1 | Representative Coley offered the following: |
2 |
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3 | Amendment to Amendment (940817) (with title amendment) |
4 | Remove lines 268-762 and insert: |
5 | Section 7. Subsections (6) through (26) of section |
6 | 409.811, Florida Statutes, are renumbered as subsections (7) |
7 | through (27), respectively, and a new subsection (6) is added to |
8 | that section, to read: |
9 | 409.811 Definitions relating to Florida Kidcare Act.--As |
10 | used in ss. 409.810-409.820, the term: |
11 | (6) "Autism spectrum disorder" means any of the following |
12 | disorders as defined with most recent edition of the Diagnostic |
13 | and Statistical Manual of Mental Disorders of the American |
14 | Psychiatric Association: |
15 | 1. Autistic disorder; |
16 | 2. Asperger syndrome; or |
17 | 3. Pervasive developmental disorder not otherwise |
18 | specified. |
19 | Section 8. Paragraphs (r) through (v) of subsection (2) of |
20 | section 409.815, Florida Statutes, are redesignated as |
21 | paragraphs (s) through (w), respectively, present paragraphs |
22 | (o), (r), and (u) are amended, and a new paragraph (r) is added |
23 | to that subsection, to read: |
24 | 409.815 Health benefits coverage; limitations.-- |
25 | (2) BENCHMARK BENEFITS.--In order for health benefits |
26 | coverage to qualify for premium assistance payments for an |
27 | eligible child under ss. 409.810-409.820, the health benefits |
28 | coverage, except for coverage under Medicaid and Medikids, must |
29 | include the following minimum benefits, as medically necessary. |
30 | (o) Therapy services.--Covered services include |
31 | habilitative and rehabilitative services, including |
32 | occupational, physical, respiratory, and speech therapies, with |
33 | the following limitations: |
34 | 1. Rehabilitative services are limited to: |
35 | a.1. Services must be for Short-term rehabilitation when |
36 | where significant improvement in the enrollee's condition will |
37 | result; and |
38 | b.2. Services shall be limited to Not more than 24 |
39 | treatment sessions within a 60-day period per episode or injury, |
40 | with the 60-day period beginning with the first treatment. |
41 | 2. Effective October 1, 2009, habilitative services shall |
42 | be offered and are limited to: |
43 | a. Habilitation when improvements in and maintenance of |
44 | human behavior, skill acquisition, and communication will |
45 | result; and |
46 | b. Enrollees that are diagnosed with a developmental |
47 | disability as defined in s. 393.063 or autism spectrum disorder |
48 | as defined in paragraph (r)1. |
49 | (r) Behavior analysis services.--Effective October 1, |
50 | 2009, behavior analysis and behavior assistant services shall be |
51 | covered for enrollees that are diagnosed with a developmental |
52 | disability as defined in s. 393.063 or autism spectrum disorder. |
53 | For purposes of this paragraph: |
54 | 1. "Autism spectrum disorder" means any of the following |
55 | disorders as defined with most recent edition of the Diagnostic |
56 | and Statistical Manual of Mental Disorders of the American |
57 | Psychiatric Association: |
58 | a. Autistic disorder; |
59 | b. Asperger syndrome; or |
60 | c. Pervasive developmental disorder not otherwise |
61 | specified. |
62 | 2. "Behavior analysis" means the design, implementation, |
63 | and evaluation of instructional and environmental modifications |
64 | to produce socially significant improvements in human behavior |
65 | through skill acquisition and the reduction of problematic |
66 | behavior. Behavior analysis shall be provided by an individual |
67 | certified pursuant to s. 393.17 or an individual licensed under |
68 | chapter 490 or chapter 491. |
69 | 3. "Behavior assistant services" means services provided |
70 | by an individual with specific training to assist in carrying |
71 | out plans designed by a behavior analyst. |
72 | (s)(r) Lifetime maximum and limitations.--Health benefits |
73 | coverage obtained under ss. 409.810-409.820 shall pay an |
74 | enrollee's covered expenses at a lifetime maximum of $1 million |
75 | per covered child. However, coverage for the combination of |
76 | behavior analysis services and habilitative therapy services for |
77 | recipients diagnosed with a developmental disability as defined |
78 | in s. 393.063 or autism spectrum disorder as defined in |
79 | paragraph (r)1. shall be limited to $36,000 annually and may not |
80 | exceed $108,000 in total lifetime benefits. Without prior |
81 | authorization by the Florida Healthy Kids plan, not more than 12 |
82 | percent of the annual maximum amount for combined habilitative |
83 | therapy and behavior analysis services may be used on a monthly |
