under the Aid to
30 Families with Dependent Children (AFDC) state plan in effect
31 prior to August 22, 1996.
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1 (13) "Florida Kidcare program," "Kidcare program," or
2 "program" means the health benefits program administered
3 through ss. 409.810-409.820.
4 (14) "Guarantee issue" means that health benefits
5 coverage must be offered to an individual regardless of the
6 individual's health status, preexisting condition, or claims
7 history.
8 (15) "Health benefits coverage" means protection that
9 provides payment of benefits for covered health care services
10 or that otherwise provides, either directly or through
11 arrangements with other persons, covered health care services
12 on a prepaid per capita basis or on a prepaid aggregate
13 fixed-sum basis.
14 (16) "Health insurance plan" means health benefits
15 coverage under the following:
16 (a) A health plan offered by any certified health
17 maintenance organization or authorized health insurer, except
18 a plan that is limited to the following: a limited benefit,
19 specified disease, or specified accident; hospital indemnity;
20 accident only; limited benefit convalescent care; Medicare
21 supplement; credit disability; dental; vision; long-term care;
22 disability income; coverage issued as a supplement to another
23 health plan; workers' compensation liability or other
24 insurance; or motor vehicle medical payment only; or
25 (b) An employee welfare benefit plan that includes
26 health benefits established under the Employee Retirement
27 Income Security Act of 1974, as amended.
28 (17) "Healthy Kids" means a component of the Florida
29 Kidcare program of medical assistance for children who are 5
30 through 18 years of age as authorized under s. 624.91 and
31 administered by the Florida Healthy Kids Corporation.
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1 (18)(17) "Medicaid" means the medical assistance
2 program authorized by Title XIX of the Social Security Act,
3 and regulations thereunder, and ss. 409.901-409.920, as
4 administered in this state by the agency.
5 (19)(18) "Medically necessary" means the use of any
6 medical treatment, service, equipment, or supply necessary to
7 palliate the effects of a terminal condition, or to prevent,
8 diagnose, correct, cure, alleviate, or preclude deterioration
9 of a condition that threatens life, causes pain or suffering,
10 or results in illness or infirmity and which is:
11 (a) Consistent with the symptom, diagnosis, and
12 treatment of the enrollee's condition;
13 (b) Provided in accordance with generally accepted
14 standards of medical practice;
15 (c) Not primarily intended for the convenience of the
16 enrollee, the enrollee's family, or the health care provider;
17 (d) The most appropriate level of supply or service
18 for the diagnosis and treatment of the enrollee's condition;
19 and
20 (e) Approved by the appropriate medical body or health
21 care specialty involved as effective, appropriate, and
22 essential for the care and treatment of the enrollee's
23 condition.
24 (20)(19) "Medikids" means a component of the Florida
25 Kidcare program of medical assistance authorized by Title XXI
26 of the Social Security Act, and regulations thereunder, and s.
27 409.8132, as administered in the state by the agency.
28 (21)(20) "Preexisting condition exclusion" means, with
29 respect to coverage, a limitation or exclusion of benefits
30 relating to a condition based on the fact that the condition
31 was present before the date of enrollment for such coverage,
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1 whether or not any medical advice, diagnosis, care, or
2 treatment was recommended or received before such date.
3 (22)(21) "Premium" means the entire cost of a health
4 insurance plan, including the administration fee or the risk
5 assumption charge.
6 (23)(22) "Premium assistance payment" means the
7 monthly consideration paid by the agency per enrollee in the
8 Florida Kidcare program towards health insurance premiums.
9 (24)(23) "Qualified alien" means an alien as defined
10 in s. 431 of the Personal Responsibility and Work Opportunity
11 Reconciliation Act of 1996, as amended, Pub. L. No. 104-193.
12 (25)(24) "Resident" means a United States citizen, or
13 qualified alien, who is domiciled in this state.
14 (26)(25) "Rural county" means a county having a
15 population density of less than 100 persons per square mile,
16 or a county defined by the most recent United States Census as
17 rural, in which there is no prepaid health plan participating
18 in the Medicaid program as of July 1, 1998.
19 (27)(26) "Substantially similar" means that, with
20 respect to additional services as defined in s. 2103(c)(2) of
21 Title XXI of the Social Security Act, these services must have
22 an actuarial value equal to at least 75 percent of the
23 actuarial value of the coverage for that service in the
24 benchmark benefit plan and, with respect to the basic services
25 as defined in s. 2103(c)(1) of Title XXI of the Social
26 Security Act, these services must be the same as the services
27 in the benchmark benefit plan.
28 Section 2. Section 409.812, Florida Statutes, is
29 amended to read:
30 409.812 Program created; purpose.--The Florida Kidcare
31 program is created to provide a defined set of health benefits
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1 to previously uninsured, low-income children through the
2 establishment of a variety of affordable health benefits
3 coverage options from which families may select coverage and
4 through which families may contribute financially to the
5 health care of their children.
6 Section 3. Paragraph (b) of subsection (6) and
7 subsection (7) of section 409.8132, Florida Statutes, are
8 amended to read:
9 409.8132 Medikids program component.--
10 (6) ELIGIBILITY.--
11 (b) The provisions of s. 409.814(3), (4), and (5), and
12 (6) apply shall be applicable to the Medikids program.
13 (7) ENROLLMENT.--Enrollment in the Medikids program
14 component may occur at any time throughout the year. A child
15 may not receive services under the Medikids program until the
16 child is enrolled in a managed care plan or MediPass. Once
17 determined eligible, an applicant may receive choice
18 counseling and select a managed care plan or MediPass. The
19 agency may initiate mandatory assignment for a Medikids
20 applicant who has not chosen a managed care plan or MediPass
21 provider after the applicant's voluntary choice period ends.
