Florida Senate - 2008 CS for SB 888
By the Committee on Health Policy; and Senator Dawson
587-07043-08 2008888c1
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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. 20.43, F.S.; redesignating the Division of Children's
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Medical Services Network within the Department of Health
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as the "Division of Children's Medical Services Network
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and Specialty Programs"; creating the Division of
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Children's Health Insurance and the Office of Child Health
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Coordination within the Department of Health; amending s.
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391.011, F.S.; redesignating ch. 391, F.S., as the
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"Children's Health Act"; amending s. 391.016, F.S.;
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revising legislative intent with respect to certain
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responsibilities of the Children's Health program;
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amending s. 391.021, F.S.; revising and providing
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definitions; amending s. 391.025, F.S.; revising the
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components of the Children's Health program; conforming
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provisions to changes made by the act; amending s.
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391.026, F.S.; requiring the Department of Health to
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administer the Florida Kidcare program; amending s.
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391.028, F.S.; revising the duties of the Children's
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Medical Services Network; revising the duties of the
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director; requiring the Division of Children's Health
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Insurance to administer the Florida Kidcare program;
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specifying that the Office of Child Health Coordination is
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responsible for child health services not directly related
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to Florida Kidcare; amending s. 391.029, F.S.; requiring
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the Department of Health to establish clinical eligibility
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requirements for Florida Kidcare Plus benefits; revising
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eligibility criteria; amending s. 409.810, F.S.;
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conforming provisions; amending s. 409.811, F.S.; revising
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and providing definitions relating to the Florida Kidcare
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Act; amending s. 409.812, F.S.; revising the purpose of
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the Florida Kidcare program; amending s. 409.813, F.S.;
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specifying the components of the program which are
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marketed collectively as the Florida Kidcare program;
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amending s. 409.8132, F.S.; revising the assignment
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requirements in the Medikids program component; amending
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s. 409.8134, F.S.; revising requirements for the
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department in conducting enrollment in the Florida Kidcare
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program; amending s. 409.814, F.S.; revising the
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eligibility requirements for the program; establishing
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good cause reasons for voluntarily canceling employer or
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other private coverage; increasing the cap on enrollment
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of full-pay children in MediKids and Healthy Kids under
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certain conditions; requiring notification of changes in
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eligibility for health plans and providers; requiring the
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electronic verification of an applicant's family income;
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providing that full-pay enrollees are not subject to the
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eligibility documentation requirements of this section;
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amending s. 409.815, F.S.; requiring that the health
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benefits coverage of the Florida Kidcare program be
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equivalent to the pediatric Medicaid benefit package;
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amending s. 409.8177, F.S.; requiring the department to
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assume responsibility from the Agency for Health Care
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Administration for contracting for the annual evaluation
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of the Florida Kidcare program; amending s. 409.818, F.S.;
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requiring the Department of Children and Family Services
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to develop and use a standardized eligibility application;
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requiring the Department of Children and Family Services
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to develop a plan for determining the eligibility of
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certain children for coverage and to submit a report of
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the plan to the Governor and the Legislature by a
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specified date; revising the duties of the Department of
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Health with respect to reviewing the intake process;
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requiring the department to publicize the Florida Kidcare
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program, determine eligibility for Florida Kidcare Plus
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coverage, and develop standards for pediatric quality
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assurance and access; requiring the department to adopt
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rules; authorizing the department to make certain program
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modifications upon the approval of the Legislature;
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requiring the Agency for Health Care Administration to
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establish a toll-free telephone number to assist families;
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requiring the agency to apply for waivers and adopt rules
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to comply with federal laws and the requirements of the
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act; requiring the Florida Healthy Kids Corporation to
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conduct eligibility determination based on rules developed
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by the Department of Health; repealing s. 409.820, F.S.,
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relating to quality assurance and access standards;
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amending s. 624.91, F.S.; revising provisions of the
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Florida Healthy Kids Corporation Act; providing for the
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transfer of certain functions to the Department of Health;
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requiring the Florida Healthy Kids Corporation to
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administer the program based on the rules and policies
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developed by the Department of Health; requiring the
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corporation to allow health plans to market the program;
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specifying the corporation's assignment process for family
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members in the program; requesting Florida's Congressional
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Delegation to support certain amendments to Title XXI of
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the Social Security Act; 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. Subsection (3) of section 20.43, Florida
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Statutes, is amended to read:
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20.43 Department of Health.--There is created a Department
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of Health.
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(3) The following divisions of the Department of Health are
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established:
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(a) Division of Administration.
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(b) Division of Environmental Health.
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(c) Division of Disease Control.
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(d) Division of Family Health Services.
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(e) Division of Children's Medical Services Network and
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Specialty Programs.
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(f) Division of Emergency Medical Operations.
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(g) Division of Medical Quality Assurance, which is
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responsible for the following boards and professions established
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within the division:
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1. The Board of Acupuncture, created under chapter 457.
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2. The Board of Medicine, created under chapter 458.
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3. The Board of Osteopathic Medicine, created under chapter
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459.
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4. The Board of Chiropractic Medicine, created under
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chapter 460.
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5. The Board of Podiatric Medicine, created under chapter
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461.
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6. Naturopathy, as provided under chapter 462.
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7. The Board of Optometry, created under chapter 463.
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8. The Board of Nursing, created under part I of chapter
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464.
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9. Nursing assistants, as provided under part II of chapter
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464.
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10. The Board of Pharmacy, created under chapter 465.
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11. The Board of Dentistry, created under chapter 466.
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12. Midwifery, as provided under chapter 467.
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13. The Board of Speech-Language Pathology and Audiology,
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created under part I of chapter 468.
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14. The Board of Nursing Home Administrators, created under
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part II of chapter 468.
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15. The Board of Occupational Therapy, created under part
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III of chapter 468.
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16. Respiratory therapy, as provided under part V of
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chapter 468.
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17. Dietetics and nutrition practice, as provided under
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part X of chapter 468.
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18. The Board of Athletic Training, created under part XIII
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of chapter 468.
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19. The Board of Orthotists and Prosthetists, created under
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part XIV of chapter 468.
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20. Electrolysis, as provided under chapter 478.
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21. The Board of Massage Therapy, created under chapter
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480.
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22. The Board of Clinical Laboratory Personnel, created
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under part III of chapter 483.
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23. Medical physicists, as provided under part IV of
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chapter 483.
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24. The Board of Opticianry, created under part I of
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chapter 484.
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25. The Board of Hearing Aid Specialists, created under
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part II of chapter 484.
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26. The Board of Physical Therapy Practice, created under
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chapter 486.
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27. The Board of Psychology, created under chapter 490.
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28. School psychologists, as provided under chapter 490.
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29. The Board of Clinical Social Work, Marriage and Family
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Therapy, and Mental Health Counseling, created under chapter 491.
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(h) Division of Children's Medical Services Prevention and
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Intervention.
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(i) Division of Information Technology.
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(j) Division of Health Access and Tobacco.
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(k) Division of Disability Determinations.
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(l) Division of Children's Health Insurance.
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(m) Division of Child Health Coordination.
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Section 2. Section 391.011, Florida Statutes, is amended to
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read:
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391.011 Short title.--The provisions of this chapter may be
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cited as the "Children's Health Medical Services Act."
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Section 3. Section 391.016, Florida Statutes, is amended to
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read:
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391.016 Legislative intent.--The Legislature intends that
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the Children's Health Medical Services program:
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(1) Provide to children with special health care needs a
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family-centered, comprehensive, and coordinated statewide managed
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system of care that links community-based health care with
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multidisciplinary, regional, and tertiary pediatric specialty
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care. The program may provide for the coordination and
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maintenance of consistency of the medical home for children in
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families with a Children's Medical Services program participant,
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in order to achieve family-centered care.
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(2) Provide essential preventive, evaluative, and early
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intervention services for children at risk for or having special
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health care needs, in order to prevent or reduce long-term
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disabilities.
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(3) Serve as a principal provider for children with special
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health care needs under Titles XIX and XXI of the Social Security
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Act.
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(4) Be complementary to children's health training programs
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essential for the maintenance of a skilled pediatric health care
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workforce for all Floridians.
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(5) Consolidate and coordinate Florida Kidcare child health
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policy, develop pediatric benefit packages, develop budget and
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federal and state legislative issues, and develop pediatric
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quality assurance and access standards.