84 | basis. |
85 | (v)(u) Enhancements to minimum requirements.-- |
86 | 1. This section sets the minimum benefits that must be |
87 | included in any health benefits coverage, other than Medicaid or |
88 | Medikids coverage, offered under ss. 409.810-409.820. Health |
89 | benefits coverage may include additional benefits not included |
90 | under this subsection, but may not include benefits excluded |
91 | under paragraph (t) (s). |
92 | 2. Health benefits coverage may extend any limitations |
93 | beyond the minimum benefits described in this section. |
94 |
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95 | Except for the Children's Medical Services Network, the agency |
96 | may not increase the premium assistance payment for either |
97 | additional benefits provided beyond the minimum benefits |
98 | described in this section or the imposition of less restrictive |
99 | service limitations. |
100 | Section 9. Paragraph (b) of subsection (1) of section |
101 | 409.818, Florida Statutes, is amended to read: |
102 | 409.818 Administration.--In order to implement ss. |
103 | 409.810-409.820, the following agencies shall have the following |
104 | duties: |
105 | (1) The Department of Children and Family Services shall: |
106 | (b) Establish and maintain the eligibility determination |
107 | process under the program except as specified in subsection (5). |
108 | The department shall directly, or through the services of a |
109 | contracted third-party administrator, establish and maintain a |
110 | process for determining eligibility of children for coverage |
111 | under the program. The eligibility determination process must be |
112 | used solely for determining eligibility of applicants for health |
113 | benefits coverage under the program. The eligibility |
114 | determination process must include an initial determination of |
115 | eligibility for any coverage offered under the program, as well |
116 | as a redetermination or reverification of eligibility each |
117 | subsequent 12 6 months. Effective January 1, 1999, a child who |
118 | has not attained the age of 5 and who has been determined |
119 | eligible for the Medicaid program is eligible for coverage for |
120 | 12 months without a redetermination or reverification of |
121 | eligibility. In conducting an eligibility determination, the |
122 | department shall determine if the child has special health care |
123 | needs. The department, in consultation with the Agency for |
124 | Health Care Administration and the Florida Healthy Kids |
125 | Corporation, shall develop procedures for redetermining |
126 | eligibility which enable a family to easily update any change in |
127 | circumstances which could affect eligibility. The department may |
128 | accept changes in a family's status as reported to the |
129 | department by the Florida Healthy Kids Corporation without |
130 | requiring a new application from the family. Redetermination of |
131 | a child's eligibility for Medicaid may not be linked to a |
132 | child's eligibility determination for other programs. |
133 | Section 10. Subsection (26) is added to section 409.906, |
134 | Florida Statutes, to read: |
135 | 409.906 Optional Medicaid services.--Subject to specific |
136 | appropriations, the agency may make payments for services which |
137 | are optional to the state under Title XIX of the Social Security |
138 | Act and are furnished by Medicaid providers to recipients who |
139 | are determined to be eligible on the dates on which the services |
140 | were provided. Any optional service that is provided shall be |
141 | provided only when medically necessary and in accordance with |
142 | state and federal law. Optional services rendered by providers |
143 | in mobile units to Medicaid recipients may be restricted or |
144 | prohibited by the agency. Nothing in this section shall be |
145 | construed to prevent or limit the agency from adjusting fees, |
146 | reimbursement rates, lengths of stay, number of visits, or |
147 | number of services, or making any other adjustments necessary to |
148 | comply with the availability of moneys and any limitations or |
149 | directions provided for in the General Appropriations Act or |
150 | chapter 216. If necessary to safeguard the state's systems of |
151 | providing services to elderly and disabled persons and subject |
152 | to the notice and review provisions of s. 216.177, the Governor |
153 | may direct the Agency for Health Care Administration to amend |
154 | the Medicaid state plan to delete the optional Medicaid service |
155 | known as "Intermediate Care Facilities for the Developmentally |
156 | Disabled." Optional services may include: |