22 An applicant may select MediPass under the Medikids program
23 component only in counties that have fewer than two managed
24 care plans available to serve Medicaid recipients and only if
25 the federal Centers for Medicare and Medicaid Services Health
26 Care Financing Administration determines that MediPass
27 constitutes "health insurance coverage" as defined in Title
28 XXI of the Social Security Act.
29 Section 4. Section 409.8134, Florida Statutes, is
30 amended to read:
31 409.8134 Program expenditure ceiling.--
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1 (1) Except for the Medicaid program, a ceiling shall
2 be placed on annual federal and state expenditures for the
3 Florida Kidcare program as provided each year in the General
4 Appropriations Act.
5 (2) The Florida Kidcare program may conduct enrollment
6 at any time throughout the year for the purpose of enrolling
7 children eligible for all program components listed in s.
8 409.813 except Medicaid. The four Florida Kidcare
9 administrators shall work together to ensure that the
10 year-round enrollment period is announced statewide. Eligible
11 children shall be enrolled on a first-come, first-served basis
12 using the date the enrollment application is received.
13 Enrollment shall immediately cease when the expenditure
14 ceiling is reached. Year-round enrollment shall only be held
15 if the Social Services Estimating Conference determines that
16 sufficient federal and state funds will be available to
17 finance the increased enrollment through federal fiscal year
18 2007. Any individual who is not enrolled must reapply by
19 submitting a new application. The application for the Florida
20 Kidcare program is shall be valid for a period of 120 days
21 after the date it was received. At the end of the 120-day
22 period, if the applicant has not been enrolled in the program,
23 the application is shall be invalid and the applicant shall be
24 notified of the action. The applicant may resubmit the
25 application after notification of the action taken by the
26 program. Except for the Medicaid program, whenever the Social
27 Services Estimating Conference determines that there are
28 presently, or will be by the end of the current fiscal year,
29 insufficient funds to finance the current or projected
30 enrollment in the Florida Kidcare program, all additional
31 enrollment must cease and additional enrollment may not resume
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1 until sufficient funds are available to finance the such
2 enrollment.
3 (3) Upon determination by the Social Services
4 Estimating Conference that there are insufficient funds to
5 finance the current enrollment in the Florida Kidcare program
6 within current appropriations, the program shall initiate
7 disenrollment procedures to remove enrollees, except those
8 children enrolled in the Children's Medical Services Network,
9 on a last-in, first-out basis until the expenditure and
10 appropriation levels are balanced.
11 (4) The agencies that administer the Florida Kidcare
12 program components shall collect and analyze the data needed
13 to project program enrollment costs, including price level
14 adjustments, participation and attrition rates, current and
15 projected caseloads, utilization, and current and projected
16 expenditures for the next 3 years. The agencies shall report
17 caseload and expenditure trends to the Social Services
18 Estimating Conference in accordance with chapter 216.
19 Section 5. Section 409.814, Florida Statutes, is
20 amended to read:
21 409.814 Eligibility.--A child who has not reached 19
22 years of age whose family income is equal to or below 200
23 percent of the federal poverty level is eligible for the
24 Florida Kidcare program as provided in this section. For
25 enrollment in the Children's Medical Services Network, a
26 complete application includes the clinical eligibility medical
27 or behavioral health screening. If, subsequently, an
28 individual is determined to be ineligible for coverage, he or
29 she must immediately be disenrolled from the respective
30 Florida Kidcare program component.
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1 (1) A child who is eligible for Medicaid coverage
2 under s. 409.903 or s. 409.904 must be enrolled in Medicaid
3 and is not eligible to receive health benefits under any other
4 health benefits coverage authorized under the Florida Kidcare
5 program.
6 (2) A child who is not eligible for Medicaid, but who
7 is eligible for the Florida Kidcare program, may obtain health
8 benefits coverage under any of the other components listed in
9 s. 409.813 if such coverage is approved and available in the
10 county in which the child resides. However, a child who is
11 eligible for Medikids may participate in the Florida Healthy
12 Kids program only if the child has a sibling participating in
13 the Florida Healthy Kids program and the child's county of
14 residence permits such enrollment.
15 (3) A child who is eligible for the Florida Kidcare
16 program who is a child with special health care needs, as
17 determined through the clinical eligibility a medical or
18 behavioral screening instrument, is eligible for health
19 benefits coverage from and shall be referred to the Children's
20 Medical Services Network.
21 (4) A child who loses eligibility for Medicaid or
22 Medikids due to exceeding income or age limits shall have 60
23 days of continued eligibility following redetermination in
24 order to allow for a transition to the Florida Healthy Kids
25 program without a break in coverage.
26 (5)(4) The following children are not eligible to
27 receive premium assistance for health benefits coverage under
28 the Florida Kidcare program, except under Medicaid if the
29 child would have been eligible for Medicaid under s. 409.903
30 or s. 409.904 as of June 1, 1997:
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1 (a) A child who is eligible for coverage under a state
2 health benefit plan on the basis of a family member's
3 employment with a public agency in the state.
4 (b) A child who is currently eligible for or covered
5 under a family member's group health benefit plan or under
6 other employer health insurance coverage, excluding coverage
7 provided under the Florida Healthy Kids Corporation as
8 established under s. 624.91, provided that the cost of the
9 child's participation is not greater than 5 percent of the
10 family's income. This provision shall be applied during
11 redetermination for children who were enrolled prior to July
12 1, 2004. These enrollees shall have 6 months of eligibility
13 following redetermination to allow for a transition to the
14 other health benefit plan.
