Florida Senate - 2007 COMMITTEE AMENDMENT
Bill No. CS for SB 930
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CHAMBER ACTION
Senate House
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11 The Committee on Governmental Operations (Lawson) recommended
12 the following amendment:
13
14 Senate Amendment (with title amendment)
15 Delete everything after the enacting clause
16
17 and insert:
18 Section 1. Section 14.35, Florida Statutes, is created
19 to read:
20 14.35 Florida Council on Children's Health.--
21 (1)(a) For purposes of this section, the term "health"
22 includes physical, mental, and dental health.
23 (b) The Florida Council on Children's Health is
24 established in the Executive Office of the Governor. The term
25 "council" means a coordinated council as defined in s. 20.03
26 which is subject to the requirements of s. 20.052, except as
27 otherwise provided in this section. The council shall be
28 administratively housed within the Executive Office of the
29 Governor. The council shall consist of 12 members who shall be
30 appointed by the Governor. Council members shall broadly
31 represent the interests of children in obtaining necessary
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1 health care services and health care coverage. Each member of
2 the council shall be appointed to a 4-year term. A member may
3 not serve more than two consecutive terms. A vacancy shall be
4 filled in the same manner as the original appointment. Voting
5 members of the council may not be employees of the Florida
6 Kidcare partner agencies, the Florida Healthy Kids
7 Corporation, or other state agencies.
8 (2) The council shall meet quarterly and upon the call
9 of the chair and two other council members. Annually, at the
10 meeting in the first quarter, officers consisting of a chair,
11 vice chair, secretary, and treasurer shall be elected. Each
12 officer shall serve until a successor is elected and
13 qualified. An officer may not serve more than 2 consecutive
14 years in the same office.
15 (3) Members of the council shall serve without
16 compensation, but are entitled to reimbursement for per diem
17 and travel expenses in accordance with s. 112.061.
18 (4) The council shall identify and develop specific
19 strategies for addressing issues related to children's lack of
20 access to high-quality and affordable health care services and
21 health care coverage in this state for recommendation to the
22 Governor and the Legislature. The council shall assist in the
23 coordination of agencies and departments in the state in order
24 to increase accountability regarding children's health issues.
25 The council shall:
26 (a) Provide recommendations for implementing the
27 consolidation of the Florida Kidcare program.
28 (b) Study the barriers to children's accessing
29 high-quality and affordable health care services and health
30 care coverage in this state.
31 (c) Submit an annual report to the Governor concerning
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1 the status of children's health issues, including, but not
2 limited to, an assessment of the number of uninsured children,
3 the health status of children in this state using public
4 health indicators, the gaps in health care services for
5 children with special health care needs, and the status of
6 programs affecting children's health in this state.
7 (d) Analyze the responsiveness of state government to
8 the health needs of children and the appropriateness of the
9 response. The council may submit a plan for recommended
10 restructuring and change to the Governor, the President of the
11 Senate, the Speaker of the House of Representatives, and the
12 Chief Financial Officer at any time it considers appropriate.
13 (e) Receive quarterly updates from the Department of
14 Health concerning the status of implementing policy changes to
15 the programs affecting children's health and the
16 implementation of the council's recommendations.
17 (f) Identify and provide recommendations for ways to
18 improve the delivery of services for children.
19 (g) Review proposed federal and state legislation
20 affecting children's health and provide recommendations to the
21 Governor on appropriate actions pertaining to this section.
22 (h) Study and make recommendations to refine the
23 eligibility determination process for the Florida Kidcare
24 program.
25 (5) All executive branch agencies are instructed, and
26 all other state agencies are requested, to aid and assist the
27 council in any way that helps it accomplish its purpose.
28 Section 2. Subsection (3) of section 20.43, Florida
29 Statutes, is amended to read:
30 20.43 Department of Health.--There is created a
31 Department of Health.
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1 (3) The following divisions of the Department of
2 Health are established:
3 (a) Division of Administration.
4 (b) Division of Environmental Health.
5 (c) Division of Disease Control.
6 (d) Division of Family Health Services.
7 (e) Division of Children's Medical Services Network
8 and Specialty Programs.
9 (f) Division of Emergency Medical Operations.
10 (g) Division of Medical Quality Assurance, which is
11 responsible for the following boards and professions
12 established within the division:
13 1. The Board of Acupuncture, created under chapter
14 457.
15 2. The Board of Medicine, created under chapter 458.
16 3. The Board of Osteopathic Medicine, created under
17 chapter 459.
18 4. The Board of Chiropractic Medicine, created under
19 chapter 460.
20 5. The Board of Podiatric Medicine, created under
21 chapter 461.
22 6. Naturopathy, as provided under chapter 462.
23 7. The Board of Optometry, created under chapter 463.
24 8. The Board of Nursing, created under part I of
25 chapter 464.
26 9. Nursing assistants, as provided under part II of
27 chapter 464.
28 10. The Board of Pharmacy, created under chapter 465.
29 11. The Board of Dentistry, created under chapter 466.
30 12. Midwifery, as provided under chapter 467.
31 13. The Board of Speech-Language Pathology and
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1 Audiology, created under part I of chapter 468.
2 14. The Board of Nursing Home Administrators, created
3 under part II of chapter 468.
4 15. The Board of Occupational Therapy, created under
5 part III of chapter 468.
6 16. Respiratory therapy, as provided under part V of
7 chapter 468.
8 17. Dietetics and nutrition practice, as provided
9 under part X of chapter 468.
10 18. The Board of Athletic Training, created under part
11 XIII of chapter 468.
12 19. The Board of Orthotists and Prosthetists, created
13 under part XIV of chapter 468.
14 20. Electrolysis, as provided under chapter 478.
15 21. The Board of Massage Therapy, created under
16 chapter 480.
17 22. The Board of Clinical Laboratory Personnel,
18 created under part III of chapter 483.
19 23. Medical physicists, as provided under part IV of
20 chapter 483.
21 24. The Board of Opticianry, created under part I of
22 chapter 484.
23 25. The Board of Hearing Aid Specialists, created
24 under part II of chapter 484.
25 26. The Board of Physical Therapy Practice, created
26 under chapter 486.
27 27. The Board of Psychology, created under chapter
28 490.
29 28. School psychologists, as provided under chapter
30 490.
31 29. The Board of Clinical Social Work, Marriage and
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1 Family Therapy, and Mental Health Counseling, created under
2 chapter 491.
3 (h) Division of Children's Medical Services Prevention
4 and Intervention.
5 (i) Division of Information Technology.
6 (j) Division of Health Access and Tobacco.
7 (k) Division of Disability Determinations.
8 (l) Division of Children's Health Insurance.
9 (m) Office of Child Health Coordination.
10 Section 3. Section 391.011, Florida Statutes, is
11 amended to read:
12 391.011 Short title.--The provisions of this chapter
13 may be cited as the "Children's Health Act." "Children's
14 Medical Services Act."
15 Section 4. Section 391.016, Florida Statutes, is
16 amended to read:
17 391.016 Legislative intent.--The Legislature intends
18 that the Children's Health Medical Services program:
19 (1) Provide to children with special health care needs
20 a family-centered, comprehensive, and coordinated statewide
21 managed system of care that links community-based health care
22 with multidisciplinary, regional, and tertiary pediatric
23 specialty care. The program may provide for the coordination
24 and maintenance of consistency of the medical home for
25 children in families with a Children's Medical Services
26 program participant, in order to achieve family-centered care.
27 (2) Provide essential preventive, evaluative, and
28 early intervention services for children at risk for or having
29 special health care needs, in order to prevent or reduce
30 long-term disabilities.
31 (3) Serve as a principal provider for children with
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1 special health care needs under Titles XIX and XXI of the
2 Social Security Act.
3 (4) Be complementary to children's health training
4 programs essential for the maintenance of a skilled pediatric
5 health care workforce for all Floridians.
6 (5) Consolidate and coordinate Florida Kidcare child
7 health policy, development of pediatric benefit packages,
8 development of budget and federal and state legislative
9 issues, and development of pediatric quality assurance and
10 access standards.
11 Section 5. Section 391.021, Florida Statutes, is
12 amended to read:
13 391.021 Definitions.--When used in this act, unless
14 the context clearly indicates otherwise:
15 (1) "Children's Medical Services network" or "network"
16 means a statewide managed care service system that includes
17 health care providers, health care facilities, or entities
18 licensed or certified to provide health services in this state
19 which meet the pediatric access and quality standards
20 established by the department as defined in this section. The
21 network shall provide Florida Kidcare Plus benefits as defined
22 in s. 409.811.
23 (2) "Children with special health care needs" means
24 those children younger than 21 years of age who have chronic
25 physical, developmental, behavioral, or emotional conditions
26 and who also require health care and related services of a
27 type or amount beyond that which is generally required by
28 children.
29 (3) "Department" means the Department of Health.
30 (4) "Eligible individual" means a child with a special
31 health care need or a female with a high-risk pregnancy, who
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1 meets the financial and medical eligibility standards
2 established in s. 391.029.
3 (5) "Health care provider" means a health care
4 professional, health care facility, or entity licensed or
5 certified to provide health services in this state that meets
6 the criteria as established by the department.
7 (6) "Health services" includes the prevention,
8 diagnosis, and treatment of human disease, pain, injury,
9 deformity, or disabling conditions.
10 (7) "Maximum income threshold" has the same meaning as
11 in s. 409.811.
12 (8)(7) "Participant" means an eligible individual who
13 is enrolled in the Children's Medical Services program.
14 (9) "Pediatric benefit" means a benefit that is
15 determined to be medically necessary to treat a health
16 condition. The scope, duration, and frequency of the service
17 are based on medical-necessity criteria.
18 (10)(8) "Program" means the Children's Medical
19 Services program established in the department.
20 (11) "Safety net" means limited services provided to
21 children with special health care needs who are uninsured or
22 underinsured and do not qualify for Title XIX-funded or Title
23 XXI-funded health benefits coverage.
24 Section 6. Section 391.025, Florida Statutes, is
25 amended to read:
26 391.025 Applicability and scope.--
27 (1) The Children's Health Medical Services program
28 consists of the following components:
29 (a) The newborn screening program established in s.
30 383.14.
31 (b) The regional perinatal intensive care centers
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1 program established in ss. 383.15-383.21.
2 (c) A federal or state program authorized by the
3 Legislature.
4 (d) The developmental evaluation and intervention
5 program, including the Florida Infants and Toddlers Early
6 Intervention Program.
7 (e) The Children's Medical Services Network.
8 (f) The Division of Children's Health Insurance.
9 (g) The Office of Child Health Coordination.
10 (2) The Children's Medical Services Network program
11 shall not be deemed an insurer and is not subject to the
12 licensing requirements of the Florida Insurance Code or the
13 rules adopted thereunder, when providing services to children
14 who receive Title XIX-funded Medicaid benefits, other Title
15 XIX-eligible Medicaid-eligible children with special health
16 care needs, or Title XXI-funded and children with special
17 health care needs participating in the Florida Kidcare
18 program.
19 Section 7. Subsection (19) is added to section
20 391.026, Florida Statutes, to read:
21 391.026 Powers and duties of the department.--The
22 department shall have the following powers, duties, and
23 responsibilities:
24 (19) To administer the provisions of the Florida
25 Kidcare Act assigned to the Department of Health in ss.
26 409.810-409.820.
27 Section 8. Section 391.028, Florida Statutes, is
28 amended to read:
29 391.028 Administration.--The Children's Medical
30 Services Network program shall have a central office and area
31 offices.