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Section 4. Section 391.021, Florida Statutes, is amended to
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read:
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391.021 Definitions.--When used in this act, unless the
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context clearly indicates otherwise:
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(1) "Children's Medical Services network" or "network"
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means a statewide managed care service system that includes
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health care providers, health care facilities, or entities
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licensed or certified to provide health services in this state
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which meet the pediatric access and quality standards established
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by the department. The network shall provide Florida Kidcare Plus
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benefits as defined in s. 409.811 as defined in this section.
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(2) "Children with special health care needs" means those
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children younger than 21 years of age who have chronic physical,
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developmental, behavioral, or emotional conditions and who also
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require health care and related services of a type or amount
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beyond that which is generally required by children.
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(3) "Department" means the Department of Health.
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(4) "Eligible individual" means a child with a special
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health care need or a female with a high-risk pregnancy, who
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meets the financial and medical eligibility standards established
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in s. 391.029.
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(5) "Health care provider" means a health care
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professional, health care facility, or entity licensed or
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certified to provide health services in this state that meets the
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criteria as established by the department.
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(6) "Health services" includes the prevention, diagnosis,
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and treatment of human disease, pain, injury, deformity, or
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disabling conditions.
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(7) "Participant" means an eligible individual who is
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enrolled in the Children's Medical Services program.
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(8) "Pediatric benefit" means a benefit that is determined
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to be medically necessary to treat a health condition. The scope,
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duration, and frequency of the service are based on medical-
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necessity criteria "Program" means the Children's Medical
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Services program established in the department.
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(9) "Program" means the Children's Health program
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established in the department.
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(10) "Safety net" means limited services provided to
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children with special health care needs who are uninsured or
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underinsured and do not qualify for Title XIX-funded or Title
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XXI-funded health benefits coverage.
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Section 5. Section 391.025, Florida Statutes, is amended to
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read:
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391.025 Applicability and scope.--
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(1) The Children's Health Medical Services program consists
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of the following components:
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(a) The newborn screening program established in s. 383.14.
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(b) The regional perinatal intensive care centers program
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(c) A federal or state program authorized by the
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Legislature.
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(d) The developmental evaluation and intervention program,
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including the Florida Infants and Toddlers Early Intervention
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Program.
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(e) The Children's Medical Services network.
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(f) The Division of Children's Health Insurance.
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(g) The Office of Child Health Coordination.
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(2) The Children's Medical Services Network program shall
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not be deemed an insurer and is not subject to the licensing
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requirements of the Florida Insurance Code or the rules adopted
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thereunder, when providing services to children who receive Title
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XIX-funded Medicaid benefits, to other Title XIX-eligible
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Medicaid-eligible children with special health care needs, or to
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Title XIX-funded and children with special health care needs
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participating in the Florida Kidcare program.
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Section 6. Subsection (19) is added to section 391.026,
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Florida Statutes, to read:
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391.026 Powers and duties of the department.--The
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department shall have the following powers, duties, and
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responsibilities:
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(19) To administer the provisions of the Florida Kidcare
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Section 7. Section 391.028, Florida Statutes, is amended to
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read:
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391.028 Administration.--The Children's Medical Services
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Network program shall have a central office and area offices.
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(1) The Director of Children's Health Medical Services must
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be a physician licensed under chapter 458 or chapter 459 who has
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specialized training and experience in the provision of health
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care to children and who has recognized skills in leadership and
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the promotion of children's health programs. The director shall
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be the deputy secretary and the Deputy State Health Officer for
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Children's Health Medical Services and is appointed by and
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reports to the State Surgeon General. The director may appoint
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division directors subject to the approval of the State Surgeon
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General.
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(2) The director shall designate Children's Medical
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Services Network area offices to perform operational activities
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for children with special health care needs, including, but not
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limited to:
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(a) Providing case management services for the network.
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(b) Providing local oversight of the program.
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(c) Determining an individual's clinical medical and
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financial eligibility for the program.
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(d) Participating in the determination of a level of care
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and medical complexity for long-term care services.
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(e) Authorizing services in the program and developing
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spending plans.
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(f) Participating in the development of treatment plans.
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(g) Taking part in the resolution of complaints and
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grievances from participants and health care providers.
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(3) Each Children's Medical Services Network area office
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shall be directed by a physician licensed under chapter 458 or
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chapter 459 who has specialized training and experience in the
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provision of health care to children. The director of a
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Children's Medical Services area office shall be appointed by the
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director from the active panel of Children's Medical Services
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physician consultants.
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(4) The Division of Children's Health Insurance shall be
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responsible for administering the provisions of the Florida
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Kidcare Act assigned to the Department of Health in ss. 409.810-
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(5) The Office of Child Health Coordination is responsible
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for child health services not directly related to Florida Kidcare
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health benefits coverage.
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Section 8. Subsections (1), (2), and (3) of section
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391.029, Florida Statutes, are amended to read:
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391.029 Program eligibility.--
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(1) The department shall establish clinical eligibility the
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medical criteria to determine whether if an applicant for Florida
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Kidcare Plus benefits the Children's Medical Services program is
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an eligible individual.
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(2) The following individuals are financially eligible to
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receive services through the Children's Medical Services Network
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program:
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(a) A high-risk pregnant female who is eligible for
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Medicaid.
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(b) Children with special health care needs from birth to
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21 years of age who are eligible for Medicaid.
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(c) Children with special health care needs from birth to
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19 years of age who are eligible for a program under Title XXI of
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the Social Security Act.
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(3) Subject to the availability of funds, the following
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individuals may receive services through the program:
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(a) Children with special health care needs from birth to
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21 years of age whose families do not qualify for Title XIX-
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financed or Title XXI-financed health benefits coverage family
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income is above the requirements for financial eligibility under
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Title XXI of the Social Security Act and whose projected annual
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cost of care adjusts the family income to Medicaid financial
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criteria. In cases where the family income is adjusted based on a
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projected annual cost of care, the family shall participate
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financially in the cost of care based on criteria established by
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the department. These children may receive safety net services,
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subject to the availability of funds.
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(b) Children with special health care needs from birth to
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21 years of age, as provided in Title V of the Social Security
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Act.
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(c) An infant who receives an award of compensation under
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s. 766.31(1). The Florida Birth-Related Neurological Injury
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Compensation Association shall reimburse the Children's Medical
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Services Network the state's share of funding, which must
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thereafter be used to obtain matching federal funds under Title
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XXI of the Social Security Act.
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Section 9. Section 409.810, Florida Statutes, is amended to
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read:
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409.820 may be cited as the "Florida Kidcare Act."
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Section 10. Section 409.811, Florida Statutes, is amended
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to read:
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409.811 Definitions relating to Florida Kidcare Act.--As
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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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(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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who has a chronic physical, developmental, behavioral, or
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emotional condition and who also requires health care and related
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services of a type or amount beyond that which is generally
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required by children whose serious or chronic physical or
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developmental condition requires extensive preventive and
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maintenance care beyond that required by typically healthy
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children. Health care utilization by such a child exceeds the
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statistically expected usage of the normal child adjusted for
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chronological age, and such a child often needs complex care
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requiring multiple providers, rehabilitation services, and
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specialized equipment in a number of 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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(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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(11)(12) "Family income" means cash received at periodic
405
intervals from any source, such as wages, benefits,
406
contributions, or rental property. Family income is calculated
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using the budget methodologies authorized under Title XIX of the
408
Social Security Act. Income also may include any money that would
409
have been counted as income under the Aid to Families with
410
Dependent Children (AFDC) state plan in effect prior to August
411
22, 1996.
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(12) Florida Kidcare Plus" means health benefits coverage
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for children with special health care needs which benefits are
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delivered through the Children's Medical Services Network
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established in chapter 391.
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(13) "Florida Kidcare program," "Kidcare program," or
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"program" means the health benefits program for children
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(14) "Guarantee issue" means that health benefits coverage
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must be offered to an individual regardless of the individual's
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health status, preexisting condition, or claims history.
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(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
425
with other persons, covered health care services on a prepaid per
426
capita basis or on a prepaid aggregate fixed-sum basis.