15 (c) A child who is seeking premium assistance for the
16 Florida Kidcare program through employer-sponsored group
17 coverage, if the child has been covered by the same employer's
18 group coverage during the 6 months prior to the family's
19 submitting an application for determination of eligibility
20 under the program.
21 (d) A child who is an alien, but who does not meet the
22 definition of qualified alien, in the United States.
23 (e) A child who is an inmate of a public institution
24 or a patient in an institution for mental diseases.
25 (f) A child who has had his or her coverage in an
26 employer-sponsored health benefit plan voluntarily canceled in
27 the last 6 months, except those children whose cost of
28 participation in an employer-sponsored health benefit plan is
29 greater than 5 percent of the family's income who were on the
30 waiting list prior to March 12, 2004.
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1 (g) A child who is otherwise eligible for Kidcare and
2 who has a preexisting condition that prevents coverage under
3 another insurance plan as described in paragraph (b) which
4 would have disqualified the child for Kidcare if the child
5 were able to enroll in the plan shall be eligible for Kidcare
6 coverage when enrollment is possible.
7 (6)(5) A child whose family income is above 200
8 percent of the federal poverty level or a child who is
9 excluded under the provisions of subsection (4) may
10 participate in the Medikids program as provided in s. 409.8132
11 or, if the child is ineligible for Medikids by reason of age,
12 in the Florida Healthy Kids program, subject to the following
13 provisions:
14 (a) The family is not eligible for premium assistance
15 payments and must pay the full cost of the premium, including
16 any administrative costs.
17 (b) The agency is authorized to place limits on
18 enrollment in Medikids by these children in order to avoid
19 adverse selection. The number of children participating in
20 Medikids whose family income exceeds 200 percent of the
21 federal poverty level must not exceed 10 percent of total
22 enrollees in the Medikids program.
23 (c) The board of directors of the Florida Healthy Kids
24 Corporation is authorized to place limits on enrollment of
25 these children in order to avoid adverse selection. In
26 addition, the board is authorized to offer a reduced benefit
27 package to these children in order to limit program costs for
28 such families. The number of children participating in the
29 Florida Healthy Kids program whose family income exceeds 200
30 percent of the federal poverty level must not exceed 10
31
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1 percent of total enrollees in the Florida Healthy Kids
2 program.
3 (7)(6) Once a child is enrolled in the Florida Kidcare
4 program, the child is eligible for coverage under the program
5 for 12 months without a redetermination or reverification of
6 eligibility, if the family continues to pay the applicable
7 premium. Eligibility for program components funded through
8 Title XXI of the Social Security Act shall terminate when a
9 child attains the age of 19. Effective January 1, 1999, a
10 child who has not attained the age of 5 and who has been
11 determined eligible for the Medicaid program is eligible for
12 coverage for 12 months without a redetermination or
13 reverification of eligibility.
14 (8)(7) When determining or reviewing a child's
15 eligibility under the Florida Kidcare program, the applicant
16 shall be provided with reasonable notice of changes in
17 eligibility which may affect enrollment in one or more of the
18 program components. When a transition from one program
19 component to another is authorized, there shall be cooperation
20 between the program components, and the affected family, the
21 child's health plan, and providers which promotes continuity
22 of health care coverage. The agency, in coordination with the
23 Department of Children and Family Services, shall notify
24 Medicaid HMOs and other providers of their members or patients
25 who lose eligibility for Medicaid or Medikids so that the
26 health plans and providers may assist the family in applying
27 for the Florida Healthy Kids program. Any authorized transfers
28 must be managed within the program's overall appropriated or
29 authorized levels of funding. Each component of the program
30 shall establish a reserve to ensure that transfers between
31 components will be accomplished within current year
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1 appropriations. These reserves shall be reviewed by each
2 convening of the Social Services Estimating Conference to
3 determine the adequacy of such reserves to meet actual
4 experience.
5 (9)(8) In determining the eligibility of a child, an
6 assets test is not required. Each applicant shall provide
7 written documentation during the application process and the
8 redetermination process, including, but not limited to, the
9 following:
10 (a) Proof of family income, which must include a copy
11 of the applicant's most recent federal income tax return. In
12 the absence of a federal income tax return, an applicant may
13 submit wages and earnings statements (pay stubs), W-2 forms,
14 or other appropriate documents.
15 (b) A statement from all family members that:
16 1. Their employer does not sponsor a health benefit
17 plan for employees; or
18 2. The potential enrollee is not covered by the
19 employer-sponsored health benefit plan because the potential
20 enrollee is not eligible for coverage, or, if the potential
21 enrollee is eligible but not covered, a statement of the cost
22 to enroll the potential enrollee in the employer-sponsored
23 health benefit plan.
24 (c) Documentation of nontaxable family income.
25 (d) Documentation of birth and identity.
26 (10)(9) Subject to paragraph (5)(b) (4)(b) and s.
27 624.91(4), the Florida Kidcare program shall withhold benefits
28 from an enrollee if the program obtains evidence that the
29 enrollee is no longer eligible, submitted incorrect or
30 fraudulent information in order to establish eligibility, or
31 failed to provide verification of eligibility. The applicant
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1 or enrollee shall be notified that because of such evidence
2 program benefits will be withheld unless the applicant or
3 enrollee contacts a designated representative of the program
4 by a specified date, which must be within 10 days after the
5 date of notice, to discuss and resolve the matter. The program
6 shall make every effort to resolve the matter within a
7 timeframe that will not cause benefits to be withheld from an
8 eligible enrollee.
9 (11)(10) The following individuals may be subject to
10 prosecution in accordance with s. 414.39:
11 (a) An applicant obtaining or attempting to obtain
12 benefits for a potential enrollee under the Florida Kidcare
13 program when the applicant knows or should have known the
14 potential enrollee does not qualify for the Florida Kidcare
15 program.