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1 (1) The Director of Children's Health Medical Services
2 must be a physician licensed under chapter 458 or chapter 459
3 who has specialized training and experience in the provision
4 of health care to children and who has recognized skills in
5 leadership and the promotion of children's health programs.
6 The director shall be the deputy secretary and the Deputy
7 State Health Officer for Children's Health Medical Services
8 and is appointed by and reports to the secretary. The director
9 may appoint division directors subject to the approval of the
10 secretary.
11 (2) The director shall designate Children's Medical
12 Services Network area offices to perform operational
13 activities for children with special health care needs,
14 including, but not limited to:
15 (a) Providing case management services for the
16 network.
17 (b) Providing local oversight of the program.
18 (c) Determining an individual's clinical medical and
19 financial eligibility for the program.
20 (d) Participating in the determination of a level of
21 care and medical complexity for long-term care services.
22 (e) Authorizing services in the program and developing
23 spending plans.
24 (f) Participating in the development of treatment
25 plans.
26 (g) Taking part in the resolution of complaints and
27 grievances from participants and health care providers.
28 (3) Each Children's Medical Services Network area
29 office shall be directed by a physician licensed under chapter
30 458 or chapter 459 who has specialized training and experience
31 in the provision of health care to children. The director of
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1 a Children's Medical Services area office shall be appointed
2 by the director from the active panel of Children's Medical
3 Services physician consultants.
4 (4) The Division of Children's Health Insurance shall
5 be responsible for administering the provisions of the Florida
6 Kidcare Act assigned to the Department of Health in ss.
7 409.810-409.820.
8 (5) The Office of Child Health Coordination is
9 responsible for child health services not directly related to
10 Florida Kidcare health benefits coverage. This office also
11 shall be responsible for providing staff support to the
12 Council on Children's Health.
13 Section 9. Section 391.029, Florida Statutes, is
14 amended to read:
15 391.029 Program eligibility.--
16 (1) The department shall establish clinical
17 eligibility the medical criteria to determine if an applicant
18 for Florida Kidcare Plus benefits the Children's Medical
19 Services program is an eligible individual.
20 (2) The following individuals are financially eligible
21 to receive services through the Children's Medical Services
22 Network program:
23 (a) A high-risk pregnant female who is eligible for
24 Medicaid.
25 (b) Children with special health care needs from birth
26 to 21 years of age who are eligible for Medicaid.
27 (c) Children with special health care needs from birth
28 to 19 years of age who are eligible for a program under Title
29 XXI of the Social Security Act.
30 (3) Subject to the availability of funds, the
31 following individuals may receive services through the
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1 program:
2 (a) Children with special health care needs from birth
3 to 21 years of age whose families do not qualify for Title
4 XIX-financed or Title XXI-financed health benefits coverage
5 family income is above the requirements for financial
6 eligibility under Title XXI of the Social Security Act and
7 whose projected annual cost of care adjusts the family income
8 to Medicaid financial criteria. In cases where the family
9 income is adjusted based on a projected annual cost of care,
10 the family shall participate financially in the cost of care
11 based on criteria established by the department. These
12 children may receive safety net services, subject to the
13 availability of funds.
14 (b) Children with special health care needs from birth
15 to 21 years of age, as provided in Title V of the Social
16 Security Act.
17 (c) An infant who receives an award of compensation
18 under s. 766.31(1). The Florida Birth-Related Neurological
19 Injury Compensation Association shall reimburse the Children's
20 Medical Services Network the state's share of funding, which
21 must thereafter be used to obtain matching federal funds under
22 Title XXI of the Social Security Act.
23 (d) Children with special health care needs with
24 family incomes above the maximum income threshold may receive
25 Florida Kidcare Plus health benefits coverage if the Family
26 Opportunity Act is authorized.
27 (4) The department shall determine the financial and
28 medical eligibility of children with special health care needs
29 for the program. The department shall also determine the
30 financial ability of the parents, or persons or other agencies
31 having legal custody over such individuals, to pay the costs
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1 of health services under the program. The department may pay
2 reasonable travel expenses related to the determination of
3 eligibility for or the provision of health services.
4 (5) Any child who has been provided with surgical or
5 medical care or treatment under this act prior to being
6 adopted shall continue to be eligible to be provided with such
7 care or treatment after his or her adoption, regardless of the
8 financial ability of the persons adopting the child.
9 Section 10. Section 409.811, Florida Statutes, is
10 amended to read:
11 409.811 Definitions relating to Florida Kidcare
12 Act.--As used in ss. 409.810-409.820, the term:
13 (1) "Actuarially equivalent" means that:
14 (a) The aggregate value of the benefits included in
15 health benefits coverage is equal to the value of the benefits
16 in the benchmark benefit plan; and
17 (b) The benefits included in health benefits coverage
18 are substantially similar to the benefits included in the
19 benchmark benefit plan, except that preventive health services
20 must be the same as in the benchmark benefit plan.
21 (2) "Agency" means the Agency for Health Care
22 Administration.
23 (3) "Applicant" means a parent or guardian of a child
24 or a child whose disability of nonage has been removed under
25 chapter 743, who applies for determination of eligibility for
26 health benefits coverage under ss. 409.810-409.820.
27 (4) "Benchmark benefit plan" means the form and level
28 of health benefits coverage established in s. 409.815.
29 (5) "Child" means any person under 19 years of age.
30 (6) "Child with special health care needs" means a
31 child who has a chronic physical, developmental, behavioral,
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1 or emotional condition and who also required health care and
2 related services of a type or amount beyond that which is
3 generally required by children. whose serious or chronic
4 physical or developmental condition requires extensive
5 preventive and maintenance care beyond that required by
6 typically healthy children. Health care utilization by such a
7 child exceeds the statistically expected usage of the normal
8 child adjusted for chronological age, and such a child often
9 needs complex care requiring multiple providers,
10 rehabilitation services, and specialized equipment in a number
11 of different settings.
12 (7) "Children's Medical Services Network" or "network"
13 means a statewide managed care service system as defined in s.
14 391.021(1).
15 (8) "Community rate" means a method used to develop
16 premiums for a health insurance plan that spreads financial
17 risk across a large population and allows adjustments only for
18 age, gender, family composition, and geographic area.
19 (9) "Department" means the Department of Health.
20 (10) "Enrollee" means a child who has been determined
21 eligible for and is receiving coverage under ss.
22 409.810-409.820.
23 (11) "Family" means the group or the individuals whose
24 income is considered in determining eligibility for the
25 Florida Kidcare program. The family includes a child with a
26 custodial parent or caretaker relative who resides in the same
27 house or living unit or, in the case of a child whose
28 disability of nonage has been removed under chapter 743, the
29 child. The family may also include other individuals whose
30 income and resources are considered in whole or in part in
31 determining eligibility of the child.
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1 (11)(12) "Family income" means cash received at
2 periodic intervals from any source, such as wages, benefits,
3 contributions, or rental property. Family income is calculated
4 using the budget methodologies authorized under Title XIX of
5 the Social Security Act. Income also may include any money
6 that would have been counted as income under the Aid to
7 Families with Dependent Children (AFDC) state plan in effect
8 prior to August 22, 1996.
9 (12) "Florida Kidcare Plus" means health benefits
10 coverage for children with special health care needs which
11 benefits are delivered through the Children's Medical Services
12 Network established in chapter 391.
13 (13) "Florida Kidcare program," "Kidcare program," or
14 "program" means the health benefits program for children
15 administered through ss. 409.810-409.820.
16 (14) "Guarantee issue" means that health benefits
17 coverage must be offered to an individual regardless of the
18 individual's health status, preexisting condition, or claims
19 history.
20 (15) "Health benefits coverage" means protection that
21 provides payment of benefits for covered health care services
22 or that otherwise provides, either directly or through
23 arrangements with other persons, covered health care services
24 on a prepaid per capita basis or on a prepaid aggregate
25 fixed-sum basis.
26 (16) "Health insurance plan" means health benefits
27 coverage under the following:
28 (a) A health plan offered by any certified health
29 maintenance organization or authorized health insurer, except
30 a plan that is limited to the following: a limited benefit,
31 specified disease, or specified accident; hospital indemnity;
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1 accident only; limited benefit convalescent care; Medicare
2 supplement; credit disability; dental; vision; long-term care;
3 disability income; coverage issued as a supplement to another
4 health plan; workers' compensation liability or other
5 insurance; or motor vehicle medical payment only; or
6 (b) An employee welfare benefit plan that includes
7 health benefits established under the Employee Retirement
8 Income Security Act of 1974, as amended.
9 (17) "Healthy Kids" means a component of the Florida
10 Kidcare program of medical assistance for children who are 5
11 through 18 years of age as authorized under s. 624.91 and
12 administered by the Florida Healthy Kids Corporation.
13 (18) "Maximum income threshold" means a percentage of
14 the current federal poverty level used to determine
15 eligibility for certain program components, as approved by
16 federal waiver or an amendment to the state plan. Unless
17 otherwise approved by a federal waiver or an amendment to the
18 state plan, the maximum income threshold is 200 percent of the
19 most recent federal poverty level.
20 (19)(17) "Medicaid" means the medical assistance
21 program authorized by Title XIX of the Social Security Act,
22 and regulations thereunder, and ss. 409.901-409.920, as
23 administered in this state by the agency.
24 (20)(18) "Medically necessary" means the use of any
25 medical treatment, service, equipment, or supply necessary to
26 palliate the effects of a terminal condition, or to prevent,
27 diagnose, correct, cure, alleviate, or preclude deterioration
28 of a condition that threatens life, causes pain or suffering,
29 or results in illness or infirmity and which is:
30 (a) Consistent with the symptom, diagnosis, and
31 treatment of the enrollee's condition;
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1 (b) Provided in accordance with generally accepted
2 standards of medical practice;
3 (c) Not primarily intended for the convenience of the
4 enrollee, the enrollee's family, or the health care provider;
5 (d) The most appropriate level of supply or service
6 for the diagnosis and treatment of the enrollee's condition;
7 and
8 (e) Approved by the appropriate medical body or health
9 care specialty involved as effective, appropriate, and
10 essential for the care and treatment of the enrollee's
11 condition.
12 (21)(19) "Medikids" means a component of the Florida
13 Kidcare program of medical assistance authorized by Title XXI
14 of the Social Security Act, and regulations thereunder, and s.
15 409.8132, as administered in the state by the agency.
16 (22) "Pediatric benefit" means a benefit that is
17 determined to be medically necessary to treat a health
18 condition. The scope, duration, and frequency of the service
19 are based on medical-necessity criteria.
20 (23)(20) "Preexisting condition exclusion" means, with
21 respect to coverage, a limitation or exclusion of benefits
22 relating to a condition based on the fact that the condition
23 was present before the date of enrollment for such coverage,
24 whether or not any medical advice, diagnosis, care, or
25 treatment was recommended or received before such date.
26 (24)(21) "Premium" means the entire cost of a health
27 insurance plan, including the administration fee or the risk
28 assumption charge.
29 (25)(22) "Premium assistance payment" means the
30 monthly consideration paid by the agency per enrollee in the
31 Florida Kidcare program towards health insurance premiums.
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1 (26)(23) "Qualified alien" means an alien as defined
2 in s. 431 of the Personal Responsibility and Work Opportunity
3 Reconciliation Act of 1996, as amended, Pub. L. No. 104-193.
4 (27)(24) "Resident" means a United States citizen, or
5 qualified alien, who is domiciled in this state.