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(16) "Health insurance plan" means health benefits coverage
428
under the following:
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(a) A health plan offered by any certified health
430
maintenance organization or authorized health insurer, except a
431
plan that is limited to the following: a limited benefit,
432
specified disease, or specified accident; hospital indemnity;
433
accident only; limited benefit convalescent care; Medicare
434
supplement; credit disability; dental; vision; long-term care;
435
disability income; coverage issued as a supplement to another
436
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
439
benefits established under the Employee Retirement Income
440
Security Act of 1974, as amended.
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(17) "Healthy Kids" means a component of the Florida
442
Kidcare program of medical assistance for children who are 5
443
through 18 years of age as authorized under s. 624.91 and
444
administered by the Florida Healthy Kids Corporation.
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(18)(17) "Medicaid" means the medical assistance program
446
authorized by Title XIX of the Social Security Act, and
448
in this state by the agency.
449
(19)(18) "Medically necessary" means the use of any medical
450
treatment, service, equipment, or supply necessary to palliate
451
the effects of a terminal condition, or to prevent, diagnose,
452
correct, cure, alleviate, or preclude deterioration of a
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condition that threatens life, causes pain or suffering, or
454
results in illness or infirmity and which is:
455
(a) Consistent with the symptom, diagnosis, and treatment
456
of the enrollee's condition;
457
(b) Provided in accordance with generally accepted
458
standards of medical practice;
459
(c) Not primarily intended for the convenience of the
460
enrollee, the enrollee's family, or the health care provider;
461
(d) The most appropriate level of supply or service for the
462
diagnosis and treatment of the enrollee's condition; and
463
(e) Approved by the appropriate medical body or health care
464
specialty involved as effective, appropriate, and essential for
465
the care and treatment of the enrollee's condition.
466
(20)(19) "Medikids" means a component of the Florida
467
Kidcare program of medical assistance authorized by Title XXI of
468
the Social Security Act, and regulations thereunder, and s.
469
409.8132, as administered in the state by the agency.
470
(21) "Pediatric benefit" means a benefit that is determined
471
to be medically necessary to treat a health condition. The scope,
472
duration, and frequency of the service are based on medical-
473
necessity criteria.
474
(22)(20) "Preexisting condition exclusion" means, with
475
respect to coverage, a limitation or exclusion of benefits
476
relating to a condition based on the fact that the condition was
477
present before the date of enrollment for such coverage, whether
478
or not any medical advice, diagnosis, care, or treatment was
479
recommended or received before such date.
480
(23)(21) "Premium" means the entire cost of a health
481
insurance plan, including the administration fee or the risk
482
assumption charge.
483
(24)(22) "Premium assistance payment" means the monthly
484
consideration paid by the agency per enrollee in the Florida
485
Kidcare program towards health insurance premiums.
486
(25)(23) "Qualified alien" means an alien as defined in s.
487
431 of the Personal Responsibility and Work Opportunity
488
Reconciliation Act of 1996, as amended, Pub. L. No. 104-193.
489
(26)(24) "Resident" means a United States citizen, or
490
qualified alien, who is domiciled in this state.
491
(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
493
defined by the most recent United States Census as rural, in
494
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
497
to additional services as defined in s. 2103(c)(2) of Title XXI
498
of the Social Security Act, these services must have an actuarial
499
value equal to at least 75 percent of the actuarial value of the
500
coverage for that service in the benchmark benefit plan and, with
501
respect to the basic services as defined in s. 2103(c)(1) of
502
Title XXI of the Social Security Act, these services must be the
503
same as the services in the benchmark benefit plan.
504
Section 11. Section 409.812, Florida Statutes, is amended
505
to read:
506
409.812 Program created; purpose.--The Florida Kidcare
507
program is created to provide a defined set of health benefits to
508
previously uninsured, low-income children through the
509
establishment of a variety of affordable health benefits coverage
510
options from which families may select coverage and through which
511
families may contribute financially to the health care of their
512
children.
513
Section 12. Section 409.813, Florida Statutes, is amended
514
to read:
515
409.813 Health benefits coverage; program components;
516
entitlement and nonentitlement.--The Florida Kidcare program
517
includes health benefits coverage provided to children through
518
the following components, which shall be marketed as the Florida
519
Kidcare program:
520
(1) Medicaid;
521
(2) Medikids as created in s. 409.8132;
522
(3) The Florida Healthy Kids Corporation as created in s.
523
524
(4) Employer-sponsored group health insurance plans
526
(5) The Children's Medical Services network established in
527
chapter 391.
528
529
Except for coverage through the Title XIX-funded Florida Kidcare
530
program under the Medicaid program, coverage under the Florida
531
Kidcare program is not an entitlement. No cause of action shall
532
arise against the state, the department, the Department of
533
Children and Family Services, or the agency for failure to make
536
Section 13. Subsection (7) of section 409.8132, Florida
537
Statutes, is amended to read:
538
409.8132 Medikids program component.--
539
(7) ENROLLMENT.--Enrollment in the Medikids program
540
component may occur at any time throughout the year. A child may
541
not receive services under the Medikids program until the child
542
is enrolled in a managed care plan or MediPass. Once determined
543
eligible, an applicant may receive choice counseling and select a
544
managed care plan or MediPass. The agency may initiate mandatory
545
assignment for a Medikids applicant who has not chosen a managed
546
care plan or MediPass provider after the applicant's voluntary
547
choice period ends. The agency shall assign the Medikids
548
applicant to the same managed care plan or to the same MediPass
549
provider to which other family members are assigned, to the
550
greatest extent possible, even if some family members are
551
enrolled in Medicaid and others are enrolled in the Medikids
552
program. An applicant may select MediPass under the Medikids
553
program component only in counties that have fewer than two
554
managed care plans available to serve Medicaid recipients and
555
only if the federal Health Care Financing Administration
556
determines that MediPass constitutes "health insurance coverage"
557
as defined in Title XXI of the Social Security Act.
558
Section 14. Section 409.8134, Florida Statutes, is amended
559
to read:
560
409.8134 Program expenditure ceiling.--
561
(1) Except for the Medicaid program, a ceiling shall be
562
placed on annual federal and state expenditures for the Florida
563
Kidcare program as provided each year in the General
564
Appropriations Act.
565
(2) The Florida Kidcare program may conduct enrollment at
566
any time throughout the year for the purpose of enrolling
567
children eligible for all program components listed in s. 409.813
568
except Medicaid. The four Florida Kidcare administrators shall
569
work together to ensure that the year-round enrollment period is
570
announced statewide. Eligible children shall be enrolled on a
571
first-come, first-served basis using the date the enrollment
572
application is received. Enrollment shall immediately cease when
573
the expenditure ceiling is reached. Year-round enrollment shall
574
only be held only if the Social Services Estimating Conference
575
determines that sufficient federal and state funds will be
576
available to finance the increased enrollment through federal
577
fiscal year 2007. Any individual who is not enrolled must reapply
578
by submitting a new application. The application for the Florida
579
Kidcare program is shall be valid for a period of 120 days after
580
the date it was received. At the end of the 120-day period, if
581
the applicant has not been enrolled in the program, the
582
application is shall be invalid and the applicant must shall be
583
notified of the action. The applicant may resubmit the
584
application after notification of the action taken by the
585
program. Except for the Medicaid program, whenever the Social
586
Services Estimating Conference determines that there are
587
presently, or will be by the end of the current fiscal year,
588
insufficient funds to finance the current or projected enrollment
589
in the Florida Kidcare program, all additional enrollment must
590
cease and additional enrollment may not resume until sufficient
591
funds are available to finance such enrollment.
592
(3) Upon determination by the Social Services Estimating
593
Conference that there are insufficient funds to finance the
594
current enrollment in the Florida Kidcare program within current
595
appropriations, the program shall initiate disenrollment
596
procedures to remove enrollees, except those children who receive
597
Florida Kidcare Plus benefits enrolled in the Children's Medical
598
Services Network, on a last-in, first-out basis until the
599
expenditure and appropriation levels are balanced.
600
(4) The agencies that administer the Florida Kidcare
601
program components shall collect and analyze the data needed to
602
project program enrollment costs, including price level
603
adjustments, participation and attrition rates, current and
604
projected caseloads, utilization, and current and projected
605
expenditures for the next 3 years. The agencies shall report
606
caseload and expenditure trends to the Social Services Estimating
607
Conference in accordance with chapter 216.
