Florida Senate - 2008 SB 2472

By Senator Rich

34-03475B-08 20082472__

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A bill to be entitled

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An act relating to the Florida Kidcare program; amending

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s. 409.810, F.S.; correcting a cross-reference; amending

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s. 409.811, F.S.; providing definitions; conforming cross-

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references; amending s. 409.812, F.S.; expanding

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application of the Florida Kidcare program to include all

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uninsured, low-income children; amending s. 409.813, F.S.;

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specifying funding sources for health benefits coverage

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for certain children; specifying program components to be

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marketed as the Florida Kidcare program; conforming cross-

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references; amending s. 409.8132, F.S.; conforming a

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cross-reference; revising provisions relating to penalties

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for nonpayment of premiums and waiting periods for

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reinstatement of coverage; amending s. 409.8134, F.S.;

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revising provisions relating to enrollment in the Florida

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Kidcare program; amending s. 409.814, F.S.; removing a

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restriction on participation in the Florida Healthy Kids

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program; authorizing certain enrollees to opt out of the

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Children's Medical Services network; providing for

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continuation of Florida Kidcare program eligibility under

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certain circumstances; revising coverage limitations;

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restricting enrollment of children whose coverage was

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voluntarily canceled; providing exceptions; deleting

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provisions that place a limit on enrollment in Medikids

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and the Florida Healthy Kids program; revising age and

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income limitations for Title XXI-funded Florida Kidcare

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coverage; requiring notice to health plans and providers

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when a child is no longer eligible for certain coverage;

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requiring electronic verification of applicants' income;

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providing circumstances under which written documentation

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is required; revising the timeframe for an enrollee to

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resolve disputes regarding the withholding of benefits;

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amending s. 409.815, F.S.; providing an exception to a

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limitation on health benefits coverage for certain

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maternity services; permitting the Agency for Health Care

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Administration to increase certain premium assistance

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payments for Florida Kidcare Plus benefits under certain

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circumstances; conforming cross-references; amending s.

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409.816, F.S.; providing limitations on premiums and cost-

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sharing payments by enrollees covered under Title XIX of

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the Social Security Act; conforming a cross-reference;

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amending s. 409.817, F.S.; conforming a cross-reference;

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amending s. 409.8177, F.S.; revising information to be

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included in the annual program evaluation report to the

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Governor and Legislature; amending s. 409.818, F.S.;

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revising an age limitation for Florida Kidcare coverage;

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requiring the Department of Health to chair a Florida

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Kidcare coordinating council and adopt certain rules in

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conjunction therewith; removing a provision requiring

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establishment of a toll-free telephone line; conforming

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cross-references; amending s. 409.821, F.S., relating to

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the Florida Kidcare program public records exemption;

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providing for disclosure of certain confidential and

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exempt information relating to an enrollee's application

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or coverage to an enrollee's parent or legal guardian;

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amending s. 409.904, F.S.; revising provisions relating to

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eligibility of certain children for the Medicaid program;

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amending s. 624.91, F.S.; revising the duties of the

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Florida Healthy Kids Corporation; deleting provisions

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relating to publicizing the Florida Kidcare Corporation;

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correcting a cross-reference; providing an effective date.

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Be It Enacted by the Legislature of the State of Florida:

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     Section 1.  Section 409.810, Florida Statutes, is amended to

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read:

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     409.810 Short title.--Sections 409.810-409.821 409.810-

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409.820 may be cited as the "Florida Kidcare Act."

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     Section 2.  Section 409.811, Florida Statutes, is amended to

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read:

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     409.811  Definitions relating to Florida Kidcare Act.--As

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used in ss. 409.810-409.821 409.810-409.820, the term:

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     (1)  "Actuarially equivalent" means that:

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     (a)  The aggregate value of the benefits included in health

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benefits coverage is equal to the value of the benefits in the

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benchmark benefit plan; and

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     (b)  The benefits included in health benefits coverage are

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substantially similar to the benefits included in the benchmark

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benefit plan, except that preventive health services must be the

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same as in the benchmark benefit plan.

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     (2)  "Agency" means the Agency for Health Care

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Administration.

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     (3)  "Applicant" means a parent or guardian of a child or a

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child whose disability of nonage has been removed under chapter

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743, who applies for determination of eligibility for health

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benefits coverage under ss. 409.810-409.821 409.810-409.820.

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     (4)  "Benchmark benefit plan" means the form and level of

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health benefits coverage established in s. 409.815.

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     (5)  "Child" means any person under 19 years of age.

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     (6)  "Child with special health care needs" means a child

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whose serious or chronic physical or developmental condition

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requires extensive preventive and maintenance care beyond that

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required by typically healthy children. Health care utilization

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by such a child exceeds the statistically expected usage of the

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normal child adjusted for chronological age, and such a child

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often needs complex care requiring multiple providers,

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rehabilitation services, and specialized equipment in a number of

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different settings.

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     (7)  "Children's Medical Services network" or "network"

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means a statewide managed care service system as defined in s.

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391.021(1).

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     (8)  "Community rate" means a method used to develop

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premiums for a health insurance plan that spreads financial risk

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across a large population and allows adjustments only for age,

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gender, family composition, and geographic area.

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     (9)  "Department" means the Department of Health.

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     (10)  "Enrollee" means a child who has been determined

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eligible for and is receiving coverage under ss. 409.810-409.821

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409.810-409.820.

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     (11)  "Family" means the group or the individuals whose

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income is considered in determining eligibility for the Florida

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Kidcare program. The family includes a child with a custodial

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parent or caretaker relative who resides in the same house or

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living unit or, in the case of a child whose disability of nonage

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has been removed under chapter 743, the child. The family may

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also include other individuals whose income and resources are

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considered in whole or in part in determining eligibility of the

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child.

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     (12)  "Family income" means cash received at periodic

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intervals from any source, such as wages, benefits,

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contributions, or rental property. Income also may include any

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money that would have been counted as income under the Aid to

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Families with Dependent Children (AFDC) state plan in effect

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prior to August 22, 1996.

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     (13) "Florida Kidcare Plus" means health benefits coverage

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for children with special health care needs delivered through the

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Children's Medical Services network.

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     (14)(13) "Florida Kidcare program," "Kidcare program," or

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"program" means the health benefits program administered through

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ss. 409.810-409.821 409.810-409.820.

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     (15)(14) "Guarantee issue" means that health benefits

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coverage must be offered to an individual regardless of the

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individual's health status, preexisting condition, or claims

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history.

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     (16)(15) "Health benefits coverage" means protection that

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provides payment of benefits for covered health care services or

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that otherwise provides, either directly or through arrangements

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with other persons, covered health care services on a prepaid per

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capita basis or on a prepaid aggregate fixed-sum basis.

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     (17)(16) "Health insurance plan" means health benefits

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coverage under the following:

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     (a)  A health plan offered by any certified health

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maintenance organization or authorized health insurer, except a

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plan that is limited to the following: a limited benefit,

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specified disease, or specified accident; hospital indemnity;

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accident only; limited benefit convalescent care; Medicare

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supplement; credit disability; dental; vision; long-term care;

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disability income; coverage issued as a supplement to another

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health plan; workers' compensation liability or other insurance;

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or motor vehicle medical payment only; or

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     (b)  An employee welfare benefit plan that includes health

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benefits established under the Employee Retirement Income

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Security Act of 1974, as amended.