16 (b) An individual who assists an applicant in
17 obtaining or attempting to obtain benefits for a potential
18 enrollee under the Florida Kidcare program when the individual
19 knows or should have known the potential enrollee does not
20 qualify for the Florida Kidcare program.
21 Section 6. Subsection (3) of section 409.816, Florida
22 Statutes, is amended to read:
23 409.816 Limitations on premiums and cost-sharing.--The
24 following limitations on premiums and cost-sharing are
25 established for the program.
26 (3) Enrollees in families with a family income above
27 150 percent of the federal poverty level, who are not
28 receiving coverage under the Medicaid program or who are not
29 eligible under s. 409.814(6) s. 409.814(5), may be required to
30 pay enrollment fees, premiums, copayments, deductibles,
31 coinsurance, or similar charges on a sliding scale related to
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1 income, except that the total annual aggregate cost-sharing
2 with respect to all children in a family may not exceed 5
3 percent of the family's income. However, copayments,
4 deductibles, coinsurance, or similar charges may not be
5 imposed for preventive services, including well-baby and
6 well-child care, age-appropriate immunizations, and routine
7 hearing and vision screenings.
8 Section 7. Section 409.818, Florida Statutes, is
9 amended to read:
10 409.818 Administration.--In order to implement ss.
11 409.810-409.820, the following agencies shall have the
12 following duties:
13 (1) The Department of Children and Family Services
14 shall:
15 (a) Develop a standardized simplified eligibility
16 application mail-in form to be used for determining the
17 eligibility of children for coverage for all components of
18 under the Florida Kidcare program, in consultation with the
19 agency, the Department of Health, and the Florida Healthy Kids
20 Corporation. The standardized simplified eligibility
21 application form must include an item that provides an
22 opportunity for the applicant to indicate whether coverage is
23 being sought for a child with special health care needs.
24 Families applying for children's Medicaid coverage must also
25 be able to use the standardized simplified application form
26 without having to pay a premium.
27 (b) Establish and maintain the eligibility
28 determination process under the program except as specified in
29 subsection (5). The department shall directly, or through the
30 services of a contracted third-party administrator, establish
31 and maintain a process for determining eligibility of children
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1 for coverage under the program. The eligibility determination
2 process must be used solely for determining eligibility of
3 applicants for health benefits coverage under the program. The
4 eligibility determination process must include an initial
5 determination of eligibility for any coverage offered under
6 the program, as well as a redetermination or reverification of
7 eligibility each subsequent 6 months. Effective January 1,
8 1999, a child who has not attained the age of 5 and who has
9 been determined eligible for the Medicaid program is eligible
10 for coverage for 12 months without a redetermination or
11 reverification of eligibility. In conducting an eligibility
12 determination, the department shall determine if the child has
13 special health care needs. The department, in consultation
14 with the Agency for Health Care Administration and the Florida
15 Healthy Kids Corporation, shall develop procedures for
16 redetermining eligibility which enable a family to easily
17 update any change in circumstances which could affect
18 eligibility. The department may accept changes in a family's
19 status as reported to the department by the Florida Healthy
20 Kids Corporation without requiring a new application from the
21 family. Redetermination of a child's eligibility for Medicaid
22 may not be linked to a child's eligibility determination for
23 other programs.
24 (c) Inform program applicants about eligibility
25 determinations and provide information about eligibility of
26 applicants to Medicaid, Medikids, the Children's Medical
27 Services Network, and the Florida Healthy Kids Corporation,
28 and to insurers and their agents, through a centralized
29 coordinating office.
30 (d) Adopt rules necessary for conducting program
31 eligibility functions.
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1 (2) The Department of Health shall:
2 (a) Develop a minimum set of quality assurance and
3 access standards for all program components except Medicaid.
4 These standards shall be developed in consultation with the
5 agency and the Florida Healthy Kids Corporation. The standards
6 must include a process for granting exceptions to specific
7 requirements for quality assurance and access. Compliance with
8 the standards shall be a condition of program participation by
9 providers of health benefits. These standards must comply with
10 the provisions of this chapter, chapter 641, and Title XXI of
11 the Social Security Act. Design an eligibility intake process
12 for the program, in coordination with the Department of
13 Children and Family Services, the agency, and the Florida
14 Healthy Kids Corporation. The eligibility intake process may
15 include local intake points that are determined by the
16 Department of Health in coordination with the Department of
17 Children and Family Services.
18 (b) Chair a state-level coordinating council to review
19 and make recommendations concerning the implementation and
20 operation of the program. The coordinating council shall
21 include representatives from the department, the Department of
22 Children and Family Services, the agency, the Florida Healthy
23 Kids Corporation, the Office of Insurance Regulation of the
24 Financial Services Commission, local government, health
25 insurers, health maintenance organizations, health care
26 providers, families participating in the program, and
27 organizations representing low-income families.
28 (c) In consultation with the Florida Healthy Kids
29 Corporation and the Department of Children and Family
30 Services, establish a toll-free telephone line to assist
31 families with questions about the program.
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1 (d) Adopt rules necessary to implement outreach
2 activities.