608
Section 15. Section 409.814, Florida Statutes, is amended
609
to read:
610
409.814 Eligibility.--A child who has not reached 19 years
611
of age whose family income is equal to or below 200 percent of
612
the federal poverty level is eligible for the Florida Kidcare
613
program as provided in this section. For enrollment in Florida
614
Kidcare Plus the Children's Medical Services Network, a complete
615
application includes clinical eligibility the medical or
616
behavioral health screening. If, subsequently, an individual is
617
determined to be ineligible for coverage, he or she must
618
immediately be disenrolled from the respective Florida Kidcare
619
program component.
620
(1) A child who is eligible for Medicaid coverage under s.
622
eligible to receive health benefits under any other health
623
benefits coverage authorized under the Florida Kidcare program.
624
(2) A child who is not eligible for Medicaid, but who is
625
eligible for the Florida Kidcare program, may obtain health
626
benefits coverage under any of the other components listed in s.
627
409.813 if such coverage is approved and available in the county
628
in which the child resides. However, a child who is eligible for
629
Medikids may participate in the Florida Healthy Kids program only
630
if the child has a sibling participating in the Florida Healthy
631
Kids program and the child's county of residence permits such
632
enrollment.
633
(3) A child who is eligible for the Florida Kidcare program
634
and has who is a child with special health care needs, as
635
determined through a clinical-eligibility medical or behavioral
636
screening instrument, is eligible for health benefits coverage
637
from and must shall be referred to the Children's Medical
638
Services Network.
639
(4) The following children are not eligible to receive
640
premium assistance for health benefits coverage under the Florida
641
Kidcare program, except under Medicaid if the child would have
643
June 1, 1997:
644
(a) A child who is eligible for coverage under a state
645
health benefit plan on the basis of a family member's employment
646
with a public agency in the state.
647
(b) A child who is currently eligible for or covered under
648
a family member's group health benefit plan or under other
649
employer health insurance coverage, excluding coverage provided
650
under the Florida Healthy Kids Corporation as established under
651
s. 624.91, provided that the cost of the child's participation is
652
not greater than 5 percent of the family's income. This provision
653
shall be applied during redetermination for children who were
654
enrolled prior to July 1, 2004. These enrollees shall have 6
655
months of eligibility following redetermination to allow for a
656
transition to the other health benefit plan.
657
(c) A child who is seeking premium assistance for the
658
Florida Kidcare program through employer-sponsored group
659
coverage, if the child has been covered by the same employer's
660
group coverage during the 6 months before prior to the family's
661
submitting an application for determination of eligibility under
662
the program.
663
(d) A child who is an alien, but who does not meet the
664
definition of qualified alien, in the United States.
665
(e) A child who is an inmate of a public institution or a
666
patient in an institution for mental diseases.
667
(f) A child who is otherwise eligible for premium
668
assistance for the Florida Kidcare program and has had his or her
669
coverage in an employer-sponsored or private health benefit plan
670
voluntarily canceled in the last 6 months, except those children
671
whose coverage was voluntarily canceled for good cause,
672
including, but not limited to, the following circumstances:
673
1. The parent lost a job that provided an employer-
674
sponsored health benefit plan for children;
675
2. The parent with health benefits coverage for the child
676
is deceased;
677
3. The child has a medical condition that, without medical
678
care, would cause serious disability, loss of function, or death;
679
4. The employer of the parent canceled health benefits
680
coverage for children;
681
5. The child's health benefits coverage ended because the
682
child reached the maximum lifetime coverage amount;
683
6. The child has exhausted coverage under a COBRA
684
continuation provision;
685
7. The health benefits coverage does not cover the child's
686
health care needs; or
687
8. Domestic violence led to loss of coverage who were on
688
the waiting list prior to March 12, 2004.
689
(g) A child who is otherwise eligible for the Florida
690
Kidcare program and who has a preexisting condition that prevents
691
coverage under another insurance plan as described in paragraph
692
(b) which would have disqualified the child for the Florida
693
Kidcare program if the child were able to enroll in the plan
694
shall be eligible for Florida Kidcare coverage when enrollment is
695
possible.
696
(5) A child whose family income is above 200 percent of the
697
federal poverty level or a child who is excluded under the
698
provisions of subsection (4) may participate in the Florida
699
Kidcare program. However, Medikids program as provided in s.
700
409.8132 or, if the child is ineligible for Medikids by reason of
701
age, in the Florida Healthy Kids program, subject to the
702
following provisions:
703
(a) the family is not eligible for premium assistance
704
payments and must pay the full cost of the premium, including any
705
administrative costs.
706
(a)(b) The agency is authorized to place limits on
707
enrollment in Medikids by these children in order to avoid
708
adverse selection. The number of children participating in
709
Medikids whose family income exceeds 250 200 percent of the
710
federal poverty level must not exceed 25 10 percent of total
711
enrollees in the Medikids program. Except for families who are
712
enrolled in the program on July 1, 2008, or who are in transition
713
from coverage in a subsidized Kidcare program, a family whose
714
income exceeds 250 percent of the federal poverty level must have
715
been uninsured for 6 consecutive months before enrollment in the
716
program.
717
(b)(c) The board of directors of the Florida Healthy Kids
718
Corporation is authorized to place limits on enrollment of these
719
children in order to avoid adverse selection. In addition, the
720
board is authorized to offer a reduced benefit package to these
721
children in order to limit program costs for such families. The
722
number of children participating in the Florida Healthy Kids
723
program whose family income exceeds 250 200 percent of the
724
federal poverty level must not exceed 25 10 percent of total
725
enrollees in the Florida Healthy Kids program. However, a family
726
that is enrolled in the program on July 1, 2008, or that is in
727
transition from coverage in a subsidized program, or a family
728
whose income exceeds 250 percent of the federal poverty level
729
must have been uninsured for 6 consecutive months before
730
enrollment in the program.
731
(6) Once a child is enrolled in the Florida Kidcare
732
program, the child is eligible for coverage under the program for
733
12 months without a redetermination or reverification of
734
eligibility, if the family continues to pay the applicable
735
premium. Eligibility for Florida Kidcare coverage program
736
components funded through Title XXI of the Social Security Act
737
terminates shall terminate when a child attains the age of 19.
738
Effective January 1, 1999, a child who has not attained the age
739
of 5 and who has been determined eligible for the Medicaid
740
program is eligible for coverage for 12 months without a
741
redetermination or reverification of eligibility.
742
(7) When determining or reviewing a child's eligibility
743
under the Florida Kidcare program, the applicant must shall be
744
provided with reasonable notice of changes in eligibility which
745
may affect enrollment in one or more of the program components.
746
When a transition from one program component to another is
747
authorized, there must shall be cooperation between the program
748
components, and the affected family, the child's health plan, and
749
the child's health care providers to promote which promotes
750
continuity of health care coverage. When a child is no longer
751
eligible for Florida Kidcare coverage funded through Title XIX or
752
Title XXI of the Social Security Act, the child's health plan and
753
other MediPass providers shall be notified so that the health
754
plans and providers may assist the family in obtaining coverage
755
through other available healthcare providers. Any authorized
756
transfers must be managed within the program's overall
757
appropriated or authorized levels of funding. Each component of
758
the program shall establish a reserve to ensure that transfers
759
between components will be accomplished within current year
760
appropriations. These reserves shall be reviewed by each
761
convening of the Social Services Estimating Conference to
762
determine the adequacy of such reserves to meet actual
763
experience.
764
(8) In determining the eligibility of a child, an assets
765
test is not required. An applicant's information must be
766
available electronically, if possible, to determine eligibility
767
for the Florida Kidcare program. If such information cannot be
768
verified electronically, each applicant shall provide written
769
documentation during the application process and the
770
redetermination process, including, but not limited to, the
771
following:
772
(a) Proof of family income, which includes must include a
773
copy of the applicant's most recent federal income tax return. In
774
the absence of a federal income tax return, an applicant may
775
submit wages and earnings statements (pay stubs), W-2 forms, or
776
other appropriate documents.
777
(b) A statement from all employed family members that:
778
1. Their employer does not sponsor a health benefit plan
779
for employees; or
780
2. The potential enrollee is not covered by the employer-
781
sponsored health benefit plan because the potential enrollee is
782
not eligible for coverage, or, if the potential enrollee is
783
eligible but not covered, a statement of the cost to enroll the
784
potential enrollee in the employer-sponsored health benefit plan.