157 | (26) HOME AND COMMUNITY-BASED SERVICES FOR AUTISM SPECTRUM |
158 | DISORDER AND OTHER DEVELOPMENTAL DISABILITIES.--The agency is |
159 | authorized to seek federal approval through a Medicaid waiver or |
160 | a state plan amendment for the provision of occupational |
161 | therapy, speech therapy, physical therapy, behavior analysis, |
162 | and behavior assistant services to individuals who are 5 years |
163 | of age and under and have a diagnosed developmental disability |
164 | as defined in s. 393.063 or autism spectrum disorder as defined |
165 | in s. 391.026(2)(r)1. Coverage for such services shall be |
166 | limited to $36,000 annually and may not exceed $108,000 in total |
167 | lifetime benefits. The agency shall submit an annual report |
168 | beginning on January 1, 2009, to the President of the Senate, |
169 | the Speaker of the House of Representatives, and the relevant |
170 | committees of the Senate and the House of Representatives |
171 | regarding progress on obtaining federal approval and |
172 | recommendations for the implementation of these home and |
173 | community-based services. The agency may not implement this |
174 | subsection without prior legislative approval. |
175 | Section 11. Section 456.0291, Florida Statutes, is created |
176 | to read: |
177 | 456.0291 Requirement for instruction on developmental |
178 | disabilities.-- |
179 | (1)(a) The appropriate board shall require each person |
180 | licensed or certified under part I of chapter 464, chapter 490, |
181 | or chapter 491 to complete a 2-hour continuing education course, |
182 | approved by the board, on developmental disabilities, as defined |
183 | in s. 393.063, with the addition of autism spectrum disorder as |
184 | defined in paragraph (r)1., as part of every third biennial |
185 | relicensure or recertification. The course shall consist of |
186 | information on the diagnosis and treatment of developmental |
187 | disabilities and information on counseling and education of a |
188 | parent whose child is diagnosed with a developmental disability, |
189 | with an emphasis on autism spectrum disorder as defined in |
190 | paragraph (r)1. |
191 | (b) The Board of Medicine and the Board of Osteopathic |
192 | Medicine shall require each physician with a primary care |
193 | specialty of pediatrics to complete a 2-hour continuing |
194 | education course, approved by the appropriate board, on |
195 | developmental disabilities, as defined in s. 393.063, with the |
196 | addition of autism spectrum disorder as defined in s. |
197 | 391.026(2)(r)1., as part of every third biennial relicensure. |
198 | The course shall consist of information on the diagnosis and |
199 | treatment of developmental disabilities and information on |
200 | counseling and education of a parent whose child is diagnosed |
201 | with a developmental disability, with an emphasis on autism |
202 | spectrum disorder as defined in s. 391.026(2)(r)1.. |
203 | (c) Each such licensee or certificateholder shall submit |
204 | confirmation of having completed the course, on a form provided |
205 | by the board, when submitting fees for every third biennial |
206 | renewal. |
207 | (d) The board may approve additional equivalent courses |
208 | that may be used to satisfy the requirements of paragraph (a). |
209 | Each licensing board that requires a licensee to complete an |
210 | educational course pursuant to this subsection may include the |
211 | hours required for completion of the course in the total hours |
212 | of continuing education required by law for such profession |
213 | unless the continuing education requirements for such profession |
214 | consist of fewer than 30 hours biennially. |
215 | (e) Any person holding two or more licenses subject to the |
216 | provisions of this subsection shall be permitted to show proof |
217 | of having taken one board-approved course on developmental |
218 | disabilities for purposes of relicensure or recertification for |
219 | additional licenses. |
220 | (f) Failure to comply with the requirements of this |
221 | subsection shall constitute grounds for disciplinary action |
222 | under each respective practice act and under s. 456.072(1)(k). |
223 | In addition to discipline by the board, the licensee shall be |
224 | required to complete such course. |
225 | (2) Each board may adopt rules pursuant to ss. 120.536(1) |
226 | and 120.54 to carry out the provisions of this section. |
227 | (3) The department shall implement a plan to promote |
228 | awareness of developmental disabilities, with a focus on autism |
229 | spectrum disorder as defined in s. 391.026(2)(r)1., to |
230 | physicians licensed under chapter 458 or chapter 459 and |