6 (28)(25) "Rural county" means a county having a
7 population density of less than 100 persons per square mile,
8 or a county defined by the most recent United States Census as
9 rural, in which there is no prepaid health plan participating
10 in the Medicaid program as of July 1, 1998.
11 (29)(26) "Substantially similar" means that, with
12 respect to additional services as defined in s. 2103(c)(2) of
13 Title XXI of the Social Security Act, these services must have
14 an actuarial value equal to at least 75 percent of the
15 actuarial value of the coverage for that service in the
16 benchmark benefit plan and, with respect to the basic services
17 as defined in s. 2103(c)(1) of Title XXI of the Social
18 Security Act, these services must be the same as the services
19 in the benchmark benefit plan.
20 Section 11. Section 409.812, Florida Statutes, is
21 amended to read:
22 409.812 Program created; purpose.--The Florida Kidcare
23 program is created to provide a defined set of health benefits
24 to previously uninsured, low-income children through the
25 establishment of a variety of affordable health benefits
26 coverage options from which families may select coverage and
27 through which families may contribute financially to the
28 health care of their children.
29 Section 12. Section 409.813, Florida Statutes, is
30 amended to read:
31 409.813 Program components; entitlement and
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1 nonentitlement.--The Florida Kidcare program includes health
2 benefits coverage provided to children through the following
3 funding sources, which shall be marketed as the Florida
4 Kidcare program:
5 (1) Title XIX of the Social Security Act Medicaid;
6 (2) Title XXI of the Social Security Act Medikids as
7 created in s. 409.8132;
8 (3) The Title V Program of the Social Security Act, as
9 it relates to children with special health care needs The
10 Florida Healthy Kids Corporation as created in s. 624.91;
11 (4) Employer-sponsored group health insurance plans
12 approved under ss. 409.810-409.820; and
13 (5) Full pay premiums for children with family incomes
14 above the maximum income threshold; and The Children's Medical
15 Services network established in chapter 391.
16 (6) For children with special health care needs with
17 family incomes above the maximum income threshold, the family
18 shall be afforded the opportunity to buy into the Medicaid
19 program, if the Family Opportunity Act is authorized.
20
21 Except for Title XIX-funded Florida Kidcare coverage under the
22 Medicaid program, coverage under the Florida Kidcare program
23 is not an entitlement. No cause of action shall arise against
24 the state, the department, the Department of Children and
25 Family Services, or the agency for failure to make health
26 services available to any person under ss. 409.810-409.820.
27 Section 13. Section 409.8132, Florida Statutes, is
28 amended to read:
29 409.8132 Medikids program component.--
30 (1) PROGRAM COMPONENT CREATED; PURPOSE.--The Medikids
31 program component is created in the Agency for Health Care
19
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1 Administration to provide health care services under the
2 Florida Kidcare program to eligible children using the
3 administrative structure and provider network of the Medicaid
4 program.
5 (2) ADMINISTRATION.--The secretary of the agency shall
6 appoint an administrator of the Medikids program component.
7 The Agency for Health Care Administration is designated as the
8 state agency authorized to make payments for medical
9 assistance and related services for the Medikids program
10 component of the Florida Kidcare program. Payments shall be
11 made, subject to any limitations or directions in the General
12 Appropriations Act, only for covered services provided to
13 eligible children by qualified health care providers under the
14 Florida Kidcare program.
15 (3) INSURANCE LICENSURE NOT REQUIRED.--The Medikids
16 program component shall not be subject to the licensing
17 requirements of the Florida Insurance Code or rules adopted
18 thereunder.
19 (4) APPLICABILITY OF LAWS RELATING TO MEDICAID.--The
20 provisions of ss. 409.902, 409.905, 409.906, 409.907, 409.908,
21 409.912, 409.9121, 409.9122, 409.9123, 409.9124, 409.9127,
22 409.9128, 409.913, 409.916, 409.919, 409.920, and 409.9205
23 apply to the administration of the Medikids program component
24 of the Florida Kidcare program, except that s. 409.9122
25 applies to Medikids as modified by the provisions of
26 subsection (7).
27 (5) BENEFITS.--Benefits provided under the Medikids
28 program component shall be the same benefits provided to
29 children as specified in ss. 409.905 and 409.906.
30 (6) ELIGIBILITY.--
31 (a) A child who has attained the age of 1 year but who
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1 is under the age of 5 years is eligible to enroll in the
2 Medikids program component of the Florida Kidcare program, if
3 the child is a member of a family that has a family income
4 which exceeds the Medicaid applicable income level as
5 specified in s. 409.903, but which is equal to or below the
6 maximum income threshold 200 percent of the current federal
7 poverty level. In determining the eligibility of such a
8 child, an assets test is not required. A child who is eligible
9 for Medikids may elect to enroll in Florida Healthy Kids
10 coverage or employer-sponsored group coverage. Effective July
11 1, 2009, age eligibility for the Medikids program component
12 will increase to children who are up to age 19 and who do not
13 have special health care needs. However, a child who is
14 eligible for Medikids may participate in the Florida Healthy
15 Kids program only if the child has a sibling participating in
16 the Florida Healthy Kids program and the child's county of
17 residence permits such enrollment.
18 (b) The provisions of s. 409.814(3), (5) (4), and (7)
19 (5) shall be applicable to the Medikids program.
20 (7) ENROLLMENT.--Enrollment in the Medikids program
21 component may occur at any time throughout the year. A child
22 may not receive services under the Medikids program until the
23 child is enrolled in a managed care plan or MediPass. Once
24 determined eligible, an applicant may receive choice
25 counseling and select a managed care plan or MediPass. The
26 agency may initiate mandatory assignment for a Medikids
27 applicant who has not chosen a managed care plan or MediPass
28 provider after the applicant's voluntary choice period ends.
29 An applicant may select MediPass under the Medikids program
30 component only in counties that have fewer than two managed
31 care plans available to serve Medicaid recipients and only if
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1 the federal Health Care Financing Administration determines
2 that MediPass constitutes "health insurance coverage" as
3 defined in Title XXI of the Social Security Act.
4 (8) PENALTIES FOR VOLUNTARY CANCELLATION.--The agency
5 shall establish enrollment criteria that must include
6 penalties or waiting periods of not fewer than 60 days for
7 reinstatement of coverage upon voluntary cancellation for
8 nonpayment of premiums.
9 Section 14. Section 409.8134, Florida Statutes, is
10 amended to read:
11 409.8134 Program expenditure ceiling; enrollment.--
12 (1) Except for the Medicaid program, a ceiling shall
13 be placed on annual federal and state expenditures for the
14 Florida Kidcare program as provided each year in the General
15 Appropriations Act.
16 (2) The Florida Kidcare program shall may conduct
17 enrollment continuously at any time throughout the year for
18 the purpose of enrolling children eligible for all program
19 components listed in s. 409.813 except Medicaid. The four
20 Florida Kidcare administrators shall work together to ensure
21 that the year-round enrollment period is announced statewide.
22 Children eligible for Title XXI-funded Florida Kidcare
23 coverage Eligible children shall be enrolled on a first-come,
24 first-served basis using the date the enrollment application
25 is received. Enrollment shall immediately cease when the
26 expenditure ceiling is reached. Year-round enrollment shall
27 only be held if the Social Services Estimating Conference
28 determines that sufficient federal and state funds will be
29 available to finance the increased enrollment through federal
30 fiscal year 2007. Any individual who is not enrolled must
31 reapply by submitting a new application. The application for
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1 the Florida Kidcare program is shall be valid for a period of
2 120 days after the date it was received. At the end of the
3 120-day period, if the applicant has not been enrolled in the
4 program, the application is shall be invalid and the applicant
5 shall be notified of the action. The applicant may reactivate
6 resubmit the application after notification of the action
7 taken by the program. Except for the Medicaid program,
8 whenever the Social Services Estimating Conference determines
9 that there are presently, or will be by the end of the current
10 fiscal year, insufficient funds to finance the current or
11 projected enrollment in the Florida Kidcare program, all
12 additional enrollment must cease and additional enrollment may
13 not resume until sufficient funds are available to finance
14 such enrollment.
15 (3) Upon determination by the Social Services
16 Estimating Conference that there are insufficient funds to
17 finance the current enrollment in the Florida Kidcare program
18 within current appropriations, the program shall initiate
19 disenrollment procedures to remove enrollees, except those
20 children who receive Florida Kidcare Plus benefits enrolled in
21 the Children's Medical Services Network, on a last-in,
22 first-out basis until the expenditure and appropriation levels
23 are balanced.
24 (4) The agencies that administer the Florida Kidcare
25 program components shall collect and analyze the data needed
26 to project program enrollment costs, including price level
27 adjustments, participation and attrition rates, current and
28 projected caseloads, the estimated number of children in the
29 state who are uninsured based on data from the most recent
30 United States Census, utilization, and current and projected
31 expenditures for the next 3 years. The agencies shall report
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1 caseload and expenditure trends and estimated numbers of
2 uninsured children to the Social Services Estimating
3 Conference in accordance with chapter 216.
4 Section 15. Section 409.814, Florida Statutes, is
5 amended to read:
6 409.814 Eligibility.--A child who has not reached 19
7 years of age whose family income is equal to or below the
8 maximum income threshold 200 percent of the federal poverty
9 level is eligible for the Florida Kidcare program as provided
10 in this section. For enrollment in Florida Kidcare Plus the
11 Children's Medical Services Network, a complete application
12 includes clinical eligibility the medical or behavioral health
13 screening. If, subsequently, an individual is determined to be
14 ineligible for coverage, he or she must immediately be
15 disenrolled from the respective Florida Kidcare program
16 component.
17 (1) A child who is eligible for Medicaid coverage
18 under s. 409.903 or s. 409.904 must be enrolled in Medicaid
19 and is not eligible to receive health benefits under any other
20 health benefits coverage authorized under the Florida Kidcare
21 program.
22 (2) A child who is not eligible for Medicaid, but who
23 is eligible for the Florida Kidcare program, may obtain health
24 benefits coverage under any of the other components listed in
25 s. 409.813 if such coverage is approved and available in the
26 county in which the child resides. However, a child who is
27 eligible for Medikids may participate in the Florida Healthy
28 Kids program only if the child has a sibling participating in
29 the Florida Healthy Kids program and the child's county of
30 residence permits such enrollment.
31 (3) A child who is eligible for the Florida Kidcare
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1 program who is a child with special health care needs, as
2 determined through a clinical-eligibility medical or
3 behavioral screening instrument, shall receive Florida Kidcare
4 is eligible for health benefits coverage from and shall be
5 referred to the Children's Medical Services Network. A Title
6 XIX-funded child with special health care needs may opt out of
7 Florida Kidcare Plus health benefits coverage and make another
8 selection for the delivery of the child's health benefits
9 coverage.
10 (4) A child who becomes ineligible for Title
11 XIX-funded Florida Kidcare health benefits coverage due to
12 exceeding income or age limits shall have 60 days of continued
13 eligibility following redetermination before premium payments
14 are required in order to allow for a transition to Title
15 XXI-funded Florida Kidcare without a lapse in coverage.
16 (5)(4) The following children are not eligible to
17 receive Title XXI-funded premium assistance for health
18 benefits coverage under the Florida Kidcare program, except
19 under Medicaid if the child would have been eligible for
20 Medicaid under s. 409.903 or s. 409.904 as of June 1, 1997:
21 (a) A child who is eligible for coverage under a state
22 health benefit plan on the basis of a family member's
23 employment with a public agency in the state.