785
(9) Subject to paragraph (4)(b) and s. 624.91(4), the
786
Florida Kidcare program shall withhold benefits from an enrollee
787
if the program obtains evidence that the enrollee is no longer
788
eligible, submitted incorrect or fraudulent information in order
789
to establish eligibility, or failed to provide verification of
790
eligibility. The applicant or enrollee shall be notified that
791
because of such evidence program benefits will be withheld unless
792
the applicant or enrollee contacts a designated representative of
793
the program by a specified date, which must be within 10 working
794
days after the date of notice, to discuss and resolve the matter.
795
The program shall make every effort to resolve the matter within
796
a timeframe that will not cause benefits to be withheld from an
797
eligible enrollee.
798
(10) The following individuals may be subject to
799
prosecution in accordance with s. 414.39:
800
(a) An applicant obtaining or attempting to obtain benefits
801
for a potential enrollee under the Florida Kidcare program when
802
the applicant knows or should have known the potential enrollee
803
does not qualify for the Florida Kidcare program.
804
(b) An individual who assists an applicant in obtaining or
805
attempting to obtain benefits for a potential enrollee under the
806
Florida Kidcare program when the individual knows or should have
807
known the potential enrollee does not qualify for the Florida
808
Kidcare program.
809
810
A person applying for full-pay coverage under the Florida Kidcare
811
program is not required to provide the information required under
812
this section.
813
Section 16. Section 409.815, Florida Statutes, is amended
814
to read:
815
409.815 Health benefits coverage; limitations.--
816
(1) MEDICAID BENEFITS.--For purposes of the Florida Kidcare
817
program, benefits available under Medicaid and Medikids include
818
those goods and services provided under the medical assistance
819
program authorized by Title XIX of the Social Security Act, and
820
regulations thereunder, as administered in this state by the
821
agency. This includes those mandatory Medicaid services
822
authorized under s. 409.905 and optional Medicaid services
823
authorized under s. 409.906, rendered on behalf of eligible
824
individuals by qualified providers, in accordance with federal
825
requirements for Title XIX, subject to any limitations or
826
directions provided for in the General Appropriations Act or
827
chapter 216, and according to methodologies and limitations set
828
forth in agency rules and policy manuals and handbooks
829
incorporated by reference thereto.
830
(2) BENCHMARK BENEFITS.--In order for health benefits
831
coverage to qualify for premium assistance payments for an
833
services provided to eligible Title XIX-funded children ss.
835
to the pediatric Medicaid benefit package and be based upon a
836
standard and appropriate assessment of need for the services
837
consistent with requirements for early and periodic screening,
838
diagnosis, and treatment specified in s.409.905(2) and Title XIX
839
of the Social Security Act, except for coverage under Medicaid
840
and Medikids, must include the following minimum benefits, as
841
medically necessary.
842
(a) Preventive health services.--Covered services include:
843
1. Well-child care, including services recommended in the
844
Guidelines for Health Supervision of Children and Youth as
845
developed by the American Academy of Pediatrics;
846
2. Immunizations and injections;
847
3. Health education counseling and clinical services;
848
4. Vision screening; and
849
5. Hearing screening.
850
(b) Inpatient hospital services.--All covered services
851
provided for the medical care and treatment of an enrollee who is
852
admitted as an inpatient to a hospital licensed under part I of
853
chapter 395, with the following exceptions:
854
1. All admissions must be authorized by the enrollee's
855
health benefits coverage provider.
856
2. The length of the patient stay shall be determined based
857
on the medical condition of the enrollee in relation to the
858
necessary and appropriate level of care.
859
3. Room and board may be limited to semiprivate
860
accommodations, unless a private room is considered medically
861
necessary or semiprivate accommodations are not available.
862
4. Admissions for rehabilitation and physical therapy are
863
limited to 15 days per contract year.
864
(c) Emergency services.--Covered services include visits to
865
an emergency room or other licensed facility if needed
866
immediately due to an injury or illness and delay means risk of
867
permanent damage to the enrollee's health. Health maintenance
868
organizations shall comply with the provisions of s. 641.513.
869
(d) Maternity services.--Covered services include maternity
870
and newborn care, including prenatal and postnatal care, with the
871
following limitations:
872
1. Coverage may be limited to the fee for vaginal
873
deliveries; and
874
2. Initial inpatient care for newborn infants of enrolled
875
adolescents shall be covered, including normal newborn care,
876
nursery charges, and the initial pediatric or neonatal
877
examination, and the infant may be covered for up to 3 days
878
following birth.
879
(e) Organ transplantation services.--Covered services
880
include pretransplant, transplant, and postdischarge services and
881
treatment of complications after transplantation for transplants
882
deemed necessary and appropriate within the guidelines set by the
883
Organ Transplant Advisory Council under s. 765.53 or the Bone
884
Marrow Transplant Advisory Panel under s. 627.4236.
885
(f) Outpatient services.--Covered services include
886
preventive, diagnostic, therapeutic, palliative care, and other
887
services provided to an enrollee in the outpatient portion of a
888
health facility licensed under chapter 395, except for the
889
following limitations:
890
1. Services must be authorized by the enrollee's health
891
benefits coverage provider; and
892
2. Treatment for temporomandibular joint disease (TMJ) is
893
specifically excluded.
894
(g) Behavioral health services.--
895
1. Mental health benefits include:
896
a. Inpatient services, limited to not more than 30
897
inpatient days per contract year for psychiatric admissions, or
898
residential services in facilities licensed under s. 394.875(6)
899
or s. 395.003 in lieu of inpatient psychiatric admissions;
900
however, a minimum of 10 of the 30 days shall be available only
901
for inpatient psychiatric services when authorized by a
902
physician; and
903
b. Outpatient services, including outpatient visits for
904
psychological or psychiatric evaluation, diagnosis, and treatment
905
by a licensed mental health professional, limited to a maximum of
906
40 outpatient visits each contract year.
907
2. Substance abuse services include:
908
a. Inpatient services, limited to not more than 7 inpatient
909
days per contract year for medical detoxification only and 30
910
days of residential services; and
911
b. Outpatient services, including evaluation, diagnosis,
912
and treatment by a licensed practitioner, limited to a maximum of
913
40 outpatient visits per contract year.
914
(h) Durable medical equipment.--Covered services include
915
equipment and devices that are medically indicated to assist in
916
the treatment of a medical condition and specifically prescribed
917
as medically necessary, with the following limitations:
918
1. Low-vision and telescopic aides are not included.
919
2. Corrective lenses and frames may be limited to one pair
920
every 2 years, unless the prescription or head size of the
921
enrollee changes.
922
3. Hearing aids shall be covered only when medically
923
indicated to assist in the treatment of a medical condition.
924
4. Covered prosthetic devices include artificial eyes and
925
limbs, braces, and other artificial aids.
926
(i) Health practitioner services.--Covered services include
927
services and procedures rendered to an enrollee when performed to
928
diagnose and treat diseases, injuries, or other conditions,
929
including care rendered by health practitioners acting within the
930
scope of their practice, with the following exceptions:
931
1. Chiropractic services shall be provided in the same
932
manner as in the Florida Medicaid program.
933
2. Podiatric services may be limited to one visit per day
934
totaling two visits per month for specific foot disorders.
935
(j) Home health services.--Covered services include
936
prescribed home visits by both registered and licensed practical
937
nurses to provide skilled nursing services on a part-time
938
intermittent basis, subject to the following limitations:
939
1. Coverage may be limited to include skilled nursing
940
services only;
941
2. Meals, housekeeping, and personal comfort items may be
942
excluded; and
943
3. Private duty nursing is limited to circumstances where
944
such care is medically necessary.
945
(k) Hospice services.--Covered services include reasonable
946
and necessary services for palliation or management of an
947
enrollee's terminal illness, with the following exceptions:
948
1. Once a family elects to receive hospice care for an
949
enrollee, other services that treat the terminal condition will
950
not be covered; and
951
2. Services required for conditions totally unrelated to
952
the terminal condition are covered to the extent that the
953
services are included in this section.
954
(l) Laboratory and X-ray services.--Covered services
955
include diagnostic testing, including clinical radiologic,
956
laboratory, and other diagnostic tests.