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     (18) "Maximum income threshold" means a percentage of the

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current federal poverty level used to determine eligibility for

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certain program components, as approved by federal waiver or an

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amendment to the state plan.

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     (19)(17) "Medicaid" means the medical assistance program

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authorized by Title XIX of the Social Security Act, and

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regulations thereunder, and ss. 409.901-409.920, as administered

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in this state by the agency.

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     (20)(18) "Medically necessary" means the use of any medical

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treatment, service, equipment, or supply necessary to palliate

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the effects of a terminal condition, or to prevent, diagnose,

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correct, cure, alleviate, or preclude deterioration of a

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condition that threatens life, causes pain or suffering, or

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results in illness or infirmity and which is:

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     (a)  Consistent with the symptom, diagnosis, and treatment

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of the enrollee's condition;

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     (b)  Provided in accordance with generally accepted

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standards of medical practice;

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     (c)  Not primarily intended for the convenience of the

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enrollee, the enrollee's family, or the health care provider;

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     (d)  The most appropriate level of supply or service for the

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diagnosis and treatment of the enrollee's condition; and

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     (e)  Approved by the appropriate medical body or health care

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specialty involved as effective, appropriate, and essential for

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the care and treatment of the enrollee's condition.

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     (21)(19) "Medikids" means a component of the Florida

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Kidcare program of medical assistance authorized by Title XXI of

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the Social Security Act, and regulations thereunder, and s.

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409.8132, as administered in the state by the agency.

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     (22)(20) "Preexisting condition exclusion" means, with

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respect to coverage, a limitation or exclusion of benefits

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relating to a condition based on the fact that the condition was

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present before the date of enrollment for such coverage, whether

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or not any medical advice, diagnosis, care, or treatment was

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recommended or received before such date.

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     (23)(21) "Premium" means the entire cost of a health

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insurance plan, including the administration fee or the risk

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assumption charge.

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     (24)(22) "Premium assistance payment" means the monthly

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consideration paid by the agency per enrollee in the Florida

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Kidcare program towards health insurance premiums.

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     (25)(23) "Qualified alien" means an alien as defined in s.

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431 of the Personal Responsibility and Work Opportunity

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Reconciliation Act of 1996, as amended, Pub. L. No. 104-193.

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     (26)(24) "Resident" means a United States citizen, or

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qualified alien, who is domiciled in this state.

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     (27)(25) "Rural county" means a county having a population

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density of less than 100 persons per square mile, or a county

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defined by the most recent United States Census as rural, in

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which there is no prepaid health plan participating in the

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Medicaid program as of July 1, 1998.

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     (28)(26) "Substantially similar" means that, with respect

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to additional services as defined in s. 2103(c)(2) of Title XXI

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of the Social Security Act, these services must have an actuarial

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value equal to at least 75 percent of the actuarial value of the

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coverage for that service in the benchmark benefit plan and, with

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respect to the basic services as defined in s. 2103(c)(1) of

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Title XXI of the Social Security Act, these services must be the

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same as the services in the benchmark benefit plan.

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     Section 3.  Section 409.812, Florida Statutes, is amended to

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read:

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     409.812  Program created; purpose.--The Florida Kidcare

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program is created to provide a defined set of health benefits to

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previously uninsured, low-income children through the

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establishment of a variety of affordable health benefits coverage

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options from which families may select coverage and through which

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families may contribute financially to the health care of their

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children.

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     Section 4.  Section 409.813, Florida Statutes, is amended to

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read:

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     409.813 Health benefits coverage; program components;

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entitlement and nonentitlement.--

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     (1) The Florida Kidcare program includes health benefits

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coverage provided to children as follows through:

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     (a) For children with family incomes at or below the

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applicable Medicaid eligibility level, health benefits coverage

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is funded through Title XIX of the Social Security Act.

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     (b) For children with family incomes above the applicable

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Medicaid eligibility level up to the maximum income threshold,

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health benefits coverage is funded through Title XXI of the

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Social Security Act.

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     (c) For children with family incomes up to the maximum

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income threshold who do not qualify for health benefits coverage

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under Title XXI of the Social Security Act, health benefits

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coverage is funded through general revenue or local contributions

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if a specific appropriation is provided for this purpose.

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     (d) For children with family incomes above the maximum

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income threshold, health benefits coverage is funded through

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family premiums.

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     (2) The Florida Kidcare program includes health benefits

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coverage provided to children through the following program

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components, which shall be marketed as the Florida Kidcare

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program:

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     (a)(1) Medicaid;

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     (b)(2) Medikids as created in s. 409.8132;

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     (c)(3) The Florida Healthy Kids Corporation as created in

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s. 624.91;

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     (d)(4) Employer-sponsored group health insurance plans

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approved under ss. 409.810-409.821 409.810-409.820; and

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     (e)(5) The Children's Medical Services network established

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in chapter 391.

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     (3) Except for Title XIX-funded Florida Kidcare program

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coverage under the Medicaid program, coverage under the Florida

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Kidcare program is not an entitlement. No cause of action shall

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arise against the state, the department, the Department of

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Children and Family Services, or the agency for failure to make

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health services available to any person under ss. 409.810-409.821

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409.810-409.820.

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     Section 5.  Paragraph (b) of subsection (6) and subsection

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(8) of section 409.8132, Florida Statutes, are amended to read:

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     409.8132  Medikids program component.--

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     (6)  ELIGIBILITY.--

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     (b) The provisions of s. 409.814(3), (4), and (5), (6), and

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(7) shall be applicable to the Medikids program.

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     (8)  PENALTIES FOR VOLUNTARY CANCELLATION.--The agency shall

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establish enrollment criteria that must include penalties or

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waiting periods of 30 not fewer than 60 days for reinstatement of

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coverage upon voluntary cancellation for nonpayment of premiums.

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     Section 6.  Section 409.8134, Florida Statutes, is amended

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to read:

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     409.8134 Program expenditure ceiling; enrollment.--

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     (1)  Except for the Medicaid program, a ceiling shall be

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placed on annual federal and state expenditures for the Florida

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Kidcare program as provided each year in the General

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Appropriations Act.