231 | parents. The department shall develop the plan in consultation |
232 | with organizations representing allopathic and osteopathic |
233 | physicians, the Board of Medicine, the Board of Osteopathic |
234 | Medicine, and nationally recognized organizations that promote |
235 | awareness of developmental disabilities. The department's plan |
236 | shall include the distribution of educational materials for |
237 | parents, including a developmental assessment tool. |
238 | Section 12. Paragraph (b) of subsection (2) and paragraph |
239 | (b) of subsection (5) of section 624.91, Florida Statutes, are |
240 | amended to read: |
241 | 624.91 The Florida Healthy Kids Corporation Act.-- |
242 | (2) LEGISLATIVE INTENT.-- |
243 | (b) It is the intent of the Legislature that the Florida |
244 | Healthy Kids Corporation serve as one of several providers of |
245 | services to children eligible for medical assistance under Title |
246 | XXI of the Social Security Act. Although the corporation may |
247 | serve other children, the Legislature intends the primary |
248 | recipients of services provided through the corporation be |
249 | school-age children with a family income below 200 percent of |
250 | the federal poverty level, who do not qualify for Medicaid. It |
251 | is also the intent of the Legislature that state and local |
252 | government Florida Healthy Kids funds be used to continue |
253 | coverage, subject to specific appropriations in the General |
254 | Appropriations Act, to children not eligible for federal |
255 | matching funds under Title XXI. |
256 | (5) CORPORATION AUTHORIZATION, DUTIES, POWERS.-- |
257 | (b) The Florida Healthy Kids Corporation shall: |
258 | 1. Arrange for the collection of any family, local |
259 | contributions, or employer payment or premium, in an amount to |
260 | be determined by the board of directors, to provide for payment |
261 | of premiums for comprehensive insurance coverage and for the |
262 | actual or estimated administrative expenses. |
263 | 2. Arrange for the collection of any voluntary |
264 | contributions to provide for payment of premiums for children |
265 | who are not eligible for medical assistance under Title XXI of |
266 | the Social Security Act. |
267 | 3. Subject to the provisions of s. 409.8134, accept |
268 | voluntary supplemental local match contributions that comply |
269 | with the requirements of Title XXI of the Social Security Act |
270 | for the purpose of providing additional coverage in contributing |
271 | counties under Title XXI. |
272 | 4. Establish the administrative and accounting procedures |
273 | for the operation of the corporation. |
274 | 5. Establish, with consultation from appropriate |
275 | professional organizations, standards for preventive health |
276 | services and providers and comprehensive insurance benefits |
277 | appropriate to children, provided that such standards for rural |
278 | areas shall not limit primary care providers to board-certified |
279 | pediatricians. |
280 | 6. Determine eligibility for children seeking to |
281 | participate in the Title XXI-funded components of the Florida |
282 | Kidcare program consistent with the requirements specified in s. |
283 | 409.814, as well as the non-Title-XXI-eligible children as |
284 | provided in subsection (3). |
285 | 7. Establish procedures under which providers of local |
286 | match to, applicants to and participants in the program may have |
287 | grievances reviewed by an impartial body and reported to the |
288 | board of directors of the corporation. |
289 | 8. Establish participation criteria and, if appropriate, |
290 | contract with an authorized insurer, health maintenance |
291 | organization, or third-party administrator to provide |
292 | administrative services to the corporation. |
293 | 9. Establish enrollment criteria which shall include |
294 | penalties or waiting periods of not fewer than 60 days for |
295 | reinstatement of coverage upon voluntary cancellation for |
296 | nonpayment of family premiums. |
297 | 10. Contract with authorized insurers or any provider of |
298 | health care services, meeting standards established by the |
299 | corporation, for the provision of comprehensive insurance |
300 | coverage to participants. Such standards shall include criteria |
301 | under which the corporation may contract with more than one |
302 | provider of health care services in program sites. Health plans |
303 | shall be selected through a competitive bid process. The Florida |
304 | Healthy Kids Corporation shall purchase goods and services in |
305 | the most cost-effective manner consistent with the delivery of |
306 | quality medical care. The maximum administrative cost for a |
