HB 795

1	A bill to be entitled
2	An act relating to the Florida Kidcare program; amending
3	s. 409.8132, F.S.; providing that certain children under
4	the age of 1 may participate in the Medikids program;
5	conforming cross-references; amending s. 409.814, F.S.;
6	requiring that children who are eligible for Kidcare be
7	offered the opportunity to be made presumptively eligible;
8	providing that children who are eligible for a state-
9	sponsored health benefit plan and the subsidized Kidcare
10	program may enroll in the program; providing that an
11	eligible child who is a lawful immigrant may enroll in the
12	Florida Kidcare program regardless of the child's date of
13	entry; conforming provisions to changes made by the act;
14	amending s. 409.815, F.S.; authorizing Kidcare coverage
15	for temporomandibular joint disease; amending s. 409.816,
16	F.S.; conforming a cross-reference; amending s. 409.818,
17	F.S.; conforming provisions to changes made by the act;
18	allowing a redetermination of a child's eligibility for
19	Medicaid to be linked to a child's eligibility for other
20	programs; amending s. 409.904, F.S.; providing that
21	Medicaid-eligible children are deemed eligible for 12
22	months of coverage regardless of any change in
23	circumstances; requiring that such children be offered the
24	opportunity to be made presumptively eligible; providing
25	that a pregnant woman in a family of certain income level
26	is eligible for Medicaid for the duration of her pregnancy
27	and for the postpartum period; amending s. 624.91, F.S.,
28	relating to the Florida Healthy Kids Corporation;
29	conforming provisions to changes made by the act; deleting
30	an obsolete provision; expanding the membership of the
31	board of directors of the Florida Healthy Kids
32	Corporation; directing the Agency for Health Care
33	Administration to implement the federal Family Opportunity
34	Act; providing an effective date.
35
36	Be It Enacted by the Legislature of the State of Florida:
37
38	Section 1.  Subsection (6) of section 409.8132, Florida
39	Statutes, is amended to read:
40	409.8132  Medikids program component.-
41	(6)  ELIGIBILITY.-
42	(a)  A child who has attained the age of 1 year but who is
43	under the age of 5 years is eligible to enroll in the Medikids
44	program component of the Florida Kidcare program, if the child
45	is a member of a family that has a family income that which
46	exceeds the Medicaid applicable income level as specified in s.
47	409.903, but that which is equal to or below 200 percent of the
48	current federal poverty level. In determining the eligibility of
49	such a child, an assets test is not required. A child who is
50	eligible for Medikids may elect to enroll in Florida Healthy
51	Kids coverage or employer-sponsored group coverage. However, a
52	child who is eligible for Medikids may participate in the
53	Florida Healthy Kids program only if the child has a sibling
54	participating in the Florida Healthy Kids program and the
55	child's county of residence permits such enrollment.
56	(b)  A child who is under the age of 1 year who has a
57	family income above 200 percent of the current federal poverty
58	level may participate in the Medikids program as provided in s.
59	409.814(8).
60	(c)(b)  The provisions of s. 409.814(3)-(8) apply
61	409.814(3), (4), (5), and (6) shall be applicable to the
62	Medikids program.
63	Section 2.  Section 409.814, Florida Statutes, is amended
64	to read:
65	409.814  Eligibility.-A child who has not reached 19 years
66	of age whose family income is equal to or below 200 percent of
67	the federal poverty level is eligible for the Florida Kidcare
68	program as provided in this section. A child who is eligible
69	under this section must be offered the opportunity to be made
70	presumptively eligible. For enrollment in the Children's Medical
71	Services Network, a complete application includes the medical or
72	behavioral health screening. If, subsequently, an enrolled
73	individual is determined to be ineligible for coverage, he or
74	she must be immediately be disenrolled from the respective
75	Florida Kidcare program component.
76	(1)  A child who is eligible for Medicaid coverage under s.
77	409.903 or s. 409.904 must be enrolled in Medicaid and is not
78	eligible to receive health benefits under any other health
79	benefits coverage authorized under the Florida Kidcare program.
80	(2)  A child who is not eligible for Medicaid, but who is
81	eligible for the Florida Kidcare program, may obtain health
82	benefits coverage under any of the other components listed in s.
83	409.813 if such coverage is approved and available in the county
84	in which the child resides.
85	(3)  A Title XXI-funded child who is eligible for the
86	Florida Kidcare program and who is a child with special health
87	care needs, as determined through a medical or behavioral
88	screening instrument, is eligible for health benefits coverage
89	from and shall be assigned to and may opt out of the Children's
90	Medical Services Network.
91	(4)  A child who is eligible for a state-sponsored health
92	benefit plan through a family member or guardian employed by the
93	state and who meets the eligibility requirements for the
94	subsidized Florida Kidcare program may enroll in the subsidized
95	Florida Kidcare program.
96	(5)  A child who is an immigrant lawfully residing in the
97	United States and who meets the eligibility requirements for the
98	Florida Kidcare program may enroll in the program regardless of
99	the child's date of entry.