3 (3) The Agency for Health Care Administration, under
4 the authority granted in s. 409.914(1), shall:
5 (a) Calculate the premium assistance payment necessary
6 to comply with the premium and cost-sharing limitations
7 specified in s. 409.816. The premium assistance payment for
8 each enrollee in a health insurance plan participating in the
9 Florida Healthy Kids Corporation shall equal the premium
10 approved by the Florida Healthy Kids Corporation and the
11 Office of Insurance Regulation of the Financial Services
12 Commission pursuant to ss. 627.410 and 641.31, less any
13 enrollee's share of the premium established within the
14 limitations specified in s. 409.816. The premium assistance
15 payment for each enrollee in an employer-sponsored health
16 insurance plan approved under ss. 409.810-409.820 shall equal
17 the premium for the plan adjusted for any benchmark benefit
18 plan actuarial equivalent benefit rider approved by the Office
19 of Insurance Regulation pursuant to ss. 627.410 and 641.31,
20 less any enrollee's share of the premium established within
21 the limitations specified in s. 409.816. In calculating the
22 premium assistance payment levels for children with family
23 coverage, the agency shall set the premium assistance payment
24 levels for each child proportionately to the total cost of
25 family coverage.
26 (b) Make premium assistance payments to health
27 insurance plans on a periodic basis. The agency may use its
28 Medicaid fiscal agent or a contracted third-party
29 administrator in making these payments. The agency may
30 require health insurance plans that participate in the
31 Medikids program or employer-sponsored group health insurance
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1 to collect premium payments from an enrollee's family.
2 Participating health insurance plans shall report premium
3 payments collected on behalf of enrollees in the program to
4 the agency in accordance with a schedule established by the
5 agency.
6 (c) Monitor compliance with quality assurance and
7 access standards developed under s. 409.820.
8 (d) Establish a mechanism for investigating and
9 resolving complaints and grievances from program applicants,
10 enrollees, and health benefits coverage providers, and
11 maintain a record of complaints and confirmed problems. In the
12 case of a child who is enrolled in a health maintenance
13 organization, the agency must use the provisions of s. 641.511
14 to address grievance reporting and resolution requirements.
15 (e) Approve health benefits coverage for participation
16 in the program, following certification by the Office of
17 Insurance Regulation under subsection (4).
18 (f) Adopt rules necessary for calculating premium
19 assistance payment levels, making premium assistance payments,
20 monitoring access and quality assurance standards,
21 investigating and resolving complaints and grievances,
22 administering the Medikids program, and approving health
23 benefits coverage.
24
25 The agency is designated the lead state agency for Title XXI
26 of the Social Security Act for purposes of receipt of federal
27 funds, for reporting purposes, and for ensuring compliance
28 with federal and state regulations and rules.
29 (4) The Office of Insurance Regulation shall certify
30 that health benefits coverage plans that seek to provide
31 services under the Florida Kidcare program, except those
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1 offered through the Florida Healthy Kids Corporation or the
2 Children's Medical Services Network, meet, exceed, or are
3 actuarially equivalent to the benchmark benefit plan and that
4 health insurance plans will be offered at an approved rate. In
5 determining actuarial equivalence of benefits coverage, the
6 Office of Insurance Regulation and health insurance plans must
7 comply with the requirements of s. 2103 of Title XXI of the
8 Social Security Act. The department shall adopt rules
9 necessary for certifying health benefits coverage plans.
10 (5) The Florida Healthy Kids Corporation shall retain
11 its functions as authorized in s. 624.91, including
12 eligibility determination for participation in the Healthy
13 Kids program.
14 (6) The agency, the Department of Health, the
15 Department of Children and Family Services, the Florida
16 Healthy Kids Corporation, and the Office of Insurance
17 Regulation, after consultation with and approval of the
18 Speaker of the House of Representatives and the President of
19 the Senate, are authorized to make program modifications that
20 are necessary to overcome any objections of the United States
21 Department of Health and Human Services to obtain approval of
22 the state's child health insurance plan under Title XXI of the
23 Social Security Act.
24 Section 8. Section 409.820, Florida Statutes, is
25 repealed.
26 Section 9. Section 409.821, Florida Statutes, is
27 amended to read:
28 409.821 Florida Kidcare program public records
29 exemption.--Notwithstanding any other law to the contrary, any
30 information identifying a Florida Kidcare program applicant or
31 enrollee, as defined in s. 409.811, held by the Agency for
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1 Health Care Administration, the Department of Children and
2 Family Services, the Department of Health, or the Florida
3 Healthy Kids Corporation is confidential and exempt from s.
4 119.07(1) and s. 24(a), Art. I of the State Constitution. Such
5 information may be disclosed to another governmental entity
6 only if disclosure is necessary for the entity to perform its
7 duties and responsibilities under the Florida Kidcare program
8 and shall be disclosed to the Department of Revenue for
9 purposes of administering the state Title IV-D program. The
10 receiving governmental entity must maintain the confidential
11 and exempt status of such information. Furthermore, such
12 information may not be released to any person without the
13 written consent of the program applicant. This exemption
14 applies to any information identifying a Florida Kidcare
15 program applicant or enrollee held by the Agency for Health
16 Care Administration, the Department of Children and Family
17 Services, the Department of Health, or the Florida Healthy
18 Kids Corporation before, on, or after the effective date of
19 this exemption. A violation of this section is a misdemeanor
20 of the second degree, punishable as provided in s. 775.082 or
21 s. 775.083. This section does not prohibit any enrollee's
22 parent or legal guardian from obtaining confirmation of
23 coverage, dates of coverage, name of the child's health plan,
24 and amount of premium being paid.
25 Section 10. Section 409.830, Florida Statutes, is
26 created to read:
27 409.830 The Florida Kidcare Consolidation Pilot
28 Program.--The Florida Kidcare Consolidation Pilot Program is
29 created to provide a seamless delivery system of health
30 benefits to uninsured, low-income children. The pilot program
31 shall consolidate the administration of the Florida Kidcare
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1 program in Baker, Broward, Clay, Duval, and Nassau Counties
2 under the fewest entities necessary to conduct marketing and
3 outreach, eligibility determination, contract management of
4 health plans and fiscal agents, quality assurance and
5 grievance resolution, and fiscal management of all the
6 components of the Florida Kidcare program as defined in s.