307 | Florida Healthy Kids Corporation contract shall be 15 percent. |
308 | For health care contracts, the minimum medical loss ratio for a |
309 | Florida Healthy Kids Corporation contract shall be 85 percent. |
310 | For dental contracts, the remaining compensation to be paid to |
311 | the authorized insurer or provider under a Florida Healthy Kids |
312 | Corporation contract shall be no less than an amount which is 85 |
313 | percent of premium; to the extent any contract provision does |
314 | not provide for this minimum compensation, this section shall |
315 | prevail. The health plan selection criteria and scoring system, |
316 | and the scoring results, shall be available upon request for |
317 | inspection after the bids have been awarded. |
318 | 11. Establish disenrollment criteria in the event local |
319 | matching funds are insufficient to cover enrollments. |
320 | 12. Develop and implement a plan to publicize the Florida |
321 | Kidcare program Healthy Kids Corporation, the eligibility |
322 | requirements of the program, and the procedures for enrollment |
323 | in the program and to maintain public awareness of the |
324 | corporation and the program. Health care and dental health plans |
325 | participating in the program may develop and distribute |
326 | marketing and other promotional materials and participate in |
327 | activities, such as health fairs and public events, as approved |
328 | by the corporation. Health care and dental health plans may also |
329 | contact their current and former enrollees to encourage |
330 | continued participation in the program and assist the enrollee |
331 | in transferring from a Title XIX-funded plan to a Title XXI- |
332 | funded plan. |
333 | 13. Establish an assignment process for Florida Healthy |
334 | Kids program enrollees to ensure that family members are |
335 | assigned to the same managed care plan to the greatest extent |
336 | possible, including situations in which some family members are |
337 | enrolled in a Medicaid managed care plan and other family |
338 | members are enrolled in a Florida Healthy Kids plan. The Agency |
339 | for Health Care Administration shall consult with the |
340 | corporation to implement this subparagraph. |
341 | 14.13. Secure staff necessary to properly administer the |
342 | corporation. Staff costs shall be funded from state and local |
343 | matching funds and such other private or public funds as become |
344 | available. The board of directors shall determine the number of |
345 | staff members necessary to administer the corporation. |
346 | 15.14. Provide a report annually to the Governor, Chief |
347 | Financial Officer, Commissioner of Education, Senate President, |
348 | Speaker of the House of Representatives, and Minority Leaders of |
349 | the Senate and the House of Representatives. |
350 | 16. Provide a report by October 31, 2008, to the Governor, |
351 | the Senate, and the House of Representatives, which includes an |
352 | actuarial analysis of the projected impact on premiums from the |
353 | addition of habilitative and behavior analysis services in |
354 | accordance with s. 409.815. |
355 | 17. Provide information on a quarterly basis to the |
356 | Governor, the Senate, and the House of Representatives that |
357 | assesses the cost and utilization of services for the Florida |
358 | Healthy Kids health benefits plans provided through the Florida |
359 | Healthy Kids Corporation. The information must be specific to |
360 | each eligibility component of the plan and, at a minimum, |
361 | include: |
362 | a. The monthly enrollment and expenditures for enrollees. |
363 | b. The cost and utilization of specific services. |
364 | c. An analysis of the impact on premiums prior to and |
365 | following implementation of the Window of Opportunity Act. |
366 | d. An analysis of trends regarding transfer of enrollees |
367 | from the Florida Healthy Kids plans to the Children's Medical |
368 | Services Network plan. |
369 | e. Any recommendations resulting from the analysis |
370 | conducted under this subparagraph. |
371 | 18.15. Establish benefit packages which conform to the |
372 | provisions of the Florida Kidcare program, as created in ss. |
373 | 409.810-409.820. |
374 | Section 13. Section 624.916, Florida Statutes, is created |
375 | to read: |
376 | 624.916 Developmental disabilities compact.-- |
377 | (1) The Office of Insurance Regulation shall convene a |
378 | workgroup by August 31, 2008, for the purpose of negotiating a |
379 | compact that includes a binding agreement among the participants |
380 | relating to insurance and access to services for persons with |
381 | developmental disabilities as defined in s. 393.063, with the |