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     (2)  The Florida Kidcare program may conduct enrollment

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continuously at any time throughout the year for the purpose of

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enrolling children eligible for all program components listed in

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s. 409.813 except Medicaid. The four Florida Kidcare

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administrators shall work together to ensure that the year-round

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enrollment period is announced statewide. Eligible Children

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eligible for Title XXI-funded Florida Kidcare program coverage

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shall be enrolled on a first-come, first-served basis using the

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date the enrollment application is received. Enrollment shall

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immediately cease when the expenditure ceiling is reached. Year-

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round enrollment shall only be held if the Social Services

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Estimating Conference determines that sufficient federal and

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state funds will be available to finance the increased enrollment

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through federal fiscal year 2007. Any individual who is not

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enrolled must reapply by submitting a new application. The

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application for the Florida Kidcare program is shall be valid for

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a period of 120 days after the date it was received. At the end

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of the 120-day period, if the applicant has not been enrolled in

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the program, the application is shall be invalid and the

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applicant shall be notified of the action. The applicant may

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reactivate resubmit the application after notification of the

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action taken by the program. Except for the Medicaid program,

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whenever the Social Services Estimating Conference determines

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that there are presently, or will be by the end of the current

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fiscal year, insufficient funds to finance the current or

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projected enrollment in the Florida Kidcare program, all

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additional enrollment must cease and additional enrollment may

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not resume until sufficient funds are available to finance such

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enrollment.

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     (3)  Upon determination by the Social Services Estimating

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Conference that there are insufficient funds to finance the

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current enrollment in the Florida Kidcare program within current

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appropriations, the program shall initiate disenrollment

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procedures to remove enrollees, except those children enrolled in

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Florida Kidcare Plus the Children's Medical Services Network, on

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a last-in, first-out basis until the expenditure and

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appropriation levels are balanced.

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     (4)  The agencies that administer the Florida Kidcare

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program components shall collect and analyze the data needed to

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project program enrollment costs, including price level

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adjustments, participation and attrition rates, current and

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projected caseloads, utilization, and current and projected

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expenditures for the next 3 years. The agencies shall report

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caseload and expenditure trends to the Social Services Estimating

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Conference in accordance with chapter 216.

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     Section 7.  Section 409.814, Florida Statutes, is amended to

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read:

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     409.814  Eligibility.--A child who has not reached 19 years

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of age whose family income is equal to or below 200 percent of

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the federal poverty level is eligible for the Florida Kidcare

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program as provided in this section. For enrollment in Florida

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Kidcare Plus the Children's Medical Services Network, a complete

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application includes the medical or behavioral health screening.

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If, subsequently, an individual is determined to be ineligible

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for coverage, he or she must immediately be disenrolled from the

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respective Florida Kidcare program component.

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     (1)  A child who is eligible for Medicaid coverage under s.

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409.903 or s. 409.904 must be enrolled in Medicaid and is not

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eligible to receive health benefits under any other health

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benefits coverage authorized under the Florida Kidcare program.

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     (2) A child who is not eligible for Medicaid, but who is

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eligible for the Florida Kidcare program, may obtain health

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benefits coverage under any of the other components listed in s.

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409.813 if such coverage is approved and available in the county

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in which the child resides. However, a child who is eligible for

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Medikids may participate in the Florida Healthy Kids program only

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if the child has a sibling participating in the Florida Healthy

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Kids program and the child's county of residence permits such

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enrollment.

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     (3)  A child who is eligible for the Florida Kidcare program

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who is a child with special health care needs, as determined

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through a medical or behavioral screening instrument, shall

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receive Florida Kidcare Plus is eligible for health benefits

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coverage and shall be assigned to and may opt out of from and

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shall be referred to the Children's Medical Services network.

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     (4) A child who becomes ineligible for Title XIX-funded

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Florida Kidcare program coverage due to exceeding income or age

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limits shall have 60 days of continued eligibility following

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redetermination before premium payments are required in order to

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allow for a transition to the Title XXI-funded Florida Kidcare

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program without a lapse in coverage. The state shall use a Title

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XXI financing option for the 60 days of presumptive eligibility.

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Potential Florida Kidcare Plus, Medikids, and Florida Healthy

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Kids enrollees shall retain coverage with the Children's Medical

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Services network or their Medicaid or managed care providers

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during the transition period.

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     (5)(4) The following children are not eligible to receive

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Title XXI-funded premium assistance for health benefits coverage

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under the Florida Kidcare program, except under Medicaid if the

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child would have been eligible for Medicaid under s. 409.903 or

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s. 409.904 as of June 1, 1997:

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     (a)  A child who is eligible for coverage under a state

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health benefit plan on the basis of a family member's employment

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with a public agency in the state.

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     (b) A child who is currently eligible for or covered under

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a family member's group health benefit plan or under other

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private or employer health insurance coverage, excluding coverage

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provided under the Florida Healthy Kids Corporation as

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established under s. 624.91, provided that the cost of the

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child's participation is not greater than 5 percent of the

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family's income. If a child is otherwise eligible for a subsidy

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in the Florida Kidcare program and the cost of the child's

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participation in the family member's health insurance benefit

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plan is greater than 5 percent of the family's income, this

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section does not apply. This provision shall be applied during

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redetermination for children who were enrolled prior to July 1,

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2004. These enrollees shall have 6 months of eligibility

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following redetermination to allow for a transition to the other

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health benefit plan.

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     (c)  A child who is seeking premium assistance for the

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Florida Kidcare program through employer-sponsored group

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coverage, if the child has been covered by the same employer's

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group coverage during the 90 days 6 months prior to the family's

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submitting an application for determination of eligibility under

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the program.

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     (d)  A child who is an alien, but who does not meet the

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definition of qualified alien, in the United States.

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     (e)  A child who is an inmate of a public institution or a

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patient in an institution for mental diseases.

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     (f) A child who is otherwise eligible for premium

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assistance for the Florida Kidcare program and has had his or her

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coverage in an employer-sponsored or private health benefit plan

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voluntarily canceled in the last 90 days 6 months, except those

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children whose coverage was voluntarily canceled for good cause,

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including, but not limited to, the following circumstances:

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     1. The cost of participation in an employer-sponsored

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health benefit plan is greater than 5 percent of the family's

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income;

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     2. The parent lost a job that provided an employer-

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sponsored health benefit plan for children;

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     3. The parent with health benefits coverage for the child

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is deceased;

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     4. The child has a medical condition that, without medical

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care, would cause serious disability, loss of function, or death;

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     5. The employer of the parent canceled health benefits

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coverage for children;

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     6. The child's health benefits coverage ended because the

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child reached the maximum lifetime coverage amount;

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     7. The child has exhausted coverage under a COBRA

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continuation provision;

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     8. The health benefits coverage does not cover the child's

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health care needs; or

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     9. Domestic violence led to loss of coverage who were on

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the waiting list prior to March 12, 2004.

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     (6)(g) A child who is otherwise eligible for the Florida

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Kidcare program and who has a preexisting condition that prevents

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coverage under another insurance plan as described in paragraph

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(5)(b) that which would have disqualified the child for the

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Florida Kidcare program if the child were able to enroll in the

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plan shall be eligible for Florida Kidcare coverage when

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enrollment is possible.

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     (7)(5) A child whose family income is above 200 percent of

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the federal poverty level or a child who is excluded under the

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provisions of subsection (5) (4) may participate in the Florida

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Kidcare program. However, Medikids program as provided in s.

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409.8132 or, if the child is ineligible for Medikids by reason of

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age, in the Florida Healthy Kids program, subject to the

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following provisions:

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     (a) the family is not eligible for premium assistance

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payments and must pay the full cost of the premium, including any

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administrative costs.