957
(m) Nursing facility services.--Covered services include
958
regular nursing services, rehabilitation services, drugs and
959
biologicals, medical supplies, and the use of appliances and
960
equipment furnished by the facility, with the following
961
limitations:
962
1. All admissions must be authorized by the health benefits
963
coverage provider.
964
2. The length of the patient stay shall be determined based
965
on the medical condition of the enrollee in relation to the
966
necessary and appropriate level of care, but is limited to not
967
more than 100 days per contract year.
968
3. Room and board may be limited to semiprivate
969
accommodations, unless a private room is considered medically
970
necessary or semiprivate accommodations are not available.
971
4. Specialized treatment centers and independent kidney
972
disease treatment centers are excluded.
973
5. Private duty nurses, television, and custodial care are
974
excluded.
975
6. Admissions for rehabilitation and physical therapy are
976
limited to 15 days per contract year.
977
(n) Prescribed drugs.--
978
1. Coverage shall include drugs prescribed for the
979
treatment of illness or injury when prescribed by a licensed
980
health practitioner acting within the scope of his or her
981
practice.
982
2. Prescribed drugs may be limited to generics if available
983
and brand name products if a generic substitution is not
984
available, unless the prescribing licensed health practitioner
985
indicates that a brand name is medically necessary.
986
3. Prescribed drugs covered under this section shall
987
include all prescribed drugs covered under the Florida Medicaid
988
program.
989
(o) Therapy services.--Covered services include
990
rehabilitative services, including occupational, physical,
991
respiratory, and speech therapies, with the following
992
limitations:
993
1. Services must be for short-term rehabilitation where
994
significant improvement in the enrollee's condition will result;
995
and
996
2. Services shall be limited to not more than 24 treatment
997
sessions within a 60-day period per episode or injury, with the
998
60-day period beginning with the first treatment.
999
(p) Transportation services.--Covered services include
1000
emergency transportation required in response to an emergency
1001
situation.
1002
(q) Dental services.--Dental services shall be covered and
1003
may include those dental benefits provided to children by the
1004
Florida Medicaid program under s. 409.906(6).
1005
(r) Lifetime maximum.--Health benefits coverage obtained
1007
expenses at a lifetime maximum of $1 million per covered child.
1008
(a)(s) Cost-sharing.--Cost-sharing provisions must comply
1009
with s. 409.816.
1010
(b)(t) Exclusions.--
1011
1. Experimental or investigational procedures that have not
1012
been clinically proven by reliable evidence are excluded;
1013
2. Services performed for cosmetic purposes only or for the
1014
convenience of the enrollee are excluded; and
1015
3. Abortion may be covered only if necessary to save the
1016
life of the mother or if the pregnancy is the result of an act of
1017
rape or incest.
1018
(c)(u) Enhancements to minimum requirements.--
1019
1. This section sets the minimum benefits that must be
1020
included in any health benefits coverage, other than Medicaid or
1022
benefits coverage may include additional benefits not included in
1023
the pediatric Medicaid benefit package under this subsection, but
1024
may not include benefits excluded under paragraph (b) (s).
1025
2. Health benefits coverage may extend any limitations
1026
beyond the minimum benefits described in this section.
1027
1028
Except for Florida Kidcare Plus benefits the Children's Medical
1029
Services Network, the agency may not increase the premium
1030
assistance payment for either additional benefits provided beyond
1031
the minimum benefits described in this section or the imposition
1032
of less restrictive service limitations.
1033
(d)(v) Applicability of other state laws.--Health insurers,
1034
health maintenance organizations, and their agents are subject to
1035
the provisions of the Florida Insurance Code, except for any such
1036
provisions waived in this section.
1037
1. Except as expressly provided in this section, a law
1038
requiring coverage for a specific health care service or benefit,
1039
or a law requiring reimbursement, utilization, or consideration
1040
of a specific category of licensed health care practitioner, does
1041
not apply to a health insurance plan policy or contract offered
1043
that law is made expressly applicable to such policies or
1044
contracts.
1045
2. Notwithstanding chapter 641, a health maintenance
1046
organization may issue contracts providing benefits equal to,
1047
exceeding, or actuarially equivalent to the benchmark benefit
1048
plan authorized by this section and may pay providers located in
1049
a rural county negotiated fees or Medicaid reimbursement rates
1050
for services provided to enrollees who are residents of the rural
1051
county.
1052
Section 17. Paragraph (i) of subsection (1) of section
1053
409.8177, Florida Statutes, is amended to read:
1054
409.8177 Program evaluation.--
1055
(1) The agency, in consultation with the Department of
1056
Health, the Department of Children and Family Services, and the
1057
Florida Healthy Kids Corporation, shall contract for an
1058
evaluation of the Florida Kidcare program and shall by January 1
1059
of each year submit to the Governor, the President of the Senate,
1060
and the Speaker of the House of Representatives a report of the
1061
program. In addition to the items specified under s. 2108 of
1062
Title XXI of the Social Security Act, the report shall include an
1063
assessment of crowd-out and access to health care, as well as the
1064
following:
1065
(i) An assessment of the effectiveness of the Florida
1066
Kidcare program Medikids, Children's Medical Services network,
1067
and other public and private programs in the state in increasing
1068
the availability of affordable quality health insurance and
1069
health care for children. Effective July 1, 2009, the Department
1070
of Health shall assume responsibility for contracting for an
1071
evaluation of the Florida Kidcare program.
1072
Section 18. Section 409.818, Florida Statutes, is amended
1073
to read:
1076
the following duties:
1077
(1) The Department of Children and Family Services shall:
1078
(a) Develop a standardized simplified eligibility
1079
application mail-in form to be used for determining the
1080
eligibility of children for coverage for all components of under
1081
the Florida Kidcare program, in consultation with the agency, the
1082
Department of Health, and the Florida Healthy Kids Corporation.
1083
The standardized simplified eligibility application form must
1084
include an item that provides an opportunity for the applicant to
1085
indicate whether coverage is being sought for a child with
1086
special health care needs. Families applying for children's
1087
Medicaid coverage must also be able to use the standardized
1088
simplified application form without having to pay a premium. The
1089
standardized eligibility application form must be available for
1090
use no later than July 1, 2009.
1091
(b) Establish and maintain the eligibility determination
1092
process under the program except as specified in subsections (2)
1093
and (4) subsection (5). The department shall directly, or through
1094
the services of a contracted third-party administrator, establish
1095
and maintain a process for determining eligibility of children
1096
for coverage under the program which shall be conducted in
1097
accordance with administrative rules and policies established by
1098
the Department of Health. The eligibility determination process
1099
must be used solely for determining eligibility of applicants for
1100
health benefits coverage under the program. The eligibility
1101
determination process must include an initial determination of
1102
eligibility for any coverage offered under the program, as well
1103
as a redetermination or reverification of eligibility each
1104
subsequent 6 months. Effective January 1, 1999, a child who has
1105
not attained the age of 5 and who has been determined eligible
1106
for the Medicaid program is eligible for coverage for 12 months
1107
without a redetermination or reverification of eligibility. In
1108
conducting an eligibility determination, the department shall
1109
determine if the child has special health care needs. The
1110
department, in consultation with the Agency for Health Care
1111
Administration and the Florida Healthy Kids Corporation, shall
1112
develop procedures for redetermining eligibility which enable a
1113
family to easily update any change in circumstances which could
1114
affect eligibility. The department may accept changes in a
1115
family's status as reported to the department by the Florida
1116
Healthy Kids Corporation without requiring a new application from
1117
the family. Redetermination of a child's eligibility for Medicaid
1118
may not be linked to a child's eligibility determination for
1119
other programs.
1120
(c) Inform program applicants about eligibility
1121
determinations and provide information about eligibility of
1122
applicants to the Florida Kidcare program Medicaid, Medikids, the
1123
Children's Medical Services Network, and the Florida Healthy Kids
1124
Corporation, and to insurers and their agents, through a
1125
centralized coordinating office.
1126
(d) Design a plan, in consultation with the Florida Healthy
1127
Kids Corporation, to determine an applicant's eligibility for
1128
public assistance or Medicaid which allows:
1129
1. Applicants who have children and are applying for
1130
Medicaid or other public assistance to use the same information
1131
provided when applying for the Kidcare program if they are found
1132
ineligible for Medicaid.