382 | addition of autism spectrum disorder as defined in s. |
383 | 391.026(2)(r)1. The workgroup shall consist of the following: |
384 | (a) Representatives of all health insurers licensed under |
385 | this chapter. |
386 | (b) Representatives of all health maintenance |
387 | organizations licensed under part I of chapter 641. |
388 | (c) Representatives of employers with self-insured health |
389 | benefit plans. |
390 | (d) Two designees of the Governor, one of whom must be a |
391 | consumer advocate. |
392 | (e) A designee of the President of the Senate. |
393 | (f) A designee of the Speaker of the House of |
394 | Representatives. |
395 | (2) The Office of Insurance Regulation shall convene a |
396 | consumer advisory workgroup for the purpose of providing a forum |
397 | for comment on the compact negotiated in subsection (1). The |
398 | office shall convene the workgroup prior to finalization of the |
399 | compact. |
400 | (3) The agreement shall include the following components: |
401 | (a) A requirement that each signatory to the agreement |
402 | increase coverage for behavior analysis and behavior assistant |
403 | services as defined in s. 409.815(2)(r) and speech therapy, |
404 | physical therapy, and occupational therapy when necessary due to |
405 | the presence of a developmental disability as defined in s. |
406 | 393.063 or autism spectrum disorder as defined in s. |
407 | 391.026(2)(r)1. |
408 | (b) Procedures for clear and specific notice to |
409 | policyholders identifying the amount, scope, and conditions |
410 | under which coverage is provided for behavior analysis and |
411 | behavior assistant services as defined in s. 409.815(2)(r) and |
412 | speech therapy, physical therapy, and occupational therapy when |
413 | necessary due to the presence of a developmental disability as |
414 | defined in s. 393.063 or autism spectrum disorder as defined in |
415 | s. 391.026(2)(r)1. |
416 | (c) Penalties for documented cases of denial of claims for |
417 | medically necessary services due to the presence of a |
418 | developmental disability as defined in s. 393.063 or autism |
419 | spectrum disorder as defined in s. 391.026(2)(r)1. |
420 | (d) Proposals for new product lines that may be offered in |
421 | conjunction with traditional health insurance and provide a more |
422 | appropriate means of spreading risk, financing costs, and |
423 | accessing favorable prices. |
424 | (4) Upon completion of the negotiations for the compact, |
425 | the office shall report the results to the Governor, the |
426 | President of the Senate, and the Speaker of the House of |
427 | Representatives. |
428 | (5) Beginning February 15, 2009, and continuing annually |
429 | thereafter, the Office of Insurance Regulation shall provide a |
430 | report to the Governor, the President of the Senate, and the |
431 | Speaker of the House of Representatives regarding the |
432 | implementation of the agreement negotiated under this section. |
433 | The report shall include: |
434 | (a) The signatories to the agreement. |
435 | (b) An analysis of the coverage provided under the |
436 | agreement in comparison to the coverage required under ss. |
437 | 627.6686 and 641.31098. |
438 | (c) An analysis of the compliance with the agreement by |
439 | the signatories, including documented cases of claims denied in |
440 | violation of the agreement. |
441 | (6) The Office of Insurance Regulation shall continue to |
442 | monitor participation, compliance, and effectiveness of the |
443 | agreement and report its findings at least annually. |
444 | Section 14. Section 627.6686, Florida Statutes, is created |
445 | to read: |
446 | 627.6686 Coverage for individuals with developmental |
447 | disabilities required; exception.-- |
448 | (1) As used in this section, the term: |
449 | (a) "Autism spectrum disorder" means any of the following |
450 | disorders as defined with most recent edition of the Diagnostic |
451 | and Statistical Manual of Mental Disorders of the American |
452 | Psychiatric Association: |
453 | 1. Autistic disorder; |
454 | 2. Asperger syndrome; or |
455 | 3. Pervasive developmental disorder not otherwise |
456 | specified. |
457 | (b) "Developmental disability" has the same meaning as |
458 | provided in s. 393.063. |
459 | (c) "Eligible individual" means an individual under 18 |
460 | years of age or an individual 18 years of age or older who is in |
461 | high school who has been diagnosed as having a developmental |
462 | disability at 8 years of age or younger. |
463 | (d) "Health insurance plan" means a group health insurance |
464 | policy or group health benefit plan offered by an insurer which |
465 | includes the state group insurance program provided under s. |