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     (a)(b) The agency is authorized to place limits on

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enrollment in Medikids by these children in order to avoid

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adverse selection. The number of children participating in

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Medikids whose family income exceeds 250 200 percent of the

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federal poverty level must not exceed 25 10 percent of total

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enrollees in the Medikids program. Except for families who are

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enrolled in the program on July 1, 2008, or who are in transition

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from coverage in a subsidized Kidcare program, a family whose

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income exceeds 250 percent of the federal poverty level must have

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been uninsured for 6 consecutive months prior to enrollment in

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the program.

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     (b)(c) The board of directors of the Florida Healthy Kids

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Corporation is authorized to place limits on enrollment of these

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children in order to avoid adverse selection. In addition, the

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board is authorized to offer a reduced benefit package to these

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children in order to limit program costs for such families. The

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number of children participating in the Florida Healthy Kids

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program whose family income exceeds 250 200 percent of the

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federal poverty level must not exceed 25 10 percent of total

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enrollees in the Florida Healthy Kids program. However, a family

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who is enrolled in the program on July 1, 2008, or who is in

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transition from coverage in a subsidized program, or a family

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whose income exceeds 250 percent of the federal poverty level

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must have been uninsured for 6 consecutive months before

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enrollment in the program.

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     (8)(6) Once a child is enrolled in the Florida Kidcare

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program, the child is eligible for coverage under the program for

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12 months without a redetermination or reverification of

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eligibility, if the family continues to pay the applicable

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premium. Eligibility for Florida Kidcare coverage program

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components funded through Title XXI of the Social Security Act

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shall terminate when a child attains the age of 19. Effective

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January 1, 1999, A child who has not attained the age of 19 5 and

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who has been determined eligible for the Medicaid program is

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eligible for coverage for 12 months without a redetermination or

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reverification of eligibility.

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     (9)(7) When determining or reviewing a child's eligibility

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under the Florida Kidcare program, the applicant shall be

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provided with reasonable notice of changes in eligibility which

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may affect enrollment in one or more of the program components.

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When a transition from one program component to another is

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authorized, there shall be cooperation between the program

482

components, and the affected family, the child's health plan, and

483

MediPass providers that which promotes continuity of health care

484

coverage. When a child is no longer eligible for Florida Kidcare

485

coverage funded through Title XIX or Title XXI of the Social

486

Security Act, the child's health plan and other MediPass

487

providers shall be notified so that the health plans and

488

providers may assist the family in obtaining coverage through

489

other available healthcare providers. Any authorized transfers

490

must be managed within the program's overall appropriated or

491

authorized levels of funding. Each component of the program shall

492

establish a reserve to ensure that transfers between components

493

will be accomplished within current year appropriations. These

494

reserves shall be reviewed by each convening of the Social

495

Services Estimating Conference to determine the adequacy of such

496

reserves to meet actual experience.

497

     (10)(8) In determining the eligibility of a child, an

498

assets test is not required. Each applicant shall provide written

499

documentation During the application process and the

500

redetermination process, including, but not limited to, the

501

following:

502

     (a) Each applicant's Proof of family income shall be

503

verified electronically to determine financial eligibility for

504

the Florida Kidcare program. Written documentation, which may

505

must include wages and earnings statements (pay stubs), W-2

506

forms, or a copy of the applicant's most recent federal income

507

tax return, shall be required only if the electronic verification

508

is not available or does not substantiate the applicant's income.

509

In the absence of a federal income tax return, an applicant may

510

submit wages and earnings statements (pay stubs), W-2 forms, or

511

other appropriate documents.

512

     (b) Each applicant shall provide a statement from all

513

applicable, employed family members that:

514

     1. Their employers do employer does not sponsor a health

515

benefit plans plan for employees; or

516

     2. The potential enrollee is not covered by an the

517

employer-sponsored health benefit plan because the potential

518

enrollee is not eligible for coverage, or, if the potential

519

enrollee is eligible but not covered, a statement of the cost to

520

enroll the potential enrollee in the employer-sponsored health

521

benefit plan. If the cost of the employer-sponsored health

522

benefit plan is greater than 5 percent of the family's income and

523

the potential enrollee is otherwise eligible for premium

524

assistance, he or she may be enrolled in the appropriate Florida

525

Kidcare program component.

526

     (11)(9) Subject to paragraph (5)(b) (4)(b) and s.

527

624.91(4), the Florida Kidcare program shall withhold benefits

528

from an enrollee if the program obtains evidence that the

529

enrollee is no longer eligible, submitted incorrect or fraudulent

530

information in order to establish eligibility, or failed to

531

provide verification of eligibility. The applicant or enrollee

532

shall be notified that because of such evidence, program benefits

533

will be withheld unless the applicant or enrollee contacts a

534

designated representative of the program by a specified date,

535

which must be within 10 working days after the date of notice, to

536

discuss and resolve the matter. The program shall make every

537

effort to resolve the matter within a timeframe that will not

538

cause benefits to be withheld from an eligible enrollee.

539

     (12)(10) The following individuals may be subject to

540

prosecution in accordance with s. 414.39:

541

     (a)  An applicant obtaining or attempting to obtain benefits

542

for a potential enrollee under the Florida Kidcare program when

543

the applicant knows or should have known the potential enrollee

544

does not qualify for the Florida Kidcare program.

545

     (b)  An individual who assists an applicant in obtaining or

546

attempting to obtain benefits for a potential enrollee under the

547

Florida Kidcare program when the individual knows or should have

548

known the potential enrollee does not qualify for the Florida

549

Kidcare program.

550

     Section 8.  Subsection (2) of section 409.815, Florida

551

Statutes, is amended to read:

552

     409.815  Health benefits coverage; limitations.--

553

     (2)  BENCHMARK BENEFITS.--In order for health benefits

554

coverage to qualify for premium assistance payments for an

555

eligible child under ss. 409.810-409.821 409.810-409.820, the

556

health benefits coverage, except for coverage under Medicaid and

557

Medikids, must include the following minimum benefits, as

558

medically necessary.

559

     (a)  Preventive health services.--Covered services include:

560

     1.  Well-child care, including services recommended in the

561

Guidelines for Health Supervision of Children and Youth as

562

developed by the American Academy of Pediatrics;

563

     2.  Immunizations and injections;

564

     3.  Health education counseling and clinical services;

565

     4.  Vision screening; and

566

     5.  Hearing screening.

567

     (b)  Inpatient hospital services.--All covered services

568

provided for the medical care and treatment of an enrollee who is

569

admitted as an inpatient to a hospital licensed under part I of

570

chapter 395, with the following exceptions:

571

     1.  All admissions must be authorized by the enrollee's

572

health benefits coverage provider.

573

     2.  The length of the patient stay shall be determined based

574

on the medical condition of the enrollee in relation to the

575

necessary and appropriate level of care.

576

     3.  Room and board may be limited to semiprivate

577

accommodations, unless a private room is considered medically

578

necessary or semiprivate accommodations are not available.

579

     4.  Admissions for rehabilitation and physical therapy are

580

limited to 15 days per contract year.