1133
2. Applicants to submit all information required for
1134
enrollment in the Kidcare program, including whether coverage is
1135
being sought for a child who has special health care needs.
1136
3. The department to forward an applicant's information and
1137
accompanying documentation to the Florida Healthy Kids
1138
Corporation, if necessary.
1139
4. The Florida Healthy Kids Corporation to process
1140
application information and other documents for enrollment in the
1141
Kidcare program without requiring the applicant to submit a
1142
separate application.
1143
1144
The department shall submit the plan to the Governor, the
1145
President of the Senate, and the Speaker of the House of
1146
Representatives by December 31, 2008.
1147
(e)(d) Adopt rules necessary for conducting program
1148
eligibility functions.
1149
(2) The Department of Health shall:
1150
(a) Design an eligibility intake process and policies for
1151
non-Title XIX eligibility determination for the program, in
1152
coordination with the Department of Children and Family Services,
1153
the agency, and the Florida Healthy Kids Corporation. The
1154
eligibility intake process may include local intake points that
1155
are determined by the Department of Health in coordination with
1156
the Department of Children and Family Services.
1157
(b) Develop and implement a plan to publicize the Florida
1158
Kidcare program, the eligibility requirements of the program, and
1159
the procedures for enrollment in the program and to maintain
1160
public awareness of and outreach for the Florida Kidcare program.
1161
(c) Determine clinical eligibility for and administer
1162
Florida Kidcare Plus health benefits coverage.
1163
(d) In consultation with the agency, develop a minimum set
1164
of pediatric quality assurance and access standards, including
1165
reporting requirements, for the Florida Kidcare program. The
1166
standards must include a process for granting exceptions to
1167
specific requirements for quality assurance and access.
1168
Compliance with the standards shall be a condition of program
1169
participation by health benefits coverage providers. These
1170
standards shall comply with the provisions of this chapter,
1171
chapter 641, and Title XXI of the Social Security Act.
1172
(e) In consultation with the agency, the Department of
1173
Children and Family Services, and the Florida Healthy Kids
1174
Corporation and effective July 1, 2009, coordinate non-Title XIX-
1175
funded Florida Kidcare administrative activities, including, but
1176
not limited to:
1177
1. Florida Kidcare policy development;
1178
2. Federal and state legislative and budget request issue
1179
development; and
1180
3. Administrative rules as assigned by this act.
1181
(f) In consultation with the agency, develop pediatric
1182
benefit packages for Florida Kidcare enrollees.
1183
(b) Chair a state-level coordinating council to review and
1184
make recommendations concerning the implementation and operation
1185
of the program. The coordinating council shall include
1186
representatives from the department, the Department of Children
1187
and Family Services, the agency, the Florida Healthy Kids
1188
Corporation, the Office of Insurance Regulation of the Financial
1189
Services Commission, local government, health insurers, health
1190
maintenance organizations, health care providers, families
1191
participating in the program, and organizations representing low-
1192
income families.
1193
(c) In consultation with the Florida Healthy Kids
1194
Corporation and the Department of Children and Family Services,
1195
establish a toll-free telephone line to assist families with
1196
questions about the program.
1197
(d) Adopt rules necessary to implement outreach activities.
1198
(3) The Agency for Health Care Administration, under the
1199
authority granted in s. 409.914(1), shall:
1200
(a) Calculate the premium assistance payment necessary to
1201
comply with the premium and cost-sharing limitations specified in
1202
s. 409.816. The premium assistance payment for each enrollee in a
1203
health insurance plan participating in the Florida Healthy Kids
1204
Corporation must shall equal the premium approved by the Florida
1205
Healthy Kids Corporation and the Office of Insurance Regulation
1206
of the Financial Services Commission pursuant to ss. 627.410 and
1207
641.31, less any enrollee's share of the premium established
1208
within the limitations specified in s. 409.816. The premium
1209
assistance payment for each enrollee in an employer-sponsored
1212
any benchmark benefit plan actuarial equivalent benefit rider
1213
approved by the Office of Insurance Regulation pursuant to ss.
1215
established within the limitations specified in s. 409.816. In
1216
calculating the premium assistance payment levels for children
1217
with family coverage, the agency shall set the premium assistance
1218
payment levels for each child proportionately to the total cost
1219
of family coverage.
1220
(b) Make premium assistance payments to health insurance
1221
plans on a periodic basis. The agency may use its Medicaid fiscal
1222
agent or a contracted third-party administrator in making these
1223
payments. The agency may require health insurance plans that
1224
participate in the Medikids program or employer-sponsored group
1225
health insurance to collect premium payments from an enrollee's
1226
family. Participating health insurance plans shall report premium
1227
payments collected on behalf of enrollees in the program to the
1228
agency in accordance with a schedule established by the agency.
1229
(c) Monitor compliance with pediatric quality assurance and
1230
access standards developed by the Department of Health under s.
1231
1232
(d) Establish a mechanism for investigating and resolving
1233
complaints and grievances from program applicants, enrollees, and
1234
health benefits coverage providers, and maintain a record of
1235
complaints and confirmed problems. In the case of a child who is
1236
enrolled in a health maintenance organization, the agency must
1237
use the provisions of s. 641.511 to address grievance reporting
1238
and resolution requirements.
1239
(e) Approve health benefits coverage for participation in
1240
the program, following certification by the Office of Insurance
1241
Regulation under subsection (4).
1242
(f) In consultation with the Department of Children and
1243
Family Services and the Florida Healthy Kids Corporation,
1244
establish a single toll-free telephone number by July 1, 2009, to
1245
assist families who have questions about the Florida Kidcare
1246
program. The toll-free number must provide information regarding
1247
eligibility, enrollment, benefits, and other information relating
1248
to all components of the Florida Kidcare program and ensure that
1249
such information is easily accessible.
1250
(g) Seek and implement federal waivers or state plan
1251
amendments necessary to implement this section and ss. 409.810-
1252
1253
(h) Adopt all rules necessary to comply with or administer
1255
federal requirements, including, at a minimum, rules specifying
1256
policies, procedures, and criteria for the following activities:
1257
1. Calculating premium assistance payment levels;
1258
2. Making premium assistance payments;
1259
3. Monitoring access and quality assurance standards;
1260
4. Investigating and resolving complaints and grievances;
1261
5. Administering the Medikids program;
1262
6. Approving health benefits coverage; and
1263
7. Except for Title XIX-funded Florida Kidcare, determining
1264
application and enrollment requirements, including documentation
1265
requirements, eligibility determinations and redeterminations,
1266
enrollee premium payment requirements, cancellation of coverage,
1267
reinstatement of coverage, disenrollment procedures, applicant
1268
and enrollee notification requirements, application and
1269
enrollment time processing standards, and call center standards.
1270
1271
Effective July 1, 2009, the Department of Health shall assume
1272
responsibility for administrative rulemaking activities specified
1273
in subparagraphs 3, 4, 6, and 7.
1274
(f) Adopt rules necessary for calculating premium
1275
assistance payment levels, making premium assistance payments,
1276
monitoring access and quality assurance standards, investigating
1277
and resolving complaints and grievances, administering the
1278
Medikids program, and approving health benefits coverage.
1279
1280
The agency is designated the lead state agency for Title XXI of
1281
the Social Security Act for purposes of receipt of federal funds,
1282
for reporting purposes, and for ensuring compliance with federal
1283
and state regulations and rules.
1284
(4) The Office of Insurance Regulation shall certify that
1285
health benefits coverage plans that seek to provide services
1286
under the Florida Kidcare program, except those offered through
1287
the Florida Healthy Kids Corporation or the Children's Medical
1288
Services Network, meet, exceed, or are actuarially equivalent to
1289
the benchmark benefit plan and that health insurance plans will
1290
be offered at an approved rate. In determining actuarial
1291
equivalence of benefits coverage, the Office of Insurance
1292
Regulation and health insurance plans must comply with the
1293
requirements of s. 2103 of Title XXI of the Social Security Act.
1294
The department shall adopt rules necessary for certifying health
1295
benefits coverage plans.
1296
(4)(5) The Florida Healthy Kids Corporation shall retain
1297
its functions as authorized in s. 624.91, including eligibility
1298
determination for participation in the non-Title XIX-funded
1299
Florida Kidcare Healthy Kids program. Effective July 1, 2009,
1300
non-Title XIX-funded Florida Kidcare eligibility determinations
1301
shall be conducted in accordance with administrative rules and
1302
policies established by the Department of Health.