466 | 110.123. The term does not include any health insurance plan |
467 | offered in the individual market, any health insurance plan that |
468 | is individually underwritten, or any health insurance plan |
469 | provided to a small employer. |
470 | (e) "Insurer" means an insurer providing health insurance |
471 | coverage, which is licensed to engage in the business of |
472 | insurance in this state and is subject to insurance regulation. |
473 | (2) A health insurance plan issued or renewed on or after |
474 | July 1, 2009, shall provide coverage to an eligible individual |
475 | for: |
476 | (a) Well-baby and well-child screening for diagnosing the |
477 | presence of a developmental disability. |
478 | (b) Treatment of a developmental disability through speech |
479 | therapy, occupational therapy, physical therapy, and behavior |
480 | analysis services. Behavior analysis services shall be provided |
481 | by an individual certified pursuant to s. 393.17 or an |
482 | individual licensed under chapter 490 or chapter 491. |
483 | (3) The coverage required pursuant to subsection (2) is |
484 | subject to the following requirements: |
485 | (a) Coverage shall be limited to treatment that is |
486 | prescribed by the insured's treating physician in accordance |
487 | with a treatment plan. |
488 | (b) Coverage for the services described in subsection (2) |
489 | shall be limited to $36,000 annually and may not exceed $108,000 |
490 | in total lifetime benefits. |
491 | (c) Coverage may not be denied on the basis that provided |
492 | services are habilitative in nature. |
493 | (d) Coverage may be subject to other general exclusions |
494 | and limitations of the insurer's policy or plan, including, but |
495 | not limited to, coordination of benefits, participating provider |
496 | requirements, restrictions on services provided by family or |
497 | household members, and utilization review of health care |
498 | services, including the review of medical necessity, case |
499 | management, and other managed care provisions. |
500 | (4) The coverage required pursuant to subsection (2) may |
501 | not be subject to dollar limits, deductibles, or coinsurance |
502 | provisions that are less favorable to an insured than the dollar |
503 | limits, deductibles, or coinsurance provisions that apply to |
504 | physical illnesses that are generally covered under the health |
505 | insurance plan, except as otherwise provided in subsection (3). |
506 | (5) An insurer may not deny or refuse to issue coverage |
507 | for medically necessary services, refuse to contract with, or |
508 | refuse to renew or reissue or otherwise terminate or restrict |
509 | coverage for an individual because the individual is diagnosed |
510 | as having a developmental disability. |
511 | (6) The treatment plan required pursuant to subsection (3) |
512 | shall include all elements necessary for the health insurance |
513 | plan to appropriately pay claims. These elements include, but |
514 | are not limited to, a diagnosis, the proposed treatment by type, |
515 | the frequency and duration of treatment, the anticipated |
516 | outcomes stated as goals, the frequency with which the treatment |
517 | plan will be updated, and the signature of the treating |
518 | physician. |
519 | (7) Beginning January 1, 2011, the maximum benefit under |
520 | paragraph (3)(b) shall be adjusted annually on January 1 of each |
521 | calendar year to reflect any change from the previous year in |
522 | the medical component of the then current Consumer Price Index |
523 | for all urban consumers, published by the Bureau of Labor |
524 | Statistics of the United States Department of Labor. |
525 | (8) This section may not be construed as limiting benefits |
526 | and coverage otherwise available to an insured under a health |
527 | insurance plan. |
528 | (9) The Office of Insurance Regulation may not enforce |
529 | this section against an insurer that is a signatory to the |
530 | developmental disabilities compact established under s. 624.916. |
531 | Section 15. Section 641.31098, Florida Statutes, is |
532 | created to read: |
533 | 641.31098 Coverage for individuals with developmental |
534 | disabilities.-- |
535 | (1) As used in this section, the term: |
536 | (a) "Autism spectrum disorder" means any of the following |
537 | disorders as defined with most recent edition of the Diagnostic |
538 | and Statistical Manual of Mental Disorders of the American |
539 | Psychiatric Association: |
540 | 1. Autistic disorder; |
541 | 2. Asperger syndrome; or |
542 | 3. Pervasive developmental disorder not otherwise |
543 | specified. |
544 | (b) "Developmental disability" has the same meaning as |