7 409.813.
8 (1) ADMINISTRATION.--The pilot program shall be
9 administered by the Agency for Health Care Administration, in
10 coordination with the Department of Children and Family
11 Services. The agency is designated as the state agency
12 authorized to make payments for medical assistance and related
13 services for the Florida Kidcare Consolidation Pilot Program
14 in the designated counties.
15 (a) The agency shall develop and distribute marketing
16 and outreach materials that educate families about the Florida
17 Kidcare program as a whole, including eligibility
18 requirements, application procedures, benefit design, and
19 other information that the agency considers necessary to
20 assist families in applying for and remaining in the Florida
21 Kidcare program. Marketing and outreach materials shall
22 present the Florida Kidcare program as a single entity and
23 explain that the family's information is collected in order to
24 determine if the family is eligible for a premium discount or
25 if there is no premium requirement.
26 (b) The Department of Children and Family Services, in
27 coordination with the agency, shall be responsible for
28 determining eligibility, including receiving and processing
29 applications for all program components, determining
30 eligibility for all program components, and transmitting and
31 receiving all correspondence related to the process for
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1 determining eligibility. All correspondence shall be
2 identified solely with the Florida Kidcare program as a whole.
3 (c) The agency, in consultation with the Department of
4 Health, shall adopt and administer a clinical eligibility
5 screening instrument for assessing whether an applicant is a
6 child with special health care needs as defined in s. 409.811.
7 The clinical eligibility screening instrument shall be
8 administered by a licensed health professional who is employed
9 by or under contract with the agency.
10 (d) The agency shall contract with capitated managed
11 care plans as defined in s. 409.91211(12), to provide health
12 benefits as specified in this section.
13 (2) BENEFITS.--Health benefits shall be provided to
14 eligible children based on the Florida Kidcare program
15 component for which they are eligible.
16 (a) A health plan serving children who are eligible
17 for Medicare or Medikids must contain the same benefits
18 specified in ss. 409.905 and 409.906, except that the amount,
19 scope, and duration of the benefits may vary among capitated
20 managed care plans to the extent allowed under the Medicaid
21 managed care pilot program as created in s. 409.91211.
22 Services to recipients under plan benefits shall include Early
23 and Periodic Screening, Diagnostic, and Treatment (EPSDT)
24 services and emergency services provided under s. 409.9128.
25 (b) A health plan serving children who are qualified
26 for premium assistance other than the Medikids component must
27 contain the same benefits as specified in s. 409.815(2).
28 (c) A health plan serving children with special health
29 care needs must contain the same benefits as specified in ss.
30 409.905 and 409.906, except that the amount, scope, and
31 duration of the benefits may vary among capitated managed care
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1 plans to the extent allowed under the Medicaid managed care
2 pilot program as created in s. 409.91211. Services to
3 recipients under plan benefits shall include Early and
4 Periodic Screening, Diagnostic, and Treatment (EPSDT)
5 services, care coordination, emergency services provided under
6 s. 409.9128, and other services as are found necessary
7 following a screening of children with special health care
8 needs to determine eligibility for services.
9 (3) ELIGIBILITY.--Children eligible to participate in
10 the Florida Kidcare Consolidation Pilot Program are those
11 qualified under the eligibility standards specified in ss.
12 409.8132, 409.814, 409.903, and 409.904.
13 (4) ENROLLMENT.--Children enrolled in any component of
14 the Florida Kidcare program as of August 31, 2007, shall be
15 enrolled in a health plan under this section upon
16 redetermination or during open enrollment in the Medicaid
17 reform waiver. Children who become eligible on or after
18 September 1, 2007, shall be enrolled in the pilot program upon
19 an affirmative determination of eligibility.
20 (5) CAPITATION RATES.--Managed care plans
21 participating in the pilot program shall be compensated using
22 a risk-adjusted, per-member, and per-month capitation rate
23 using the methodology adopted under the Medicaid managed care
24 pilot program as created in s. 409.91211. The methodology may
25 be modified as necessary to ensure a capitation rate that is
26 actuarially sound.
27 (6) PILOT PROGRAM EVALUATION.--The agency shall
28 contract for an evaluation of the Florida Kidcare
29 Consolidation Pilot Program to determine whether the program
30 should be expanded to additional counties or statewide. The
31 evaluation shall also include recommendations on how to
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1 complete the consolidation of the Florida Kidcare program
2 under the model created in this section and recommended
3 statutory modifications. The agency shall report the findings
4 of the evaluation to the Governor, the President of the
5 Senate, and the Speaker of the House of Representatives by
6 January 1, 2009.
7 (7) IMPLEMENTATION.--The Florida Kidcare Consolidation
8 Pilot Program shall begin enrollment on September 1, 2007, in
9 Baker, Broward, Clay, Duval, and Nassau Counties. The agency
10 shall seek approval of a federal waiver or amendments to the
11 Medicaid state plan which are necessary to implement the pilot
12 program as specified in this section.
13 (8) RULES.--The agency shall adopt rules as necessary
14 to implement the Florida Kidcare Consolidation Pilot Program.
15 Section 11. Section 624.91, Florida Statutes, is
16 amended to read:
17 624.91 The Florida Healthy Kids Corporation Act.--
18 (1) SHORT TITLE.--This section may be cited as the
19 "William G. 'Doc' Myers Healthy Kids Corporation Act."