24 (b) A child who is currently eligible for or covered
25 under a family member's group health benefit plan or under
26 other employer health insurance coverage, excluding full pay
27 Florida Kidcare health benefits coverage provided under the
28 Florida Healthy Kids Corporation as established under s.
29 624.91, if provided that the cost of the child's participation
30 is not greater than 5 percent of the family's income. This
31 provision shall be applied during redetermination for children
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1 who were enrolled prior to July 1, 2004. These enrollees shall
2 have 6 months of eligibility following redetermination to
3 allow for a transition to the other health benefit plan.
4 (c) A child who is seeking premium assistance for the
5 Florida Kidcare program through employer-sponsored group
6 coverage, if the child has been covered by the same employer's
7 group coverage during the 60 days 6 months prior to the
8 family's submitting an application for determination of
9 eligibility under the program.
10 (d) A child who is an alien, but who does not meet the
11 definition of qualified alien, in the United States.
12 (e) A child who is an inmate of a public institution
13 or a patient in an institution for mental diseases.
14 (f) A child who has had his or her coverage in an
15 employer-sponsored health benefit plan or a private health
16 benefit plan voluntarily canceled in the last 60 days 6
17 months, except those children whose coverage was canceled for
18 good cause, including, but not limited to:
19 1. The cost of participation in an employer-sponsored
20 health benefit plan is greater than 5 percent of the family's
21 income;
22 2. The parent lost a job that provided an
23 employer-sponsored health benefit plan for children;
24 3. The parent who had health benefits coverage for the
25 child is deceased;
26 4. The child has a medical condition that, without
27 medical care, would cause serious disability, loss of
28 function, or death;
29 5. The employer of the parent canceled health benefits
30 coverage for children;
31 6. The child's health benefits coverage ended because
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1 the child reached the maximum lifetime coverage amount;
2 7. The child has exhausted coverage under a COBRA
3 continuation provision;
4 8. The health benefits coverage does not cover the
5 child's health care needs; or
6 9. Domestic violence led to loss of coverage. who were
7 on the waiting list prior to March 12, 2004.
8 (g) A child who is otherwise eligible for Kidcare and
9 who has a preexisting condition that prevents coverage under
10 another insurance plan as described in paragraph (b) which
11 would have disqualified the child for Kidcare if the child
12 were able to enroll in the plan shall be eligible for Kidcare
13 coverage when enrollment is possible.
14 (6) Subject to a specific appropriation for this
15 purpose, the following children are eligible to receive
16 nonfederal premium assistance for health benefits coverage
17 under the Florida Kidcare program if the child would otherwise
18 qualify:
19 (a) A child who is eligible for coverage under a
20 health benefit plan on the basis of a family member's
21 employment with a public agency in the state.
22 (b) A child who is an alien, but who does not meet the
23 definition of a qualified alien, in the United States.
24 (7)(5) A child whose family income is above the
25 maximum income threshold 200 percent of the federal poverty
26 level or a child who is excluded under the provisions of
27 subsection (5) (4) may participate in the Florida Kidcare
28 program if Medikids program as provided in s. 409.8132 or, if
29 the child is ineligible for Medikids by reason of age, in the
30 Florida Healthy Kids program, subject to the following
31 provisions:
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1 (a) the family is not eligible for premium assistance
2 payments and must pay the full cost of the premium, including
3 any administrative costs.
4 (b) The agency is authorized to place limits on
5 enrollment in Medikids by these children in order to avoid
6 adverse selection. The number of children participating in
7 Medikids whose family income exceeds 200 percent of the
8 federal poverty level must not exceed 10 percent of total
9 enrollees in the Medikids program.
10 (c) The board of directors of the Florida Healthy Kids
11 Corporation is authorized to place limits on enrollment of
12 these children in order to avoid adverse selection. In
13 addition, the board is authorized to offer a reduced benefit
14 package to these children in order to limit program costs for
15 such families. The number of children participating in the
16 Florida Healthy Kids program whose family income exceeds 200
17 percent of the federal poverty level must not exceed 10
18 percent of total enrollees in the Florida Healthy Kids
19 program.
20 (8)(6) Once a child is enrolled in the Florida Kidcare
21 program, the child is eligible for coverage under the program
22 for 12 months without a redetermination or reverification of
23 eligibility, if the family continues to pay the applicable
24 premium. Eligibility for Florida Kidcare coverage program
25 components funded through Title XXI of the Social Security Act
26 shall terminate when a child attains the age of 19. Effective
27 January 1, 1999, A child who has not attained the age of 19 5
28 and who has been determined eligible for the Medicaid program
29 is eligible for coverage for 12 months without a
30 redetermination or reverification of eligibility.
31 (9)(7) When determining or reviewing a child's
28
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1 eligibility under the Florida Kidcare program, the applicant
2 shall be provided with reasonable notice of changes in
3 eligibility which may affect the funding source of the child's
4 Florida Kidcare health benefits coverage enrollment in one or
5 more of the program components. When a transition from one
6 program component to another is authorized, there shall be
7 cooperation between the program components, and the affected
8 family, the child's health plan, and providers which promotes
9 continuity of health benefits care coverage. When a child is
10 no longer eligible for Title XIX-funded Florida Kidcare health
11 benefits coverage, the child's health plan and other providers
12 shall be notified at the same time the family is notified so
13 that the health plans and providers may assist the family in
14 maintaining continuous health care coverage in the Florida
15 Kidcare program. Any authorized transfers must be managed
16 within the program's overall appropriated or authorized levels
17 of funding. Each component of the program shall establish a
18 reserve to ensure that transfers between components will be
19 accomplished within current year appropriations. These
20 reserves shall be reviewed by each convening of the Social
21 Services Estimating Conference to determine the adequacy of
22 such reserves to meet actual experience.
23 (10)(8) In determining the eligibility of a child, an
24 assets test is not required. During the application process
25 and the redetermination process:
26 (a) Each applicant's family income shall be verified
27 electronically to determine financial eligibility for the
28 Florida Kidcare program. Written documentation, which may
29 include wages and earning statements such as pay stubs, W-2
30 forms, or a copy of the applicant's most recent federal income
31 tax return, shall be required only if the electronic
29
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1 verification does not substantiate the applicant's income.
2 Each applicant shall provide written documentation during the
3 application process and the redetermination process,
4 including, but not limited to, the following:
5 (a) Proof of family income, which must include a copy
6 of the applicant's most recent federal income tax return. In
7 the absence of a federal income tax return, an applicant may
8 submit wages and earnings statements (pay stubs), W-2 forms,
9 or other appropriate documents.
10 (b) Each applicant shall provide a statement from all
11 applicable family members that:
12 1. Their employers do employer does not sponsor a
13 health benefit plans plan for employees; or
14 2. The potential enrollee is not covered by an the
15 employer-sponsored health benefit plan because the potential
16 enrollee is not eligible for coverage, or, if the potential
17 enrollee is eligible but not covered, a statement of the cost
18 to enroll the potential enrollee in the employer-sponsored
19 health benefit plan.
20 (11)(9) Subject to paragraph (5) (4)(b) and s.
21 624.91(4), the Florida Kidcare program shall withhold benefits
22 from an enrollee if the program obtains evidence that the
23 enrollee is no longer eligible, submitted incorrect or
24 fraudulent information in order to establish eligibility, or
25 failed to provide verification of eligibility. The applicant
26 or enrollee shall be notified that because of such evidence
27 program benefits will be withheld unless the applicant or
28 enrollee contacts a designated representative of the program
29 by a specified date, which must be within 14 working 10 days
30 after the date of notice, to discuss and resolve the matter.
31 The program shall make every effort to resolve the matter
30
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1 within a timeframe that will not cause benefits to be withheld
2 from an eligible enrollee.
3 (12)(10) The following individuals may be subject to
4 prosecution in accordance with s. 414.39:
5 (a) An applicant obtaining or attempting to obtain
6 benefits for a potential enrollee under the Florida Kidcare
7 program when the applicant knows or should have known the
8 potential enrollee does not qualify for the Florida Kidcare
9 program.
10 (b) An individual who assists an applicant in
11 obtaining or attempting to obtain benefits for a potential
12 enrollee under the Florida Kidcare program when the individual
13 knows or should have known the potential enrollee does not
14 qualify for the Florida Kidcare program.
15 Section 16. Section 409.815, Florida Statutes, is
16 amended to read:
17 409.815 Health benefits coverage; limitations.--
18 (1) MEDICAID BENEFITS.--For purposes of the Florida
19 Kidcare program, benefits available under Medicaid and
20 Medikids include those goods and services provided under the
21 medical assistance program authorized by Title XIX of the
22 Social Security Act, and regulations thereunder, as
23 administered in this state by the agency. This includes those
24 mandatory Medicaid services authorized under s. 409.905 and
25 optional Medicaid services authorized under s. 409.906,
26 rendered on behalf of eligible individuals by qualified
27 providers, in accordance with federal requirements for Title
28 XIX, subject to any limitations or directions provided for in
29 the General Appropriations Act or chapter 216, and according
30 to methodologies and limitations set forth in agency rules and
31 policy manuals and handbooks incorporated by reference
31
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1 thereto.
2 (2) BENCHMARK BENEFITS.--In order for health benefits
3 coverage to qualify for premium assistance payments for an
4 eligible child under ss. 409.810-409.820, except for waiver
5 services provided to eligible Title XIX-funded children, the
6 health benefits coverage must be equivalent to the pediatric
7 Medicaid benefit package and be based upon a standard and
8 appropriate assessment of need for the services consistent
9 with Early and Periodic Screening, Diagnosis, and Treatment
10 requirements as specified in s. 409.905(2) and Title XIX of
11 the Social Security Act, except for coverage under Medicaid
12 and Medikids, must include the following minimum benefits, as
13 medically necessary.
14 (a) Preventive health services.--Covered services
15 include:
16 1. Well-child care, including services recommended in
17 the Guidelines for Health Supervision of Children and Youth as
18 developed by the American Academy of Pediatrics;
19 2. Immunizations and injections;
20 3. Health education counseling and clinical services;
21 4. Vision screening; and
22 5. Hearing screening.
23 (b) Inpatient hospital services.--All covered services
24 provided for the medical care and treatment of an enrollee who
25 is admitted as an inpatient to a hospital licensed under part
26 I of chapter 395, with the following exceptions:
27 1. All admissions must be authorized by the enrollee's
28 health benefits coverage provider.
29 2. The length of the patient stay shall be determined
30 based on the medical condition of the enrollee in relation to
31 the necessary and appropriate level of care.
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1 3. Room and board may be limited to semiprivate
2 accommodations, unless a private room is considered medically
3 necessary or semiprivate accommodations are not available.
4 4. Admissions for rehabilitation and physical therapy
5 are limited to 15 days per contract year.
6 (c) Emergency services.--Covered services include
7 visits to an emergency room or other licensed facility if
8 needed immediately due to an injury or illness and delay means
9 risk of permanent damage to the enrollee's health. Health
10 maintenance organizations shall comply with the provisions of
11 s. 641.513.
12 (d) Maternity services.--Covered services include
13 maternity and newborn care, including prenatal and postnatal
14 care, with the following limitations:
15 1. Coverage may be limited to the fee for vaginal
16 deliveries; and
17 2. Initial inpatient care for newborn infants of
18 enrolled adolescents shall be covered, including normal
19 newborn care, nursery charges, and the initial pediatric or
20 neonatal examination, and the infant may be covered for up to
21 3 days following birth.