545 | provided in s. 393.063 . |
546 | (c) "Eligible individual" means an individual under 18 |
547 | years of age or an individual 18 years of age or older who is in |
548 | high school who has been diagnosed as having a developmental |
549 | disability at 8 years of age or younger. |
550 | (d) "Health maintenance contract" means a group health |
551 | maintenance contract offered by a health maintenance |
552 | organization. This term does not include a health maintenance |
553 | contract offered in the individual market, a health maintenance |
554 | contract that is individually underwritten, or a health |
555 | maintenance contract provided to a small employer. |
556 | (2) A health maintenance contract issued or renewed on or |
557 | after July 1, 2009, shall provide coverage to an eligible |
558 | individual for: |
559 | (a) Well-baby and well-child screening for diagnosing the |
560 | presence of a developmental disability. |
561 | (b) Treatment of a developmental disability through speech |
562 | therapy, occupational therapy, physical therapy, and behavior |
563 | analysis services. Behavior analysis services shall be provided |
564 | by an individual certified pursuant to s. 393.17 or an |
565 | individual licensed under chapter 490 or chapter 491. |
566 | (3) The coverage required pursuant to subsection (2) is |
567 | subject to the following requirements: |
568 | (a) Coverage shall be limited to treatment that is |
569 | prescribed by the subscriber's treating physician in accordance |
570 | with a treatment plan. |
571 | (b) Coverage for the services described in subsection (2) |
572 | shall be limited to $36,000 annually and may not exceed $108,000 |
573 | in total benefits. |
574 | (c) Coverage may not be denied on the basis that provided |
575 | services are habilitative in nature. |
576 | (d) Coverage may be subject to general exclusions and |
577 | limitations of the subscriber's contract, including, but not |
578 | limited to, coordination of benefits, participating provider |
579 | requirements, and utilization review of health care services, |
580 | including the review of medical necessity, case management, and |
581 | other managed care provisions. |
582 | (4) The coverage required pursuant to subsection (2) may |
583 | not be subject to dollar limits, deductibles, or coinsurance |
584 | provisions that are less favorable to a subscriber than the |
585 | dollar limits, deductibles, or coinsurance provisions that apply |
586 | to physical illnesses that are generally covered under the |
587 | subscriber's contract, except as otherwise provided in |
588 | subsection (3). |
589 | (5) A health maintenance organization may not deny or |
590 | refuse to issue coverage for medically necessary services, |
591 | refuse to contract with, or refuse to renew or reissue or |
592 | otherwise terminate or restrict coverage for an individual |
593 | solely because the individual is diagnosed as having a |
594 | developmental disability. |
595 | (6) The treatment plan required pursuant to subsection (3) |
596 | shall include, but is not limited to, a diagnosis, the proposed |
597 | treatment by type, the frequency and duration of treatment, the |
598 | anticipated outcomes stated as goals, the frequency with which |
599 | the treatment plan will be updated, and the signature of the |
600 | treating physician. |
601 | (7) Beginning January 1, 2011, the maximum benefit under |
602 | paragraph (3)(b) shall be adjusted annually on January 1 of each |
603 | calendar year to reflect any change from the previous year in |
604 | the medical component of the then current Consumer Price Index |
605 | for all urban consumers, published by the Bureau of Labor |
606 | Statistics of the United States Department of Labor. |
607 | (8) The Office of Insurance Regulation may not enforce |
608 | this section against a health maintenance organization that is a |
609 | signatory no later than July 1, 2009, to the developmental |
610 | disabilities compact established under s. 624.916. The Office of |
611 | Insurance Regulation shall enforce this section against a health |
612 | maintenance organization that is a signatory to the compact |
613 | established under s. 624.916 if the health maintenance |
614 | organization has not complied with the terms of the compact for |
615 | all health maintenance contracts by July 1, 2010. |
616 |
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617 | ----------------------------------------------------- |
618 | T I T L E A M E N D M E N T |
619 | Remove line 1541 |
620 | premium; amending s. 409.811, F.S.; providing a definition of |
621 | the term "autism spectrum disorder"; amending s. 409.815, F.S.; |
622 | revising provisions |