20 (2) LEGISLATIVE INTENT.--
21 (a) The Legislature finds that increased access to
22 health care services could improve children's health and
23 reduce the incidence and costs of childhood illness and
24 disabilities among children in this state. Many children do
25 not have comprehensive, affordable health care services
26 available. It is the intent of the Legislature that the
27 Florida Healthy Kids Corporation provide comprehensive health
28 insurance coverage to such children. The corporation is
29 encouraged to cooperate with any existing health service
30 programs funded by the public or the private sector.
31
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1 (b) It is the intent of the Legislature that the
2 Florida Healthy Kids Corporation serve as one of several
3 providers of services to children eligible for medical
4 assistance under Title XXI of the Social Security Act.
5 Although the corporation may serve other children, the
6 Legislature intends the primary recipients of services
7 provided through the corporation be school-age children with a
8 family income below 200 percent of the federal poverty level,
9 who do not qualify for Medicaid. It is also the intent of the
10 Legislature that state and local government Florida Healthy
11 Kids funds be used to continue coverage, subject to specific
12 appropriations in the General Appropriations Act, to children
13 not eligible for federal matching funds under Title XXI.
14 (3) ELIGIBILITY FOR STATE-FUNDED ASSISTANCE.--Only the
15 following individuals are eligible for state-funded assistance
16 in paying Florida Healthy Kids premiums:
17 (a) Residents of this state who are eligible for the
18 Florida Kidcare program pursuant to s. 409.814.
19 (b) Notwithstanding s. 409.814, legal aliens who are
20 enrolled in the Florida Healthy Kids program as of January 31,
21 2004, who do not qualify for Title XXI federal funds because
22 they are not qualified aliens as defined in s. 409.811.
23 (4) NONENTITLEMENT.--Nothing in this section shall be
24 construed as providing an individual with an entitlement to
25 health care services. No cause of action shall arise against
26 the state, the Florida Healthy Kids Corporation, or a unit of
27 local government for failure to make health services available
28 under this section.
29 (5) CORPORATION AUTHORIZATION, DUTIES, POWERS.--
30 (a) There is created the Florida Healthy Kids
31 Corporation, a not-for-profit corporation. For purposes of
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1 administering the Florida Healthy Kids program, the
2 corporation shall be considered an agency under s. 120.52(1)
3 and shall comply with the provisions of chapter 120.
4 (b) The Florida Healthy Kids Corporation shall:
5 1. Arrange for the collection of any family, local
6 contributions, or employer payment or premium, in an amount to
7 be determined by the board of directors, to provide for
8 payment of premiums for comprehensive insurance coverage and
9 for the actual or estimated administrative expenses.
10 2. Arrange for the collection of any voluntary
11 contributions to provide for payment of premiums for children
12 who are not eligible for medical assistance under Title XXI of
13 the Social Security Act.
14 3. Subject to the provisions of s. 409.8134, accept
15 voluntary supplemental local match contributions that comply
16 with the requirements of Title XXI of the Social Security Act
17 for the purpose of providing additional coverage in
18 contributing counties under Title XXI.
19 4. Establish the administrative and accounting
20 procedures for the operation of the corporation.
21 5. Establish, with consultation from appropriate
22 professional organizations, standards for preventive health
23 services and providers and comprehensive insurance benefits
24 appropriate to children, provided that the such standards for
25 rural areas do shall not limit primary care providers to
26 board-certified pediatricians.
27 6. Determine eligibility for children seeking to
28 participate in the Title XXI-funded components of the Florida
29 Kidcare program consistent with the requirements specified in
30 s. 409.814, as well as the non-Title-XXI-eligible children as
31 provided in subsection (3).
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1 7. Establish procedures under which providers of local
2 match to, applicants to and participants in the program may
3 have grievances reviewed by an impartial body and reported to
4 the board of directors of the corporation.
5 8. Establish participation criteria and, if
6 appropriate, contract with an authorized insurer, health
7 maintenance organization, or third-party administrator to
8 provide administrative services to the corporation.
9 9. Establish enrollment criteria that which shall
10 include penalties or waiting periods of not fewer than 60 days
11 for reinstatement of coverage upon voluntary cancellation for
12 nonpayment of family premiums.
13 10. Contract with authorized insurers or any provider
14 of health care services, meeting standards established by the
15 corporation, for the provision of comprehensive insurance
16 coverage to participants. Such standards shall include
17 criteria under which the corporation may contract with more
18 than one provider of health care services in program sites.
19 Health plans shall be selected through a competitive bid
20 process. The Florida Healthy Kids Corporation shall purchase
21 goods and services in the most cost-effective manner
22 consistent with the delivery of quality medical care. The
23 maximum administrative cost for a Florida Healthy Kids
24 Corporation contract shall be 15 percent. For health care
25 contracts, the minimum medical loss ratio for a Florida
26 Healthy Kids Corporation contract shall be 85 percent. For
27 dental contracts, the remaining compensation to be paid to the
28 authorized insurer or provider under a Florida Healthy Kids
29 Corporation contract shall be no less than an amount which is
30 85 percent of premium; to the extent any contract provision
31 does not provide for this minimum compensation, this section
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1 shall prevail. The health plan selection criteria and scoring
2 system, and the scoring results, shall be available upon
3 request for inspection after the bids have been awarded.
4 11. Establish disenrollment criteria in the event
5 local matching funds are insufficient to cover enrollments.