581

     (c)  Emergency services.--Covered services include visits to

582

an emergency room or other licensed facility if needed

583

immediately due to an injury or illness and delay means risk of

584

permanent damage to the enrollee's health. Health maintenance

585

organizations shall comply with the provisions of s. 641.513.

586

     (d)  Maternity services.--Covered services include maternity

587

and newborn care, including prenatal and postnatal care, with the

588

following limitations:

589

     1.  Coverage may be limited to the fee for vaginal

590

deliveries unless another method of delivery is determined to be

591

medically necessary or better for the health of the mother or the

592

child; and

593

     2.  Initial inpatient care for newborn infants of enrolled

594

adolescents shall be covered, including normal newborn care,

595

nursery charges, and the initial pediatric or neonatal

596

examination, and the infant may be covered for up to 3 days

597

following birth.

598

     (e)  Organ transplantation services.--Covered services

599

include pretransplant, transplant, and postdischarge services and

600

treatment of complications after transplantation for transplants

601

deemed necessary and appropriate within the guidelines set by the

602

Organ Transplant Advisory Council under s. 765.53 or the Bone

603

Marrow Transplant Advisory Panel under s. 627.4236.

604

     (f)  Outpatient services.--Covered services include

605

preventive, diagnostic, therapeutic, palliative care, and other

606

services provided to an enrollee in the outpatient portion of a

607

health facility licensed under chapter 395, except for the

608

following limitations:

609

     1.  Services must be authorized by the enrollee's health

610

benefits coverage provider; and

611

     2.  Treatment for temporomandibular joint disease (TMJ) is

612

specifically excluded.

613

     (g)  Behavioral health services.--

614

     1.  Mental health benefits include:

615

     a.  Inpatient services, limited to not more than 30

616

inpatient days per contract year for psychiatric admissions, or

617

residential services in facilities licensed under s. 394.875(6)

618

or s. 395.003 in lieu of inpatient psychiatric admissions;

619

however, a minimum of 10 of the 30 days shall be available only

620

for inpatient psychiatric services when authorized by a

621

physician; and

622

     b.  Outpatient services, including outpatient visits for

623

psychological or psychiatric evaluation, diagnosis, and treatment

624

by a licensed mental health professional, limited to a maximum of

625

40 outpatient visits each contract year.

626

     2.  Substance abuse services include:

627

     a.  Inpatient services, limited to not more than 7 inpatient

628

days per contract year for medical detoxification only and 30

629

days of residential services; and

630

     b.  Outpatient services, including evaluation, diagnosis,

631

and treatment by a licensed practitioner, limited to a maximum of

632

40 outpatient visits per contract year.

633

     (h)  Durable medical equipment.--Covered services include

634

equipment and devices that are medically indicated to assist in

635

the treatment of a medical condition and specifically prescribed

636

as medically necessary, with the following limitations:

637

     1.  Low-vision and telescopic aides are not included.

638

     2.  Corrective lenses and frames may be limited to one pair

639

every 2 years, unless the prescription or head size of the

640

enrollee changes.

641

     3.  Hearing aids shall be covered only when medically

642

indicated to assist in the treatment of a medical condition.

643

     4.  Covered prosthetic devices include artificial eyes and

644

limbs, braces, and other artificial aids.

645

     (i)  Health practitioner services.--Covered services include

646

services and procedures rendered to an enrollee when performed to

647

diagnose and treat diseases, injuries, or other conditions,

648

including care rendered by health practitioners acting within the

649

scope of their practice, with the following exceptions:

650

     1.  Chiropractic services shall be provided in the same

651

manner as in the Florida Medicaid program.

652

     2.  Podiatric services may be limited to one visit per day

653

totaling two visits per month for specific foot disorders.

654

     (j)  Home health services.--Covered services include

655

prescribed home visits by both registered and licensed practical

656

nurses to provide skilled nursing services on a part-time

657

intermittent basis, subject to the following limitations:

658

     1.  Coverage may be limited to include skilled nursing

659

services only;

660

     2.  Meals, housekeeping, and personal comfort items may be

661

excluded; and

662

     3.  Private duty nursing is limited to circumstances where

663

such care is medically necessary.

664

     (k)  Hospice services.--Covered services include reasonable

665

and necessary services for palliation or management of an

666

enrollee's terminal illness, with the following exceptions:

667

     1.  Once a family elects to receive hospice care for an

668

enrollee, other services that treat the terminal condition will

669

not be covered; and

670

     2.  Services required for conditions totally unrelated to

671

the terminal condition are covered to the extent that the

672

services are included in this section.

673

     (l)  Laboratory and X-ray services.--Covered services

674

include diagnostic testing, including clinical radiologic,

675

laboratory, and other diagnostic tests.

676

     (m)  Nursing facility services.--Covered services include

677

regular nursing services, rehabilitation services, drugs and

678

biologicals, medical supplies, and the use of appliances and

679

equipment furnished by the facility, with the following

680

limitations:

681

     1.  All admissions must be authorized by the health benefits

682

coverage provider.

683

     2.  The length of the patient stay shall be determined based

684

on the medical condition of the enrollee in relation to the

685

necessary and appropriate level of care, but is limited to not

686

more than 100 days per contract year.

687

     3.  Room and board may be limited to semiprivate

688

accommodations, unless a private room is considered medically

689

necessary or semiprivate accommodations are not available.

690

     4.  Specialized treatment centers and independent kidney

691

disease treatment centers are excluded.

692

     5.  Private duty nurses, television, and custodial care are

693

excluded.

694

     6.  Admissions for rehabilitation and physical therapy are

695

limited to 15 days per contract year.

696

     (n)  Prescribed drugs.--

697

     1.  Coverage shall include drugs prescribed for the

698

treatment of illness or injury when prescribed by a licensed

699

health practitioner acting within the scope of his or her

700

practice.

701

     2.  Prescribed drugs may be limited to generics if available

702

and brand name products if a generic substitution is not

703

available, unless the prescribing licensed health practitioner

704

indicates that a brand name is medically necessary.

705

     3.  Prescribed drugs covered under this section shall

706

include all prescribed drugs covered under the Florida Medicaid

707

program.

708

     (o)  Therapy services.--Covered services include

709

rehabilitative services, including occupational, physical,

710

respiratory, and speech therapies, with the following

711

limitations:

712

     1.  Services must be for short-term rehabilitation where

713

significant improvement in the enrollee's condition will result;

714

and

715

     2.  Services shall be limited to not more than 24 treatment

716

sessions within a 60-day period per episode or injury, with the

717

60-day period beginning with the first treatment.

718

     (p)  Transportation services.--Covered services include

719

emergency transportation required in response to an emergency

720

situation.

721

     (q)  Dental services.--Dental services shall be covered and

722

may include those dental benefits provided to children by the

723

Florida Medicaid program under s. 409.906(6).

724

     (r)  Lifetime maximum.--Health benefits coverage obtained

725

under ss. 409.810-409.821 409.810-409.820 shall pay an enrollee's

726

covered expenses at a lifetime maximum of $1 million per covered

727

child.