22 (e) Organ transplantation services.--Covered services
23 include pretransplant, transplant, and postdischarge services
24 and treatment of complications after transplantation for
25 transplants deemed necessary and appropriate within the
26 guidelines set by the Organ Transplant Advisory Council under
27 s. 765.53 or the Bone Marrow Transplant Advisory Panel under
28 s. 627.4236.
29 (f) Outpatient services.--Covered services include
30 preventive, diagnostic, therapeutic, palliative care, and
31 other services provided to an enrollee in the outpatient
33
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1 portion of a health facility licensed under chapter 395,
2 except for the following limitations:
3 1. Services must be authorized by the enrollee's
4 health benefits coverage provider; and
5 2. Treatment for temporomandibular joint disease (TMJ)
6 is specifically excluded.
7 (g) Behavioral health services.--
8 1. Mental health benefits include:
9 a. Inpatient services, limited to not more than 30
10 inpatient days per contract year for psychiatric admissions,
11 or residential services in facilities licensed under s.
12 394.875(8) or s. 395.003 in lieu of inpatient psychiatric
13 admissions; however, a minimum of 10 of the 30 days shall be
14 available only for inpatient psychiatric services when
15 authorized by a physician; and
16 b. Outpatient services, including outpatient visits
17 for psychological or psychiatric evaluation, diagnosis, and
18 treatment by a licensed mental health professional, limited to
19 a maximum of 40 outpatient visits each contract year.
20 2. Substance abuse services include:
21 a. Inpatient services, limited to not more than 7
22 inpatient days per contract year for medical detoxification
23 only and 30 days of residential services; and
24 b. Outpatient services, including evaluation,
25 diagnosis, and treatment by a licensed practitioner, limited
26 to a maximum of 40 outpatient visits per contract year.
27 (h) Durable medical equipment.--Covered services
28 include equipment and devices that are medically indicated to
29 assist in the treatment of a medical condition and
30 specifically prescribed as medically necessary, with the
31 following limitations:
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1 1. Low-vision and telescopic aides are not included.
2 2. Corrective lenses and frames may be limited to one
3 pair every 2 years, unless the prescription or head size of
4 the enrollee changes.
5 3. Hearing aids shall be covered only when medically
6 indicated to assist in the treatment of a medical condition.
7 4. Covered prosthetic devices include artificial eyes
8 and limbs, braces, and other artificial aids.
9 (i) Health practitioner services.--Covered services
10 include services and procedures rendered to an enrollee when
11 performed to diagnose and treat diseases, injuries, or other
12 conditions, including care rendered by health practitioners
13 acting within the scope of their practice, with the following
14 exceptions:
15 1. Chiropractic services shall be provided in the same
16 manner as in the Florida Medicaid program.
17 2. Podiatric services may be limited to one visit per
18 day totaling two visits per month for specific foot disorders.
19 (j) Home health services.--Covered services include
20 prescribed home visits by both registered and licensed
21 practical nurses to provide skilled nursing services on a
22 part-time intermittent basis, subject to the following
23 limitations:
24 1. Coverage may be limited to include skilled nursing
25 services only;
26 2. Meals, housekeeping, and personal comfort items may
27 be excluded; and
28 3. Private duty nursing is limited to circumstances
29 where such care is medically necessary.
30 (k) Hospice services.--Covered services include
31 reasonable and necessary services for palliation or management
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1 of an enrollee's terminal illness, with the following
2 exceptions:
3 1. Once a family elects to receive hospice care for an
4 enrollee, other services that treat the terminal condition
5 will not be covered; and
6 2. Services required for conditions totally unrelated
7 to the terminal condition are covered to the extent that the
8 services are included in this section.
9 (l) Laboratory and X-ray services.--Covered services
10 include diagnostic testing, including clinical radiologic,
11 laboratory, and other diagnostic tests.
12 (m) Nursing facility services.--Covered services
13 include regular nursing services, rehabilitation services,
14 drugs and biologicals, medical supplies, and the use of
15 appliances and equipment furnished by the facility, with the
16 following limitations:
17 1. All admissions must be authorized by the health
18 benefits coverage provider.
19 2. The length of the patient stay shall be determined
20 based on the medical condition of the enrollee in relation to
21 the necessary and appropriate level of care, but is limited to
22 not more than 100 days per contract year.
23 3. Room and board may be limited to semiprivate
24 accommodations, unless a private room is considered medically
25 necessary or semiprivate accommodations are not available.
26 4. Specialized treatment centers and independent
27 kidney disease treatment centers are excluded.
28 5. Private duty nurses, television, and custodial care
29 are excluded.
30 6. Admissions for rehabilitation and physical therapy
31 are limited to 15 days per contract year.
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1 (n) Prescribed drugs.--
2 1. Coverage shall include drugs prescribed for the
3 treatment of illness or injury when prescribed by a licensed
4 health practitioner acting within the scope of his or her
5 practice.
6 2. Prescribed drugs may be limited to generics if
7 available and brand name products if a generic substitution is
8 not available, unless the prescribing licensed health
9 practitioner indicates that a brand name is medically
10 necessary.
11 3. Prescribed drugs covered under this section shall
12 include all prescribed drugs covered under the Florida
13 Medicaid program.
14 (o) Therapy services.--Covered services include
15 rehabilitative services, including occupational, physical,
16 respiratory, and speech therapies, with the following
17 limitations:
18 1. Services must be for short-term rehabilitation
19 where significant improvement in the enrollee's condition will
20 result; and
21 2. Services shall be limited to not more than 24
22 treatment sessions within a 60-day period per episode or
23 injury, with the 60-day period beginning with the first
24 treatment.
25 (p) Transportation services.--Covered services include
26 emergency transportation required in response to an emergency
27 situation.
28 (q) Dental services.--Dental services shall be covered
29 and may include those dental benefits provided to children by
30 the Florida Medicaid program under s. 409.906(6).
31 (r) Lifetime maximum.--Health benefits coverage
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1 obtained under ss. 409.810-409.820 shall pay an enrollee's
2 covered expenses at a lifetime maximum of $1 million per
3 covered child.
4 (a)(s) Cost-sharing.--Cost-sharing provisions must
5 comply with s. 409.816.
6 (b)(t) Exclusions.--
7 1. Experimental or investigational procedures that
8 have not been clinically proven by reliable evidence are
9 excluded;
10 2. Services performed for cosmetic purposes only or
11 for the convenience of the enrollee are excluded; and
12 3. Abortion may be covered only if necessary to save
13 the life of the mother or if the pregnancy is the result of an
14 act of rape or incest.
15 (c)(u) Enhancements to minimum requirements.--
16 1. This section sets the minimum benefits that must be
17 included in any health benefits coverage, other than Medicaid
18 or Medikids coverage, offered under ss. 409.810-409.820.
19 Health benefits coverage may include additional benefits not
20 included in the pediatric Medicaid benefit package under this
21 subsection, but may not include benefits excluded under
22 paragraph (b) (s).
23 2. Health benefits coverage may extend any limitations
24 beyond the minimum benefits described in this section.
25
26 Except for Florida Kidcare Plus benefits the Children's
27 Medical Services Network, the agency may not increase the
28 premium assistance payment for either additional benefits
29 provided beyond the minimum benefits described in this section
30 or the imposition of less restrictive service limitations.
31 (d)(v) Applicability of other state laws.--Health
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1 insurers, health maintenance organizations, and their agents
2 are subject to the provisions of the Florida Insurance Code,
3 except for any such provisions waived in this section.
4 1. Except as expressly provided in this section, a law
5 requiring coverage for a specific health care service or
6 benefit, or a law requiring reimbursement, utilization, or
7 consideration of a specific category of licensed health care
8 practitioner, does not apply to a health insurance plan policy
9 or contract offered or delivered under ss. 409.810-409.820
10 unless that law is made expressly applicable to such policies
11 or contracts.
12 2. Notwithstanding chapter 641, a health maintenance
13 organization may issue contracts providing benefits equal to,
14 exceeding, or actuarially equivalent to the benchmark benefit
15 plan authorized by this section and may pay providers located
16 in a rural county negotiated fees or Medicaid reimbursement
17 rates for services provided to enrollees who are residents of
18 the rural county.
19 Section 17. Section 409.816, Florida Statutes, is
20 amended to read:
21 409.816 Limitations on premiums and cost-sharing;
22 penalties for nonpayment of premiums.--The following
23 limitations on premiums and cost-sharing are established for
24 the program.
25 (1) Enrollees who receive coverage under Title XIX of
26 the Social Security Act the Medicaid program may not be
27 required to pay:
28 (a) Enrollment fees, premiums, or similar charges; or
29 (b) Copayments, deductibles, coinsurance, or similar
30 charges.
31 (2) Enrollees in families with a family income equal
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1 to or below 150 percent of the federal poverty level, who are
2 not receiving coverage under the Medicaid program, may not be
3 required to pay:
4 (a) Enrollment fees, premiums, or similar charges that
5 exceed the maximum monthly charge permitted under s.
6 1916(b)(1) of the Social Security Act; or
7 (b) Copayments, deductibles, coinsurance, or similar
8 charges that exceed a nominal amount, as determined consistent
9 with regulations referred to in s. 1916(a)(3) of the Social
10 Security Act. However, such charges may not be imposed for
11 preventive services, including well-baby and well-child care,
12 age-appropriate immunizations, and routine hearing and vision
13 screenings.
14 (3) Enrollees in families with a family income above
15 150 percent of the federal poverty level, who are not
16 receiving coverage under the Medicaid program or who are not
17 eligible under s. 409.814(7) s. 409.814(5), may be required to
18 pay enrollment fees, premiums, copayments, deductibles,
19 coinsurance, or similar charges on a sliding scale related to
20 income, except that the total annual aggregate cost-sharing
21 with respect to all children in a family may not exceed 5
22 percent of the family's income. However, copayments,
23 deductibles, coinsurance, or similar charges may not be
24 imposed for preventive services, including well-baby and
25 well-child care, age-appropriate immunizations, and routine
26 hearing and vision screenings.
27 (4) Enrollees in families having a family income up to
28 the maximum income threshold who receive Florida Kidcare Plus
29 benefits may not be required to pay:
30 (a) Enrollment fees, premiums, or similar charges; or
31 (b) Copayments, deductibles, coinsurance, or similar
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1 charges.
2 (5) The Department of Health may establish penalties
3 or waiting periods of not more than 30 days for reinstatement
4 of coverage upon cancellation for nonpayment of premiums.
5 Section 18. Paragraph (i) of subsection (1) of section
6 409.8177, Florida Statutes, is amended to read:
7 409.8177 Program evaluation.--
8 (1) The agency, in consultation with the Department of
9 Health, the Department of Children and Family Services, and
10 the Florida Healthy Kids Corporation, shall contract for an
11 evaluation of the Florida Kidcare program and shall by January
12 1 of each year submit to the Governor, the President of the
13 Senate, and the Speaker of the House of Representatives a
14 report of the program. In addition to the items specified
15 under s. 2108 of Title XXI of the Social Security Act, the
16 report shall include an assessment of crowd-out and access to
17 health care, as well as the following:
18 (i) An assessment of the effectiveness of the Florida
19 Kidcare program Medikids, Children's Medical Services network,
20 and other public and private programs in the state in
21 increasing the availability of affordable quality health
22 insurance and health care for children. Effective July 1,
23 2008, the Department of Health shall assume responsibility for
24 contracting for an evaluation of the Florida Kidcare program.