6 12. Develop and implement a plan to publicize the
7 Florida Healthy Kids Corporation, the eligibility requirements
8 of the program, and the procedures for enrollment in the
9 program and to maintain public awareness of the corporation
10 and the program. Health and dental plans participating in the
11 Florida Healthy Kids program may develop and distribute
12 marketing and other promotional materials and participate in
13 activities, such as health fairs and public events, as
14 approved by the corporation. The health and dental plans may
15 also contact their current and former enrollees to encourage
16 continued participation in the program and to assist the
17 enrollee in transferring from a Title XIX-financed plan to a
18 Title XXI-financed plan.
19 13. Secure staff necessary to properly administer the
20 corporation. Staff costs shall be funded from state and local
21 matching funds and such other private or public funds as
22 become available. The board of directors shall determine the
23 number of staff members necessary to administer the
24 corporation.
25 14. Provide a report annually to the Governor, Chief
26 Financial Officer, Commissioner of Education, Senate
27 President, Speaker of the House of Representatives, and
28 Minority Leaders of the Senate and the House of
29 Representatives.
30
31
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1 15. Establish benefit packages which conform to the
2 provisions of the Florida Kidcare program, as created in ss.
3 409.810-409.820.
4 (c) Coverage under the corporation's program is
5 secondary to any other available private coverage held by, or
6 applicable to, the participant child or family member.
7 Insurers under contract with the corporation are the payors of
8 last resort and must coordinate benefits with any other
9 third-party payor that may be liable for the participant's
10 medical care.
11 (d) The Florida Healthy Kids Corporation shall be a
12 private corporation not for profit, organized under pursuant
13 to chapter 617, and shall have all powers necessary to carry
14 out the purposes of this act, including, but not limited to,
15 the power to receive and accept grants, loans, or advances of
16 funds from any public or private agency and to receive and
17 accept from any source contributions of money, property,
18 labor, or any other thing of value, to be held, used, and
19 applied for the purposes of this section act.
20 (6) BOARD OF DIRECTORS.--
21 (a) The Florida Healthy Kids Corporation shall operate
22 subject to the supervision and approval of a board of
23 directors chaired by the Chief Financial Officer or her or his
24 designee, and composed of 10 other members selected for 3-year
25 terms of office as follows:
26 1. The Secretary of Health Care Administration, or his
27 or her designee;
28 2. One member appointed by the Commissioner of
29 Education from the Office of School Health Programs of the
30 Florida Department of Education;
31
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1 3. One member appointed by the Chief Financial Officer
2 from among three members nominated by the Florida Pediatric
3 Society;
4 4. One member, appointed by the Governor, who
5 represents the Children's Medical Services Program;
6 5. One member appointed by the Chief Financial Officer
7 from among three members nominated by the Florida Hospital
8 Association;
9 6. One member, appointed by the Governor, who is an
10 expert on child health policy;
11 7. One member, appointed by the Chief Financial
12 Officer, from among three members nominated by the Florida
13 Academy of Family Physicians;
14 8. One member, appointed by the Governor, who
15 represents the state Medicaid program;
16 9. One member, appointed by the Chief Financial
17 Officer, from among three members nominated by the Florida
18 Association of Counties; and
19 10. The State Health Officer or her or his designee.
20 (b) A member of the board of directors may be removed
21 by the official who appointed that member. The board shall
22 appoint an executive director, who is responsible for other
23 staff authorized by the board.
24 (c) Board members are entitled to receive, from funds
25 of the corporation, reimbursement for per diem and travel
26 expenses as provided by s. 112.061.
27 (d) There shall be no liability on the part of, and no
28 cause of action shall arise against, any member of the board
29 of directors, or its employees or agents, for any action they
30 take in the performance of their powers and duties under this
31 act.
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1 (7) LICENSING NOT REQUIRED; FISCAL OPERATION.--
2 (a) The corporation shall not be deemed an insurer.
3 The officers, directors, and employees of the corporation
4 shall not be deemed to be agents of an insurer. Neither the
5 corporation nor any officer, director, or employee of the
6 corporation is subject to the licensing requirements of the
7 insurance code or the rules of the Department of Financial
8 Services. However, any marketing representative utilized and
9 compensated by the corporation must be appointed as a
10 representative of the insurers or health services providers
11 with which the corporation contracts.
12 (b) The board has complete fiscal control over the
13 corporation and is responsible for all corporate operations.
14 (c) The Department of Financial Services shall
15 supervise any liquidation or dissolution of the corporation
16 and shall have, with respect to such liquidation or
17 dissolution, all power granted to it pursuant to the insurance
18 code.
19 (8) ACCESS TO RECORDS; CONFIDENTIALITY;
20 PENALTIES.--Notwithstanding any other laws to the contrary,
21 the Florida Healthy Kids Corporation shall have access to the
22 medical records of a student upon receipt of permission from a
23 parent or guardian of the student. Such medical records may be
24 maintained by state and local agencies. Any identifying
25 information, including medical records and family financial
26 information, obtained by the corporation pursuant to this
27 subsection is confidential and is exempt from the provisions
28 of s. 119.07(1). Neither the corporation nor the staff or
29 agents of the corporation may release, without the written
30 consent of the participant or the parent or guardian of the
31 participant, to any state or federal agency, to any private
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1 business or person, or to any other entity, any confidential
2 information received pursuant to this subsection. A violation
3 of this subsection is a misdemeanor of the second degree,
4 punishable as provided in s. 775.082 or s. 775.083.
5 Section 12. This act shall take effect July 1, 2007.
6
7 *****************************************
8 SENATE SUMMARY
9 Revises various provisions of the Florida Kidcare
Program. Revises eligibility and screening requirements
10 for applicants to the program. Provides duties of the
Agency for Health Care Administration and the Department
11 of Health. Creates the Florida Kidcare Consolidation
Pilot Program within specified counties. Provides for the
12 agency to administer the pilot program in coordination
with the Department of Children and Family Services.
13 Requires an evaluation of the pilot program and a report
to the Governor and Legislature. (See bill for details.)
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