728

     (s)  Cost-sharing.--Cost-sharing provisions must comply with

729

s. 409.816.

730

     (t)  Exclusions.--

731

     1.  Experimental or investigational procedures that have not

732

been clinically proven by reliable evidence are excluded;

733

     2.  Services performed for cosmetic purposes only or for the

734

convenience of the enrollee are excluded; and

735

     3.  Abortion may be covered only if necessary to save the

736

life of the mother or if the pregnancy is the result of an act of

737

rape or incest.

738

     (u)  Enhancements to minimum requirements.--

739

     1.  This section sets the minimum benefits that must be

740

included in any health benefits coverage, other than Medicaid or

741

Medikids coverage, offered under ss. 409.810-409.821 409.810-

742

409.820. Health benefits coverage may include additional benefits

743

not included under this subsection, but may not include benefits

744

excluded under paragraph (s).

745

     2.  Health benefits coverage may extend any limitations

746

beyond the minimum benefits described in this section.

747

748

Except for Florida Kidcare Plus benefits the Children's Medical

749

Services Network, the agency may not increase the premium

750

assistance payment for either additional benefits provided beyond

751

the minimum benefits described in this section or the imposition

752

of less restrictive service limitations.

753

     (v)  Applicability of other state laws.--Health insurers,

754

health maintenance organizations, and their agents are subject to

755

the provisions of the Florida Insurance Code, except for any such

756

provisions waived in this section.

757

     1.  Except as expressly provided in this section, a law

758

requiring coverage for a specific health care service or benefit,

759

or a law requiring reimbursement, utilization, or consideration

760

of a specific category of licensed health care practitioner, does

761

not apply to a health insurance plan policy or contract offered

762

or delivered under ss. 409.810-409.821 409.810-409.820 unless

763

that law is made expressly applicable to such policies or

764

contracts.

765

     2.  Notwithstanding chapter 641, a health maintenance

766

organization may issue contracts providing benefits equal to,

767

exceeding, or actuarially equivalent to the benchmark benefit

768

plan authorized by this section and may pay providers located in

769

a rural county negotiated fees or Medicaid reimbursement rates

770

for services provided to enrollees who are residents of the rural

771

county.

772

     Section 9.  Subsections (1) and (3) of section 409.816,

773

Florida Statutes, are amended to read:

774

     409.816  Limitations on premiums and cost-sharing.--The

775

following limitations on premiums and cost-sharing are

776

established for the program.

777

     (1) Enrollees who receive coverage under Title XIX of the

778

Social Security Act the Medicaid program may not be required to

779

pay:

780

     (a)  Enrollment fees, premiums, or similar charges; or

781

     (b)  Copayments, deductibles, coinsurance, or similar

782

charges.

783

     (3)  Enrollees in families with a family income above 150

784

percent of the federal poverty level, who are not receiving

785

coverage under the Medicaid program or who are not eligible under

786

s. 409.814(7)(5), may be required to pay enrollment fees,

787

premiums, copayments, deductibles, coinsurance, or similar

788

charges on a sliding scale related to income, except that the

789

total annual aggregate cost-sharing with respect to all children

790

in a family may not exceed 5 percent of the family's income.

791

However, copayments, deductibles, coinsurance, or similar charges

792

may not be imposed for preventive services, including well-baby

793

and well-child care, age-appropriate immunizations, and routine

794

hearing and vision screenings.

795

     Section 10.  Section 409.817, Florida Statutes, is amended

796

to read:

797

     409.817  Approval of health benefits coverage; financial

798

assistance.--In order for health insurance coverage to qualify

799

for premium assistance payments for an eligible child under ss.

800

409.810-409.821 409.810-409.820, the health benefits coverage

801

must:

802

     (1)  Be certified by the Office of Insurance Regulation of

803

the Financial Services Commission under s. 409.818 as meeting,

804

exceeding, or being actuarially equivalent to the benchmark

805

benefit plan;

806

     (2)  Be guarantee issued;

807

     (3)  Be community rated;

808

     (4)  Not impose any preexisting condition exclusion for

809

covered benefits; however, group health insurance plans may

810

permit the imposition of a preexisting condition exclusion, but

811

only insofar as it is permitted under s. 627.6561;

812

     (5)  Comply with the applicable limitations on premiums and

813

cost-sharing in s. 409.816;

814

     (6)  Comply with the quality assurance and access standards

815

developed under s. 409.820; and

816

     (7)  Establish periodic open enrollment periods, which may

817

not occur more frequently than quarterly.

818

     Section 11.  Paragraph (i) of subsection (1) of section

819

409.8177, Florida Statutes, is amended to read:

820

     409.8177  Program evaluation.--

821

     (1)  The agency, in consultation with the Department of

822

Health, the Department of Children and Family Services, and the

823

Florida Healthy Kids Corporation, shall contract for an

824

evaluation of the Florida Kidcare program and shall by January 1

825

of each year submit to the Governor, the President of the Senate,

826

and the Speaker of the House of Representatives a report of the

827

program. In addition to the items specified under s. 2108 of

828

Title XXI of the Social Security Act, the report shall include an

829

assessment of crowd-out and access to health care, as well as the

830

following:

831

     (i) An assessment of the effectiveness of the Florida

832

Kidcare program Medikids, Children's Medical Services network,

833

and other public and private programs in the state in increasing

834

the availability of affordable quality health insurance and

835

health care for children.

836

     Section 12.  Section 409.818, Florida Statutes, is amended

837

to read:

838

     409.818 Administration.--In order to implement ss. 409.810-

839

409.821 409.810-409.820, the following agencies shall have the

840

following duties:

841

     (1)  The Department of Children and Family Services shall:

842

     (a)  Develop a simplified eligibility application mail-in

843

form to be used for determining the eligibility of children for

844

coverage under the Florida Kidcare program, in consultation with

845

the agency, the Department of Health, and the Florida Healthy

846

Kids Corporation. The simplified eligibility application form

847

must include an item that provides an opportunity for the

848

applicant to indicate whether coverage is being sought for a

849

child with special health care needs. Families applying for

850

children's Medicaid coverage must also be able to use the

851

simplified application form without having to pay a premium.

852

     (b)  Establish and maintain the eligibility determination

853

process under the program except as specified in subsection (5).

854

The department shall directly, or through the services of a

855

contracted third-party administrator, establish and maintain a

856

process for determining eligibility of children for coverage

857

under the program. The eligibility determination process must be

858

used solely for determining eligibility of applicants for health

859

benefits coverage under the program and. The eligibility

860

determination process must include an initial determination of

861

eligibility for any coverage offered under the program, as well

862

as a redetermination or reverification of eligibility each

863

subsequent 6 months. Effective July 1, 2008 January 1, 1999, a

864

child who has not attained the age of 19 5 and who has been

865

determined eligible for the Medicaid program is eligible for

866

coverage for 12 months without a redetermination or

867

reverification of eligibility. In conducting an eligibility

868

determination, the department shall determine if the child has

869

special health care needs. The department, in consultation with

870

the Agency for Health Care Administration and the Florida Healthy

871

Kids Corporation, shall develop procedures for redetermining

872

eligibility which enable a family to easily update any change in

873

circumstances which could affect eligibility. The department may

874

accept changes in a family's status as reported to the department

875

by the Florida Healthy Kids Corporation without requiring a new

876

application from the family. Redetermination of a child's

877

eligibility for Medicaid may not be linked to a child's

878

eligibility determination for other programs.