25 Section 19. Section 409.818, Florida Statutes, is
26 amended to read:
27 409.818 Administration.--In order to implement ss.
28 409.810-409.820, the following agencies shall have the
29 following duties:
30 (1) The Department of Children and Family Services
31 shall:
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1 (a) Develop a simplified eligibility application
2 mail-in form to be used for determining the eligibility of
3 children for coverage under the Florida Kidcare program, in
4 consultation with the agency, the Department of Health, and
5 the Florida Healthy Kids Corporation. The simplified
6 eligibility application form must include an item that
7 provides an opportunity for the applicant to indicate whether
8 coverage is being sought for a child with special health care
9 needs. Families applying for children's Medicaid coverage must
10 also be able to use the simplified application form without
11 having to pay a premium.
12 (b) Establish and maintain the eligibility
13 determination process under the program except as specified in
14 subsections (2) and (4) subsection (5). No later than July 1,
15 2009, the department also shall directly, or through the
16 services of a contracted third-party administrator, establish
17 and maintain a process for determining non-Title XIX
18 eligibility of children for coverage under the program, which
19 shall be conducted in accordance with administrative rules and
20 policies established by the Department of Health. The
21 eligibility determination process must be used solely for
22 determining eligibility of applicants for health benefits
23 coverage under the program. The eligibility determination
24 process must include an initial determination of eligibility
25 for any coverage offered under the program, as well as a
26 redetermination or reverification of eligibility each
27 subsequent 12 6 months. Effective July 1, 2007 January 1,
28 1999, a child who has not attained the age of 19 5 and who has
29 been determined eligible for the Medicaid program is eligible
30 for coverage for 12 months without a redetermination or
31 reverification of eligibility. In conducting an eligibility
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1 determination, the department shall determine if the child has
2 special health care needs. The department, in consultation
3 with the Agency for Health Care Administration and the Florida
4 Healthy Kids Corporation, shall develop procedures for
5 redetermining eligibility which enable a family to easily
6 update any change in circumstances which could affect
7 eligibility. The department may accept changes in a family's
8 status as reported to the department by the Florida Healthy
9 Kids Corporation without requiring a new application from the
10 family. Redetermination of a child's eligibility for Medicaid
11 may not be linked to a child's eligibility determination for
12 other programs.
13 (c) Inform program applicants about eligibility
14 determinations and provide information about eligibility of
15 applicants to the Florida Kidcare program Medicaid, Medikids,
16 the Children's Medical Services Network, and the Florida
17 Healthy Kids Corporation, and to insurers and their agents,
18 through a centralized coordinating office.
19 (d) Effective July 1, 2009, maintain a toll-free
20 telephone line to assist families with questions about the
21 program.
22 (e)(d) Adopt rules necessary for conducting program
23 eligibility functions.
24 (2) The Department of Health shall:
25 (a) Design an eligibility intake process and policies
26 for non-Title XIX eligibility determination for the program,
27 in coordination with the Department of Children and Family
28 Services, the agency, and the Florida Healthy Kids
29 Corporation. The eligibility intake process may include local
30 intake points that are determined by the Department of Health
31 in coordination with the Department of Children and Family
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1 Services.
2 (b) Chair a state-level coordinating council to review
3 and make recommendations concerning the implementation and
4 operation of the program. The coordinating council shall
5 include representatives from the department, the Department of
6 Children and Family Services, the agency, the Florida Healthy
7 Kids Corporation, the Office of Insurance Regulation of the
8 Financial Services Commission, local government, health
9 insurers, health maintenance organizations, health care
10 providers, families participating in the program, and
11 organizations representing low-income families.
12 (b) In consultation with the Council on Children's
13 Health, develop and implement a plan to publicize the Florida
14 Kidcare program, the eligibility requirements of the program,
15 and the procedures for enrollment in the program and to
16 maintain public awareness of and outreach for the Florida
17 Kidcare program.
18 (c) Determine clinical eligibility for and administer
19 Florida Kidcare Plus health benefits coverage.
20 (d) In consultation with the agency, develop a minimum
21 set of pediatric quality assurance and access standards,
22 including reporting requirements, for the Florida Kidcare
23 program. The standards must include a process for granting
24 exceptions to specific requirements for quality assurance and
25 access. Compliance with the standards shall be a condition of
26 program participation by health benefits coverage providers.
27 These standards shall comply with the provisions of this
28 chapter and chapter 641 and Title XXI of the Social Security
29 Act.
30 (e) In consultation with the agency, the Department of
31 Children and Family Services, and the Florida Healthy Kids
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1 Corporation and effective July 1, 2008, coordinate non-Title
2 XIX-funded Florida Kidcare administrative activities,
3 including, but not limited to:
4 1. Florida Kidcare policy development;
5 2. Federal and state legislative and budget request
6 issue development; and
7 3. Administrative rules as assigned by this act.
8 (f) In consultation with the agency, develop pediatric
9 benefit packages for Florida Kidcare enrollees.
10 (c) In consultation with the Florida Healthy Kids
11 Corporation and the Department of Children and Family
12 Services, establish a toll-free telephone line to assist
13 families with questions about the program.
14 (d) Adopt rules necessary to implement outreach
15 activities.
16 (3) The Agency for Health Care Administration, under
17 the authority granted in s. 409.914(1), shall:
18 (a) Calculate the premium assistance payment necessary
19 to comply with the premium and cost-sharing limitations
20 specified in s. 409.816. The premium assistance payment for
21 each enrollee in a health insurance plan participating in the
22 Florida Healthy Kids Corporation shall equal the premium
23 approved by the Florida Healthy Kids Corporation and the
24 Office of Insurance Regulation of the Financial Services
25 Commission pursuant to ss. 627.410 and 641.31, less any
26 enrollee's share of the premium established within the
27 limitations specified in s. 409.816. The premium assistance
28 payment for each enrollee in an employer-sponsored health
29 insurance plan approved under ss. 409.810-409.820 shall equal
30 the premium for the plan adjusted for any benchmark benefit
31 plan actuarial equivalent benefit rider approved by the Office
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1 of Insurance Regulation pursuant to ss. 627.410 and 641.31,
2 less any enrollee's share of the premium established within
3 the limitations specified in s. 409.816. In calculating the
4 premium assistance payment levels for children with family
5 coverage, the agency shall set the premium assistance payment
6 levels for each child proportionately to the total cost of
7 family coverage.
8 (b) Make premium assistance payments to health
9 insurance plans on a periodic basis. The agency may use its
10 Medicaid fiscal agent or a contracted third-party
11 administrator in making these payments. The agency may
12 require health insurance plans that participate in the
13 Medikids program or employer-sponsored group health insurance
14 to collect premium payments from an enrollee's family.
15 Participating health insurance plans shall report premium
16 payments collected on behalf of enrollees in the program to
17 the agency in accordance with a schedule established by the
18 agency.
19 (c) Monitor compliance with pediatric quality
20 assurance and access standards developed by the Department of
21 Health under s. 409.820.
22 (d) Establish a mechanism for investigating and
23 resolving complaints and grievances from program applicants,
24 enrollees, and health benefits coverage providers, and
25 maintain a record of complaints and confirmed problems. In the
26 case of a child who is enrolled in a health maintenance
27 organization, the agency must use the provisions of s. 641.511
28 to address grievance reporting and resolution requirements.
29 (e) Approve health benefits coverage for participation
30 in the program, following certification by the Office of
31 Insurance Regulation under subsection (4).
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1 (f) Adopt all rules necessary to comply with or
2 administer ss. 409.810-409.820 and all rules necessary to
3 comply with federal requirements, including, at a minimum,
4 rules specifying policies, procedures, and criteria for the
5 following activities:
6 1. Calculating premium assistance payment levels;
7 2. Making premium assistance payments;
8 3. Monitoring access and quality assurance standards;
9 4. Investigating and resolving complaints and
10 grievances;
11 5. Administering the Medikids program;
12 6. Approving health benefits coverage; and
13 7. Except for Title XIX-funded Florida Kidcare,
14 determining application and enrollment requirements, including
15 documentation requirements, eligibility determinations and
16 redeterminations, enrollee premium payment requirements,
17 cancellation of coverage, reinstatement of coverage,
18 disenrollment procedures, applicant and enrollee notification
19 requirements, application and enrollment time processing
20 standards, and call center standards.
21
22 Effective July 1, 2008, the Department of Health shall assume
23 responsibility for administrative rulemaking activities
24 specified in subparagraphs 3, 4, 6, and 7. Adopt rules
25 necessary for calculating premium assistance payment levels,
26 making premium assistance payments, monitoring access and
27 quality assurance standards, investigating and resolving
28 complaints and grievances, administering the Medikids program,
29 and approving health benefits coverage. The agency is
30 designated the lead state agency for Title XXI of the Social
31 Security Act for purposes of receipt of federal funds, for
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1 reporting purposes, and for ensuring compliance with federal
2 and state regulations and rules.
3 (4) The Office of Insurance Regulation shall certify
4 that health benefits coverage plans that seek to provide
5 services under the Florida Kidcare program, except those
6 offered through the Florida Healthy Kids Corporation or the
7 Children's Medical Services Network, meet, exceed, or are
8 actuarially equivalent to the benchmark benefit plan and that
9 health insurance plans will be offered at an approved rate. In
10 determining actuarial equivalence of benefits coverage, the
11 Office of Insurance Regulation and health insurance plans must
12 comply with the requirements of s. 2103 of Title XXI of the
13 Social Security Act. The department shall adopt rules
14 necessary for certifying health benefits coverage plans.
15 (4)(a)(5) The Florida Healthy Kids Corporation shall
16 retain its functions as authorized in s. 624.91, including
17 eligibility determination for participation in the non-Title
18 XIX-funded Florida Kidcare program Healthy Kids program.
19 Effective July 1, 2008, non-Title XIX-funded Florida Kidcare
20 eligibility determinations shall be conducted in accordance
21 with administrative rules and policies established by the
22 Department of Health.
23 (5) The Department of Health, in consultation with the
24 agency, the Department of Children and Family Services, and
25 the Florida Healthy Kids Corporation, and
26 (6) The agency, the Department of Health, the
27 Department of Children and Family Services, the Florida
28 Healthy Kids Corporation, and the Office of Insurance
29 Regulation, after consultation with and approval of the
30 Speaker of the House of Representatives and the President of
31 the Senate, are authorized to make program modifications that
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1 are necessary to overcome any objections of the United States
2 Department of Health and Human Services to obtain approval of
3 the state's child health insurance plan under Title XXI of the
4 Social Security Act.
5 Section 20. Section 409.820, Florida Statutes, is
6 repealed.
7 Section 21. Section 409.821, Florida Statutes, is
8 amended to read:
9 409.821 Florida Kidcare program public records
10 exemption.--Notwithstanding any other law to the contrary, any
11 information identifying a Florida Kidcare program applicant or
12 enrollee, as defined in s. 409.811, held by the Agency for
13 Health Care Administration, the Department of Children and
14 Family Services, the Department of Health, or the Florida
15 Healthy Kids Corporation is confidential and exempt from s.
16 119.07(1) and s. 24(a), Art. I of the State Constitution. Such
17 information may be disclosed to another governmental entity
18 only if disclosure is necessary for the entity to perform its
19 duties and responsibilities under the Florida Kidcare program
20 and shall be disclosed to the Department of Revenue for
21 purposes of administering the state Title IV-D program. The
22 receiving governmental entity must maintain the confidential
23 and exempt status of such information. Furthermore, such
24 information may not be released to any person without the
25 written consent of the program applicant. This exemption
26 applies to any information identifying a Florida Kidcare
27 program applicant or enrollee held by the Agency for Health
28 Care Administration, the Department of Children and Family
29 Services, the Department of Health, or the Florida Healthy
30 Kids Corporation before, on, or after the effective date of
31 this exemption. A violation of this section is a misdemeanor
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1 of the second degree, punishable as provided in s. 775.082 or
2 s. 775.083. This section does not prohibit an enrollee's
3 parent or legal guardian from obtaining any record relating to
4 the enrollee's Florida Kidcare application or coverage,
5 including, but not limited to, confirmation of coverage, the
6 dates of coverage, the name of the enrollee's health plan, and
7 the amount of premium.