1303
(5) The Department of Health, in consultation with the
1304
agency, the Department of Children and Family Services, and the
1305
Florida Healthy Kids Corporation, and
1306
(6) The agency, the Department of Health, the Department of
1307
Children and Family Services, the Florida Healthy Kids
1308
Corporation, and the Office of Insurance Regulation, after
1309
consultation with and approval of the Speaker of the House of
1310
Representatives and the President of the Senate, are authorized
1311
to make program modifications that are necessary to overcome any
1312
objections of the United States Department of Health and Human
1313
Services to obtain approval of the state's child health insurance
1314
plan under Title XXI of the Social Security Act.
1315
Section 19. Section 409.820, Florida Statutes, is repealed.
1316
Section 20. Subsection (5) of section 624.91, Florida
1317
Statutes, is amended to read:
1318
624.91 The Florida Healthy Kids Corporation Act.--
1319
(5) CORPORATION AUTHORIZATION, DUTIES, POWERS.--
1320
(a) There is created the Florida Healthy Kids Corporation,
1321
a not-for-profit corporation.
1322
(b) The Florida Healthy Kids Corporation shall:
1323
1. Arrange for the collection of any family, local
1324
contributions, or employer payment or premium, in an amount to be
1325
determined by the board of directors, to provide for payment of
1326
premiums for health benefits comprehensive insurance coverage and
1327
for the actual or estimated administrative expenses.
1328
2. Arrange for the collection of any voluntary
1329
contributions to provide for payment of Florida Kidcare premiums
1330
for children who are not eligible for medical assistance under
1331
Title XXI of the Social Security Act.
1332
3. Subject to the provisions of s. 409.8134, accept
1333
voluntary supplemental local match contributions that comply with
1334
the requirements of Title XXI of the Social Security Act for the
1335
purpose of providing additional Florida Kidcare coverage in
1336
contributing counties under Title XXI.
1337
4. Establish the administrative and accounting procedures
1338
for the operation of the corporation.
1339
5. Establish, with consultation from appropriate
1340
professional organizations, standards for preventive health
1341
services and providers and comprehensive insurance benefits
1342
appropriate to children, if provided that such standards for
1343
rural areas do shall not limit primary care providers to board-
1344
certified pediatricians.
1345
6. Determine eligibility for children seeking to
1346
participate in the Title XXI-funded components of the Florida
1347
Kidcare program consistent with the requirements specified in s.
1348
409.814, as well as the non-Title-XXI-eligible children as
1349
provided in subsection (3). Effective July 1, 2009, this function
1350
shall be performed in accordance with administrative rules and
1351
policies established by the Department of Health.
1352
7. Establish procedures under which providers of local
1353
match to, applicants to and participants in the program may have
1354
grievances reviewed by an impartial body and reported to the
1355
board of directors of the corporation.
1356
8. Establish participation criteria and, if appropriate,
1357
Contract with an authorized insurer, health maintenance
1358
organization, or third-party administrator to provide
1359
administrative services for Florida Kidcare. Effective July 1,
1360
2009, this function shall be performed in accordance with
1361
administrative rules and policies established by the Department
1362
of Health to the corporation.
1363
9. Establish enrollment criteria that which shall include
1364
penalties or waiting periods of not fewer than 60 days for
1365
reinstatement of coverage upon voluntary cancellation for
1366
nonpayment of family premiums.
1367
10. Contract with authorized insurers or any provider of
1368
health care services, meeting quality assurance and access
1369
standards established by the Department of Health corporation,
1370
for the provision of comprehensive insurance coverage to
1371
participants. Such standards shall include criteria under which
1372
the corporation may contract with more than one provider of
1373
health care services in program sites. Health plans shall be
1374
selected through a competitive bid process. The Florida Healthy
1375
Kids Corporation shall purchase goods and services in the most
1376
cost-effective manner consistent with the delivery of quality
1377
medical care. The maximum administrative cost for a Florida
1378
Healthy Kids Corporation contract shall be 15 percent. For health
1379
care contracts, the minimum medical loss ratio for a Florida
1380
Healthy Kids Corporation contract shall be 85 percent. For dental
1381
contracts, the remaining compensation to be paid to the
1382
authorized insurer or provider under a Florida Healthy Kids
1383
Corporation contract shall be no less than an amount which is 85
1384
percent of premium; to the extent any contract provision does not
1385
provide for this minimum compensation, this section shall
1386
prevail. The health plan selection criteria and scoring system,
1387
and the scoring results, shall be available upon request for
1388
inspection after the bids have been awarded.
1389
11. Establish disenrollment criteria in the event local
1390
matching funds are insufficient to cover enrollments.
1391
12. Develop and implement a plan to publicize the Florida
1392
Healthy Kids Corporation, the eligibility requirements of the
1393
program, and the procedures for enrollment in the program and to
1394
maintain public awareness of the corporation and the program.
1395
12.13. Secure staff necessary to properly administer the
1396
corporation. Staff costs shall be funded from state and local
1397
matching funds and such other private or public funds as become
1398
available. The board of directors shall determine the number of
1399
staff members necessary to administer the corporation.
1400
13. No later than January 1, 2009, the health benefits
1401
coverage provided by the corporation's authorized insurers and
1402
health maintenance organizations shall conform with the benchmark
1403
benefits specified in s. 409.815.
1404
14. Allow health and dental plans participating in the
1405
Florida Healthy Kids program to develop and distribute marketing
1406
and promotional materials and participate in activities, such as
1407
health fairs and public events, which are approved by the
1408
corporation. The health and dental plans may also contact their
1409
current and former enrollees to encourage continued participation
1410
in the program and to assist the enrollees with transferring from
1411
a Title XIX-financed plan to a Title XXI-financed plan.
1412
15. Establish an assignment process that keeps enrollees in
1413
the Florida Healthy Kids program with family members assigned to
1414
the same managed care plans, to the greatest extent possible,
1415
even if some family members are enrolled in a Medicaid managed
1416
care plan and others are enrolled in a plan under the program.
1417
The Agency for Health Care Administration shall work with the
1418
corporation to implement this subparagraph.
1419
a. The assignment process must allow an enrollee in the
1420
program to enroll in a sibling's Medicaid provider service
1421
network for coverage under the program if the enrollee's sibling
1422
is currently enrolled in a Medicaid provider service network in
1423
the same county as the enrollee and the county does not contain a
1424
health plan under the program.
1425
b. The assignment process must allow an enrollee in the
1426
program to enroll in a sibling's Medicaid health maintenance
1427
organization for coverage under the program if the enrollee's
1428
sibling is currently enrolled in a Medicaid health maintenance
1429
organization in the same county as the enrollee and the county
1430
does not contain a health plan under the program that is operated
1431
by or related to the Medicaid health maintenance organization.
1432
14. Provide a report annually to the Governor, Chief
1433
Financial Officer, Commissioner of Education, Senate President,
1434
Speaker of the House of Representatives, and Minority Leaders of
1435
the Senate and the House of Representatives.
1436
15. Establish benefit packages which conform to the
1437
provisions of the Florida Kidcare program, as created in ss.
1439
(c) Coverage under the corporation's program is secondary
1440
to any other available private coverage held by, or applicable
1441
to, the participant child or family member. Insurers under
1442
contract with the corporation are the payors of last resort and
1443
must coordinate benefits with any other third-party payor that
1444
may be liable for the participant's medical care.
1445
(d) The Florida Healthy Kids Corporation shall be a private
1446
corporation not for profit, organized pursuant to chapter 617,
1447
and shall have all powers necessary to carry out the purposes of
1448
this act, including, but not limited to, the power to receive and
1449
accept grants, loans, or advances of funds from any public or
1450
private agency and to receive and accept from any source
1451
contributions of money, property, labor, or any other thing of
1452
value, to be held, used, and applied for the purposes of this
1453
act.
1454
Section 21. The Legislature respectfully requests that
1455
Florida's Congressional Delegation support the amendment of Title
1456
XXI of the Social Security Act to allow federal matching funds
1457
for the purpose of premium assistance for dependents of state
1458
employees and nonqualified legal aliens.
1459
Section 22. This act shall take effect July 1, 2008.
CODING: Words stricken are deletions; words underlined are additions.