879

     (c)  Inform program applicants about eligibility

880

determinations and provide information about eligibility of

881

applicants to Medicaid, Medikids, the Children's Medical Services

882

Network, and the Florida Kidcare program Healthy Kids

883

Corporation, and to insurers and their agents, through a

884

centralized coordinating office.

885

     (d)  Adopt rules necessary for conducting program

886

eligibility functions.

887

     (2)  The Department of Health shall:

888

     (a)  Design an eligibility intake process for the program,

889

in coordination with the Department of Children and Family

890

Services, the agency, and the Florida Healthy Kids Corporation.

891

The eligibility intake process may include local intake points

892

that are determined by the Department of Health in coordination

893

with the Department of Children and Family Services.

894

     (b) Chair a state-level Florida Kidcare coordinating

895

council to review and make recommendations concerning the

896

implementation and operation of the program. The coordinating

897

council shall include representatives from the department, the

898

Department of Children and Family Services, the agency, the

899

Florida Healthy Kids Corporation, the Office of Insurance

900

Regulation of the Financial Services Commission, local

901

government, health insurers, health maintenance organizations,

902

health care providers, families participating in the program, and

903

organizations representing low-income families.

904

     (c) In consultation with the Florida Healthy Kids

905

Corporation and the Department of Children and Family Services,

906

establish a toll-free telephone line to assist families with

907

questions about the program.

908

     (c)(d) In consultation with the Florida Kidcare

909

coordinating council, adopt rules and policies necessary to

910

implement Florida Kidcare program outreach activities.

911

     (3)  The Agency for Health Care Administration, under the

912

authority granted in s. 409.914(1), shall:

913

     (a)  Calculate the premium assistance payment necessary to

914

comply with the premium and cost-sharing limitations specified in

915

s. 409.816. The premium assistance payment for each enrollee in a

916

health insurance plan participating in the Florida Healthy Kids

917

Corporation shall equal the premium approved by the Florida

918

Healthy Kids Corporation and the Office of Insurance Regulation

919

of the Financial Services Commission pursuant to ss. 627.410 and

920

641.31, less any enrollee's share of the premium established

921

within the limitations specified in s. 409.816. The premium

922

assistance payment for each enrollee in an employer-sponsored

923

health insurance plan approved under ss. 409.810-409.821 409.810-

924

409.820 shall equal the premium for the plan adjusted for any

925

benchmark benefit plan actuarial equivalent benefit rider

926

approved by the Office of Insurance Regulation pursuant to ss.

927

627.410 and 641.31, less any enrollee's share of the premium

928

established within the limitations specified in s. 409.816. In

929

calculating the premium assistance payment levels for children

930

with family coverage, the agency shall set the premium assistance

931

payment levels for each child proportionately to the total cost

932

of family coverage.

933

     (b)  Make premium assistance payments to health insurance

934

plans on a periodic basis. The agency may use its Medicaid fiscal

935

agent or a contracted third-party administrator in making these

936

payments. The agency may require health insurance plans that

937

participate in the Medikids program or employer-sponsored group

938

health insurance to collect premium payments from an enrollee's

939

family. Participating health insurance plans shall report premium

940

payments collected on behalf of enrollees in the program to the

941

agency in accordance with a schedule established by the agency.

942

     (c)  Monitor compliance with quality assurance and access

943

standards developed under s. 409.820.

944

     (d)  Establish a mechanism for investigating and resolving

945

complaints and grievances from program applicants, enrollees, and

946

health benefits coverage providers, and maintain a record of

947

complaints and confirmed problems. In the case of a child who is

948

enrolled in a health maintenance organization, the agency must

949

use the provisions of s. 641.511 to address grievance reporting

950

and resolution requirements.

951

     (e)  Approve health benefits coverage for participation in

952

the program, following certification by the Office of Insurance

953

Regulation under subsection (4).

954

     (f)  Adopt rules necessary for calculating premium

955

assistance payment levels, making premium assistance payments,

956

monitoring access and quality assurance standards, investigating

957

and resolving complaints and grievances, administering the

958

Medikids program, and approving health benefits coverage.

959

960

The agency is designated the lead state agency for Title XXI of

961

the Social Security Act for purposes of receipt of federal funds,

962

for reporting purposes, and for ensuring compliance with federal

963

and state regulations and rules.

964

     (4)  The Office of Insurance Regulation shall certify that

965

health benefits coverage plans that seek to provide services

966

under the Florida Kidcare program, except those offered through

967

the Florida Healthy Kids Corporation or the Children's Medical

968

Services network, meet, exceed, or are actuarially equivalent to

969

the benchmark benefit plan and that health insurance plans will

970

be offered at an approved rate. In determining actuarial

971

equivalence of benefits coverage, the Office of Insurance

972

Regulation and health insurance plans must comply with the

973

requirements of s. 2103 of Title XXI of the Social Security Act.

974

The department shall adopt rules necessary for certifying health

975

benefits coverage plans.

976

     (5)  The Florida Healthy Kids Corporation shall retain its

977

functions as authorized in s. 624.91, including eligibility

978

determination for participation in the Healthy Kids program.

979

     (6)  The agency, the Department of Health, the Department of

980

Children and Family Services, the Florida Healthy Kids

981

Corporation, and the Office of Insurance Regulation, after

982

consultation with and approval of the Speaker of the House of

983

Representatives and the President of the Senate, are authorized

984

to make program modifications that are necessary to overcome any

985

objections of the United States Department of Health and Human

986

Services to obtain approval of the state's child health insurance

987

plan under Title XXI of the Social Security Act.

988

     Section 13.  Section 409.821, Florida Statutes, is amended

989

to read:

990

     409.821  Florida Kidcare program public records

991

exemption.--Notwithstanding any other law to the contrary, any

992

information identifying a Florida Kidcare program applicant or

993

enrollee, as defined in s. 409.811, held by the Agency for Health

994

Care Administration, the Department of Children and Family

995

Services, the Department of Health, or the Florida Healthy Kids

996

Corporation is confidential and exempt from s. 119.07(1) and s.

997

24(a), Art. I of the State Constitution. Such information may be

998

disclosed to another governmental entity only if disclosure is

999

necessary for the entity to perform its duties and

1000

responsibilities under the Florida Kidcare program and shall be

1001

disclosed to the Department of Revenue for purposes of

1002

administering the state Title IV-D program. The receiving

1003

governmental entity must maintain the confidential and exempt

1004

status of such information. Furthermore, such information may not

1005

be released to any person without the written consent of the

1006

program applicant. This exemption applies to any information

1007

identifying a Florida Kidcare program applicant or enrollee held

1008

by the Agency for Health Care Administration, the Department of

1009

Children and Family Services, the Department of Health, or the

1010

Florida Healthy Kids Corporation before, on, or after the

1011

effective date of this exemption. A violation of this section is

1012

a misdemeanor of the second degree, punishable as provided in s.