8 Section 22. Section 409.904, Florida Statutes, is
9 amended to read:
10 409.904 Optional payments for eligible persons.--The
11 agency may make payments for medical assistance and related
12 services on behalf of the following persons who are determined
13 to be eligible subject to the income, assets, and categorical
14 eligibility tests set forth in federal and state law. Payment
15 on behalf of these Medicaid eligible persons is subject to the
16 availability of moneys and any limitations established by the
17 General Appropriations Act or chapter 216.
18 (1)(a) From July 1, 2005, through December 31, 2005, a
19 person who is age 65 or older or is determined to be disabled,
20 whose income is at or below 88 percent of federal poverty
21 level, and whose assets do not exceed established limitations.
22 (b) Effective January 1, 2006, and subject to federal
23 waiver approval, a person who is age 65 or older or is
24 determined to be disabled, whose income is at or below 88
25 percent of the federal poverty level, whose assets do not
26 exceed established limitations, and who is not eligible for
27 Medicare or, if eligible for Medicare, is also eligible for
28 and receiving Medicaid-covered institutional care services,
29 hospice services, or home and community-based services. The
30 agency shall seek federal authorization through a waiver to
31 provide this coverage.
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1 (2) A family, a pregnant woman, a child under age 21,
2 a person age 65 or over, or a blind or disabled person, who
3 would be eligible under any group listed in s. 409.903(1),
4 (2), or (3), except that the income or assets of such family
5 or person exceed established limitations. For a family or
6 person in one of these coverage groups, medical expenses are
7 deductible from income in accordance with federal requirements
8 in order to make a determination of eligibility. A family or
9 person eligible under the coverage known as the "medically
10 needy," is eligible to receive the same services as other
11 Medicaid recipients, with the exception of services in skilled
12 nursing facilities and intermediate care facilities for the
13 developmentally disabled.
14 (3) A person who is in need of the services of a
15 licensed nursing facility, a licensed intermediate care
16 facility for the developmentally disabled, or a state mental
17 hospital, whose income does not exceed 300 percent of the SSI
18 income standard, and who meets the assets standards
19 established under federal and state law. In determining the
20 person's responsibility for the cost of care, the following
21 amounts must be deducted from the person's income:
22 (a) The monthly personal allowance for residents as
23 set based on appropriations.
24 (b) The reasonable costs of medically necessary
25 services and supplies that are not reimbursable by the
26 Medicaid program.
27 (c) The cost of premiums, copayments, coinsurance, and
28 deductibles for supplemental health insurance.
29 (4) A low-income person who meets all other
30 requirements for Medicaid eligibility except citizenship and
31 who is in need of emergency medical services. The eligibility
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1 of such a recipient is limited to the period of the emergency,
2 in accordance with federal regulations.
3 (5) Subject to specific federal authorization, a woman
4 living in a family that has an income that is at or below 200
5 185 percent of the most current federal poverty level is
6 eligible for family planning services as specified in s.
7 409.905(3) for a period of up to 24 months following a loss of
8 Medicaid benefits.
9 (6) A child who has not attained the age of 19 who has
10 been determined eligible for the Medicaid program is deemed to
11 be eligible for a total of 12 6 months, regardless of changes
12 in circumstances other than attainment of the maximum age.
13 Effective January 1, 1999, a child who has not attained the
14 age of 5 and who has been determined eligible for the Medicaid
15 program is deemed to be eligible for a total of 12 months
16 regardless of changes in circumstances other than attainment
17 of the maximum age.
18 (7) A pregnant woman for the duration of her pregnancy
19 and for the postpartum period as defined by federal law and
20 rules, or a child under 1 year of age, who lives in a family
21 that has an income above 185 percent of the most recently
22 published federal poverty level, but which is at or below 200
23 percent of such poverty level. In determining the eligibility
24 of such pregnant woman or child, an assets test is not
25 required. A child who is eligible for Medicaid under this
26 subsection must be offered the opportunity, subject to federal
27 rules, to be made presumptively eligible. A pregnant woman or
28 child who has been deemed presumptively eligible for Medicaid
29 shall not be enrolled in a managed care plan until full
30 eligibility for Medicaid has been determined.
31 (8) A child who has attained the age of 6 but has not
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1 attained the age of 19 and who lives in a family that has an
2 income above 100 percent of the most recently published
3 federal poverty level, which is at or below 133 percent of
4 such poverty level. In determining the eligibility of such
5 child, an assets test is not required. A child who is eligible
6 for Medicaid under this subsection must be offered the
7 opportunity, subject to federal rules, to be made
8 presumptively eligible.
9 (9)(8) A Medicaid-eligible individual for the
10 individual's health insurance premiums, if the agency
11 determines that such payments are cost-effective.
12 (10)(9) Eligible women with incomes at or below 200
13 percent of the federal poverty level and under age 65, for
14 cancer treatment pursuant to the federal Breast and Cervical
15 Cancer Prevention and Treatment Act of 2000, screened through
16 the Mary Brogan Breast and Cervical Cancer Early Detection
17 Program established under s. 381.93.
18 (11) The agency shall submit a state plan amendment to
19 the Federal Government to implement the provisions of the
20 Family Opportunity Act, pursuant to the Deficit Reduction Act
21 of 2005.
22 Section 23. Paragraph (a) of subsection (2) of section
23 409.91211, Florida Statutes, is amended to read:
24 409.91211 Medicaid managed care pilot program.--
25 (2) The Legislature intends for the capitated managed
26 care pilot program to:
27 (a) Provide, except for those enrolled in the Florida
28 Kidcare program, recipients in Medicaid fee-for-service or the
29 MediPass program a comprehensive and coordinated capitated
30 managed care system for all health care services specified in
31 ss. 409.905 and 409.906.
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1 Section 24. Section 624.91, Florida Statutes, is
2 amended to read:
3 624.91 The Florida Healthy Kids Corporation Act.--
4 (1) SHORT TITLE.--This section may be cited as the
5 "William G. 'Doc' Myers Healthy Kids Corporation Act."
6 (2) LEGISLATIVE INTENT.--
7 (a) The Legislature finds that increased access to
8 health care services could improve children's health and
9 reduce the incidence and costs of childhood illness and
10 disabilities among children in this state. Many children do
11 not have comprehensive, affordable health care services
12 available. It is the intent of the Legislature that the
13 Florida Healthy Kids Corporation provide comprehensive health
14 insurance coverage to such children. The corporation is
15 encouraged to cooperate with any existing health service
16 programs funded by the public or the private sector.
17 (b) It is the intent of the Legislature that the
18 Florida Healthy Kids Corporation serve as one of several
19 providers of services to children eligible for medical
20 assistance under Title XXI of the Social Security Act.
21 Although the corporation may serve other children, the
22 Legislature intends the primary recipients of services
23 provided through the corporation be school-age children with a
24 family income below 200 percent of the federal poverty level,
25 who do not qualify for Medicaid. It is also the intent of the
26 Legislature that state and local government Florida Healthy
27 Kids funds be used to continue coverage, subject to specific
28 appropriations in the General Appropriations Act, to children
29 not eligible for federal matching funds under Title XXI.
30 (3) ELIGIBILITY FOR STATE-FUNDED ASSISTANCE.--Only the
31 following individuals are eligible for state-funded assistance
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1 in paying Florida Healthy Kids premiums:
2 (a) Residents of this state who are eligible for the
3 Florida Kidcare program pursuant to s. 409.814.
4 (b) Notwithstanding s. 409.814, legal aliens who are
5 enrolled in the Florida Healthy Kids program as of January 31,
6 2004, who do not qualify for Title XXI federal funds because
7 they are not qualified aliens as defined in s. 409.811.
8 (3)(4) NONENTITLEMENT.--Nothing in this section shall
9 be construed as providing an individual with an entitlement to
10 health care services. No cause of action shall arise against
11 the state, the Florida Healthy Kids Corporation, or a unit of
12 local government for failure to make health services available
13 under this section.
14 (4)(5) CORPORATION AUTHORIZATION, DUTIES, POWERS.--
15 (a) There is created the Florida Healthy Kids
16 Corporation, a not-for-profit corporation.
17 (b) The Florida Healthy Kids Corporation shall:
18 1. Arrange for the collection of any family, local
19 contributions, or employer payment or premium, in an amount to
20 be determined by the board of directors, to provide for
21 payment of premiums for health benefits comprehensive
22 insurance coverage and for the actual or estimated
23 administrative expenses.
24 2. Arrange for the collection of any voluntary
25 contributions to provide for payment of Florida Kidcare
26 premiums for children who are not eligible for medical
27 assistance under Title XIX or Title XXI of the Social Security
28 Act.
29 3. Subject to the provisions of s. 409.8134, accept
30 voluntary supplemental local match contributions that comply
31 with the requirements of Title XXI of the Social Security Act
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1 for the purpose of providing additional Florida Kidcare
2 coverage in contributing counties under Title XXI.
3 4. Establish the administrative and accounting
4 procedures for the operation of the corporation.
5 5. Establish, with consultation from appropriate
6 professional organizations, standards for preventive health
7 services and providers and comprehensive insurance benefits
8 appropriate to children, provided that such standards for
9 rural areas shall not limit primary care providers to
10 board-certified pediatricians.
11 6. Determine eligibility for children seeking to
12 participate in the Title XXI-funded components of the Florida
13 Kidcare program consistent with the requirements specified in
14 s. 409.814, as well as the non-Title-XXI-eligible children as
15 provided in subsection (3). Effective July 1, 2008, this
16 function shall be performed in accordance with administrative
17 rules and policies established by the Department of Health.
18 7. Establish procedures under which providers of local
19 match to, applicants to and participants in the program may
20 have grievances reviewed by an impartial body and reported to
21 the board of directors of the corporation.
22 8. Establish participation criteria and, if
23 appropriate, Contract with an authorized insurer, health
24 maintenance organization, or third-party administrator to
25 provide administrative services for Florida Kidcare to the
26 corporation. Effective July 1, 2008, this function shall be
27 performed in accordance with administrative rules and policies
28 established by the Department of Health.
29 9. Establish enrollment criteria which shall include
30 penalties or waiting periods of not fewer than 60 days for
31 reinstatement of coverage upon voluntary cancellation for
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1 nonpayment of family premiums.
2 9.10. Contract with authorized insurers or any
3 provider of health care services, meeting quality assurance
4 and access standards established by the Department of Health
5 corporation, for the provision of comprehensive insurance
6 coverage to participants. Such standards shall include
7 criteria under which the corporation may contract with more
8 than one provider of health care services in program sites.
9 Health plans shall be selected through a competitive bid
10 process. The Florida Healthy Kids Corporation shall purchase
11 goods and services in the most cost-effective manner
12 consistent with the delivery of quality medical care. The
13 maximum administrative cost for a Florida Healthy Kids
14 Corporation contract shall be 15 percent. For health care
15 contracts, the minimum medical loss ratio for a Florida
16 Healthy Kids Corporation contract shall be 85 percent. For
17 dental contracts, the remaining compensation to be paid to the
18 authorized insurer or provider under a Florida Healthy Kids
19 Corporation contract shall be no less than an amount which is
20 85 percent of premium; to the extent any contract provision
21 does not provide for this minimum compensation, this section
22 shall prevail. The health plan selection criteria and scoring
23 system, and the scoring results, shall be available upon
24 request for inspection after the bids have been awarded.
25 10.11. Establish disenrollment criteria in the event
26 local matching funds are insufficient to cover enrollments.
27 11. Maintain a toll-free telephone line to assist
28 families with questions about the program. Effective July 1,
29 2008, this function shall be performed in accordance with
30 administrative rules and policies established by the
31 Department of Health.
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1 12. Develop and implement a plan to publicize the
2 Florida Healthy Kids Corporation, the eligibility requirements
3 of the program, and the procedures for enrollment in the
4 program and to maintain public awareness of the corporation
5 and the program.
6 12.13. Secure staff necessary to properly administer
7 the corporation. Staff costs shall be funded from state and
8 local matching funds and such other private or public funds as
9 become available. The board of directors shall determine the
10 number of staff members necessary to administer the
11 corporation.
12 13. No later than January 1, 2008, the health benefits
13 coverage provided by the corporation's authorized insurers and
14 health maintenance organizations shall conform with the
15 benchmark benefits specified in s. 409.815.
16 14. Provide a report annually to the Governor, Chief
17 Financial Officer, Commissioner of Education, Senate
18 President, Speaker of the House of Representatives, and
19 Minority Leaders of the Senate and the House of
20 Representatives.
21 15. Establish benefit packages which conform to the
22 provisions of the Florida Kidcare program, as created in ss.
23 409.810-409.820.
24 (c) Coverage under the corporation's program is
25 secondary to any other available private coverage held by, or
26 applicable to, the participant child or family member.
27 Insurers under contract with the corporation are the payors of
28 last resort and must coordinate benefits with any other
29 third-party payor that may be liable for the participant's
30 medical care.
31 (d) The Florida Healthy Kids Corporation shall be a
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1 private corporation not for profit, organized pursuant to
2 chapter 617, and shall have all powers necessary to carry out
3 the purposes of this act, including, but not limited to, the
4 power to receive and accept grants, loans, or advances of
5 funds from any public or private agency and to receive and
6 accept from any source contributions of money, property,
7 labor, or any other thing of value, to be held, used, and
8 applied for the purposes of this act.
9 (6) BOARD OF DIRECTORS.--
10 (a) The Florida Healthy Kids Corporation shall operate
11 subject to the supervision and approval of a board of
12 directors chaired by the Chief Financial Officer or her or his
13 designee, and composed of 10 other members selected for 3-year
14 terms of office as follows:
15 1. The Secretary of Health Care Administration, or his
16 or her designee;
17 2. One member appointed by the Commissioner of
18 Education from the Office of School Health Programs of the
19 Florida Department of Education;
20 3. One member appointed by the Chief Financial Officer
21 from among three members nominated by the Florida Pediatric
22 Society;
23 4. One member, appointed by the Governor, who
24 represents the Children's Medical Services Program;
25 5. One member appointed by the Chief Financial Officer
26 from among three members nominated by the Florida Hospital
27 Association;
28 6. One member, appointed by the Governor, who is an
29 expert on child health policy;
30 7. One member, appointed by the Chief Financial
31 Officer, from among three members nominated by the Florida
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1 Academy of Family Physicians;
2 8. One member, appointed by the Governor, who
3 represents the state Medicaid program;
4 9. One member, appointed by the Chief Financial
5 Officer, from among three members nominated by the Florida
6 Association of Counties; and
7 10. The State Health Officer or her or his designee.
8 (b) A member of the board of directors may be removed
9 by the official who appointed that member. The board shall
10 appoint an executive director, who is responsible for other
11 staff authorized by the board.
12 (c) Board members are entitled to receive, from funds
13 of the corporation, reimbursement for per diem and travel
14 expenses as provided by s. 112.061.
15 (d) There shall be no liability on the part of, and no
16 cause of action shall arise against, any member of the board
17 of directors, or its employees or agents, for any action they
18 take in the performance of their powers and duties under this
19 act.
20 (7) LICENSING NOT REQUIRED; FISCAL OPERATION.--
21 (a) The corporation shall not be deemed an insurer.
22 The officers, directors, and employees of the corporation
23 shall not be deemed to be agents of an insurer. Neither the
24 corporation nor any officer, director, or employee of the
25 corporation is subject to the licensing requirements of the
26 insurance code or the rules of the Department of Financial
27 Services. However, any marketing representative utilized and
28 compensated by the corporation must be appointed as a
29 representative of the insurers or health services providers
30 with which the corporation contracts.
31 (b) The board has complete fiscal control over the
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1 corporation and is responsible for all corporate operations.
2 (c) The Department of Financial Services shall
3 supervise any liquidation or dissolution of the corporation
4 and shall have, with respect to such liquidation or
5 dissolution, all power granted to it pursuant to the insurance
6 code.
7 (8) ACCESS TO RECORDS; CONFIDENTIALITY;
8 PENALTIES.--Notwithstanding any other laws to the contrary,
9 the Florida Healthy Kids Corporation shall have access to the
10 medical records of a student upon receipt of permission from a
11 parent or guardian of the student. Such medical records may be
12 maintained by state and local agencies. Any identifying
13 information, including medical records and family financial
14 information, obtained by the corporation pursuant to this
15 subsection is confidential and is exempt from the provisions
16 of s. 119.07(1). Neither the corporation nor the staff or
17 agents of the corporation may release, without the written
18 consent of the participant or the parent or guardian of the
19 participant, to any state or federal agency, to any private
20 business or person, or to any other entity, any confidential
21 information received pursuant to this subsection. A violation
22 of this subsection is a misdemeanor of the second degree,
23 punishable as provided in s. 775.082 or s. 775.083.
24 Section 25. Effective June 30, 2009, section 624.91,
25 Florida Statutes, as amended by this act, is repealed.
26 Section 26. Except as otherwise expressly provided in
27 this act, this act shall take effect July 1, 2007.
28
29
30 ================ T I T L E A M E N D M E N T ===============
31 And the title is amended as follows:
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1 Delete everything before the enacting clause
2
3 and insert:
4 A bill to be entitled
5 An act relating to medical assistance; creating
6 s. 14.35, F.S.; creating the Florida Council on
7 Children's Health within the Executive Office
8 of the Governor; providing for the appointment
9 of members and terms of office; providing for
10 council members to be reimbursed for per diem
11 and travel expenses; specifying the duties of
12 the council; requiring the council to submit an
13 annual report to the Governor; requiring
14 executive branch agencies to assist the
15 council; amending s. 20.43, F.S.; redesignating
16 the Division of Children's Medical Services
17 Network within the Department of Health as the
18 "Division of Children's Medical Services
19 Network and Specialty Programs"; creating the
20 Division of Children's Health Insurance and the
21 Office of Child Health Coordination within the
22 Department of Health; amending s. 391.011,
23 F.S.; redesignating ch. 391, F.S., as the
24 "Children's Health Act"; amending s. 391.016,
25 F.S.; revising legislative intent with respect
26 to certain responsibilities of the Children's
27 Health program; amending s. 391.021, F.S.;
28 revising and providing definitions; amending s.
29 391.025, F.S.; revising the components of the
30 Children's Health program; amending s. 391.026,
31 F.S.; requiring the Department of Health to
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1 administer the Florida Kidcare program;
2 amending s. 391.028, F.S.; revising the duties
3 of the Children's Medical Services Network;
4 designating the network director as the Deputy
5 State Health Office for Children's Health;
6 revising the duties of the director; requiring
7 the Division of Children's Health Insurance to
8 administer the Florida Kidcare program;
9 amending s. 391.029, F.S.; requiring the
10 Department of Health to establish clinical
11 eligibility requirements for Florida Kidcare
12 Plus benefits; providing eligibility criteria;
13 amending s. 409.811, F.S.; revising and
14 providing definitions relating to the Florida
15 Kidcare Act; amending s. 409.812, F.S.;
16 revising the purpose of the Florida Kidcare
17 program; amending s. 409.813, F.S.; revising
18 the funding sources for the health benefits
19 coverage provided to children under the
20 program; amending s. 409.8132, F.S.; revising
21 the eligibility and enrollment requirements in
22 the Medikids program component; amending s.
23 409.8134, F.S.; revising requirements for the
24 department in conducting enrollment in the
25 Florida Kidcare program; amending s. 409.814,
26 F.S.; revising the eligibility requirements for
27 the program; providing requirements for a child
28 to enroll in Florida Kidcare Plus; providing
29 for an extension of certain coverage benefits
30 in order to avoid a lapse in coverage;
31 providing for the coverage of certain children
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1 whose health benefits have been canceled;
2 providing for nonfederal premium assistance for
3 certain children; deleting provisions
4 authorizing certain limitations on enrollment
5 in Medikids and a reduction in benefits under
6 the Florida Healthy Kids program; providing
7 certain notification requirements if a child is
8 no longer eligible for benefits; requiring the
9 electronic verification of an applicant's
10 family income; amending s. 409.815, F.S.;
11 revising the health benefits coverage of the
12 Florida Kidcare program; amending s. 409.816,
13 F.S.; revising the limitations on premiums and
14 cost-sharing; providing that certain enrollees
15 are exempt from certain fees, premiums,
16 copayments, and deductibles; authorizing the
17 Department of Health to establish penalties or
18 waiting periods for nonpayment of premiums;
19 amending s. 409.8177, F.S.; requiring the
20 department to contract for an evaluation of the
21 Florida Kidcare program; amending s. 409.818,
22 F.S.; requiring a contract for establishing a
23 process for determining the eligibility of
24 certain children for coverage; revising the
25 duties of the Department of Health with respect
26 to reviewing the intake process; requiring the
27 department to publicize the Florida Kidcare
28 program, determine eligibility for Florida
29 Kidcare Plus coverage, and develop standards
30 for pediatric quality assurance and access;
31 requiring the department to adopt rules;
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1 authorizing the department to make certain
2 program modifications upon the approval of the
3 Legislature; repealing s. 409.820, F.S.,
4 relating to quality assurance and access
5 standards; amending s. 409.821, F.S.;
6 clarifying that provisions exempting certain
7 records from public-records requirements does
8 not prevent an enrollee's parent or guardian
9 from obtaining records and information
10 concerning the enrollee; amending s. 409.904,
11 F.S.; revising provisions governing optional
12 payments made under the Medicaid program;
13 requiring that certain children be
14 presumptively eligible for Medicaid; requiring
15 the Agency for Health Care Administration to
16 submit a plan to the Federal Government to
17 implement the Family Opportunity Act; amending
18 s. 409.91211, F.S.; revising certain
19 requirements of a pilot program for capitated
20 managed care to conform to changes made by the
21 act; amending s. 624.91, F.S.; revising
22 provisions of the Florida Healthy Kids
23 Corporation Act; deleting certain eligibility
24 requirements; providing for the transfer of
25 functions to the Department of Health;
26 repealing s. 624.91, F.S., relating to the
27 Florida Healthy Kids Corporation; providing
28 effective dates.
29
30
31
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