1013

775.082 or s. 775.083. This section does not prohibit an

1014

enrollee's parent or legal guardian from obtaining any record

1015

relating to the enrollee's Florida Kidcare program application or

1016

coverage, including, but not limited to, confirmation of

1017

coverage, the dates of coverage, the name of the enrollee's

1018

health plan, and the amount of premium.

1019

     Section 14.  Subsection (6) of section 409.904, Florida

1020

Statutes, is amended to read:

1021

     409.904  Optional payments for eligible persons.--The agency

1022

may make payments for medical assistance and related services on

1023

behalf of the following persons who are determined to be eligible

1024

subject to the income, assets, and categorical eligibility tests

1025

set forth in federal and state law. Payment on behalf of these

1026

Medicaid eligible persons is subject to the availability of

1027

moneys and any limitations established by the General

1028

Appropriations Act or chapter 216.

1029

     (6)  A child who has not attained the age of 19 who has been

1030

determined eligible for the Medicaid program is deemed to be

1031

eligible for a total of 12 6 months, regardless of changes in

1032

circumstances other than attainment of the maximum age. Effective

1033

January 1, 1999, a child who has not attained the age of 5 and

1034

who has been determined eligible for the Medicaid program is

1035

deemed to be eligible for a total of 12 months regardless of

1036

changes in circumstances other than attainment of the maximum

1037

age.

1038

     Section 15.  Subsection (5) of section 624.91, Florida

1039

Statutes, is amended to read:

1040

     624.91  The Florida Healthy Kids Corporation Act.--

1041

     (5)  CORPORATION AUTHORIZATION, DUTIES, POWERS.--

1042

     (a)  There is created the Florida Healthy Kids Corporation,

1043

a not-for-profit corporation.

1044

     (b)  The Florida Healthy Kids Corporation shall:

1045

     1.  Arrange for the collection of any family, local

1046

contributions, or employer payment or premium, in an amount to be

1047

determined by the board of directors, to provide for payment of

1048

premiums for comprehensive insurance coverage and for the actual

1049

or estimated administrative expenses.

1050

     2.  Arrange for the collection of any voluntary

1051

contributions to provide for payment of Florida Kidcare program

1052

premiums for children who are not eligible for medical assistance

1053

under Title XIX or Title XXI of the Social Security Act.

1054

     3.  Subject to the provisions of s. 409.8134, accept

1055

voluntary supplemental local match contributions that comply with

1056

the requirements of Title XXI of the Social Security Act for the

1057

purpose of providing additional Florida Kidcare coverage in

1058

contributing counties under Title XXI.

1059

     4.  Establish the administrative and accounting procedures

1060

for the operation of the corporation.

1061

     5.  Establish, with consultation from appropriate

1062

professional organizations, standards for preventive health

1063

services and providers and comprehensive insurance benefits

1064

appropriate to children, provided that such standards for rural

1065

areas shall not limit primary care providers to board-certified

1066

pediatricians.

1067

     6.  Determine eligibility for children seeking to

1068

participate in the Title XXI-funded components of the Florida

1069

Kidcare program consistent with the requirements specified in s.

1070

409.814, as well as the non-Title-XXI-eligible children as

1071

provided in subsection (3).

1072

     7.  Establish procedures under which providers of local

1073

match to, applicants to and participants in the program may have

1074

grievances reviewed by an impartial body and reported to the

1075

board of directors of the corporation.

1076

     8.  Establish participation criteria and, if appropriate,

1077

contract with an authorized insurer, health maintenance

1078

organization, or third-party administrator to provide

1079

administrative services to the corporation.

1080

     9. Establish enrollment criteria that which shall include

1081

penalties or waiting periods of 30 not fewer than 60 days for

1082

reinstatement of coverage upon voluntary cancellation for

1083

nonpayment of family premiums.

1084

     10.  Contract with authorized insurers or any provider of

1085

health care services, meeting standards established by the

1086

corporation, for the provision of comprehensive insurance

1087

coverage to participants. Such standards shall include criteria

1088

under which the corporation may contract with more than one

1089

provider of health care services in program sites. Health plans

1090

shall be selected through a competitive bid process. The Florida

1091

Healthy Kids Corporation shall purchase goods and services in the

1092

most cost-effective manner consistent with the delivery of

1093

quality medical care. The maximum administrative cost for a

1094

Florida Healthy Kids Corporation contract shall be 15 percent.

1095

For health care contracts, the minimum medical loss ratio for a

1096

Florida Healthy Kids Corporation contract shall be 85 percent.

1097

For dental contracts, the remaining compensation to be paid to

1098

the authorized insurer or provider under a Florida Healthy Kids

1099

Corporation contract shall be no less than an amount which is 85

1100

percent of premium; to the extent any contract provision does not

1101

provide for this minimum compensation, this section shall

1102

prevail. The health plan selection criteria and scoring system,

1103

and the scoring results, shall be available upon request for

1104

inspection after the bids have been awarded.

1105

     11.  Establish disenrollment criteria in the event local

1106

matching funds are insufficient to cover enrollments.

1107

     12. Develop and implement a plan to publicize the Florida

1108

Healthy Kids Corporation, the eligibility requirements of the

1109

program, and the procedures for enrollment in the program and to

1110

maintain public awareness of the corporation and the program.

1111

     12.13. Secure staff necessary to properly administer the

1112

corporation. Staff costs shall be funded from state and local

1113

matching funds and such other private or public funds as become

1114

available. The board of directors shall determine the number of

1115

staff members necessary to administer the corporation.

1116

     13.14. In consultation with the Florida Kidcare

1117

coordinating council and all partner agencies, provide a report

1118

on the Florida Kidcare program annually to the Governor, Chief

1119

Financial Officer, Commissioner of Education, Senate President of

1120

the Senate, Speaker of the House of Representatives, and Minority

1121

Leaders of the Senate and the House of Representatives.

1122

     14.15. Establish benefit packages that which conform to the

1123

provisions of the Florida Kidcare program, as created in ss.

1124

409.810-409.821 409.810-409.820.

1125

     (c)  Coverage under the corporation's program is secondary

1126

to any other available private coverage held by, or applicable

1127

to, the participant child or family member. Insurers under

1128

contract with the corporation are the payors of last resort and

1129

must coordinate benefits with any other third-party payor that

1130

may be liable for the participant's medical care.

1131

     (d)  The Florida Healthy Kids Corporation shall be a private

1132

corporation not for profit, organized pursuant to chapter 617,

1133

and shall have all powers necessary to carry out the purposes of

1134

this act, including, but not limited to, the power to receive and

1135

accept grants, loans, or advances of funds from any public or

1136

private agency and to receive and accept from any source

1137

contributions of money, property, labor, or any other thing of

1138

value, to be held, used, and applied for the purposes of this

1139

act.

1140

     Section 16.  This act shall take effect July 1, 2008.

CODING: Words stricken are deletions; words underlined are additions.