100	(6)(4)  The following children are not eligible to receive
101	Title XXI-funded premium assistance for health benefits coverage
102	under the Florida Kidcare program, except under Medicaid if the
103	child would have been eligible for Medicaid under s. 409.903 or
104	s. 409.904 as of June 1, 1997:
105	(a)  A child who is eligible for coverage under a state
106	health benefit plan on the basis of a family member's employment
107	with a public agency in the state.
108	(a)(b)  A child who is covered under a family member's
109	group health benefit plan or under other private or employer
110	health insurance coverage, if the cost of the child's
111	participation is not greater than 5 percent of the family's
112	income. If a child is otherwise eligible for a subsidy under the
113	Florida Kidcare program and the cost of the child's
114	participation in the family member's health insurance benefit
115	plan is greater than 5 percent of the family's income, the child
116	may enroll in the appropriate subsidized Kidcare program.
117	(b)(c)  A child who is seeking premium assistance for the
118	Florida Kidcare program through employer-sponsored group
119	coverage, if the child has been covered by the same employer's
120	group coverage during the 60 days before the family submitted
121	prior to the family's submitting an application for
122	determination of eligibility under the program.
123	(d)  A child who is an alien, but who does not meet the
124	definition of qualified alien, in the United States.
125	(c)(e)  A child who is an inmate of a public institution or
126	a patient in an institution for mental diseases.
127	(d)(f)  A child who is otherwise eligible for premium
128	assistance for the Florida Kidcare program and has had his or
129	her coverage in an employer-sponsored or private health benefit
130	plan voluntarily canceled in the last 60 days, except those
131	children whose coverage was voluntarily canceled for good cause,
132	including, but not limited to, the following circumstances:
133	1.  The cost of participation in an employer-sponsored
134	health benefit plan is greater than 5 percent of the family's
135	income;
136	2.  The parent lost a job that provided an employer-
137	sponsored health benefit plan for children;
138	3.  The parent who had health benefits coverage for the
139	child is deceased;
140	4.  The child has a medical condition that, without medical
141	care, would cause serious disability, loss of function, or
142	death;
143	5.  The employer of the parent canceled health benefits
144	coverage for children;
145	6.  The child's health benefits coverage ended because the
146	child reached the maximum lifetime coverage amount;
147	7.  The child has exhausted coverage under a COBRA
148	continuation provision;
149	8.  The health benefits coverage does not cover the child's
150	health care needs; or
151	9.  Domestic violence led to loss of coverage.
152	(7)(5)  A child who is otherwise eligible for the Florida
153	Kidcare program and who has a preexisting condition that
154	prevents coverage under another insurance plan as described in
155	paragraph (6)(a) (4)(b) which would have disqualified the child
156	for the Florida Kidcare program if the child were able to enroll
157	in the plan is shall be eligible for Florida Kidcare coverage
158	when enrollment is possible.
159	(8)(6)  A child whose family income is above 200 percent of
160	the federal poverty level or a child who is excluded under the
161	provisions of subsection (6) (4) may participate in the Florida
162	Kidcare program as provided in s. 409.8132 or, if the child is
163	ineligible for Medikids by reason of age, in the Florida Healthy
164	Kids program, subject to the following provisions:
165	(a)  The family is not eligible for premium assistance
166	payments and must pay the full cost of the premium, including
167	any administrative costs.
168	(b)  The board of directors of the Florida Healthy Kids
169	Corporation may offer a reduced benefit package to these
170	children in order to limit program costs for such families.
171	(9)(7)  Once a child is enrolled in the Florida Kidcare
172	program, the child is eligible for coverage under the program
173	for 12 months without a redetermination or reverification of
174	eligibility, if the family continues to pay the applicable
175	premium. Eligibility for program components funded through Title
176	XXI of the Social Security Act terminates shall terminate when a
177	child attains the age of 19. A child who has not attained the
178	age of 5 and who has been determined eligible for the Medicaid
179	program is eligible for coverage for 12 months without a
180	redetermination or reverification of eligibility.
181	(10)(8)  When determining or reviewing a child's
182	eligibility under the Florida Kidcare program, the applicant
183	shall be provided with reasonable notice of changes in
184	eligibility which may affect enrollment in one or more of the
185	program components. If When a transition from one program
186	component to another is authorized, there shall be cooperation
187	between the program components and the affected family which
188	promotes continuity of health care coverage. Any authorized
189	transfers must be managed within the program's overall
190	appropriated or authorized levels of funding. Each component of
191	the program shall establish a reserve to ensure that transfers
192	between components will be accomplished within current year
193	appropriations. These reserves shall be reviewed by each
194	convening of the Social Services Estimating Conference to
195	determine the adequacy of such reserves to meet actual
196	experience.
197	(11)(9)  In determining the eligibility of a child, an
198	assets test is not required. Each applicant shall provide
199	documentation during the application process and the
200	redetermination process, including, but not limited to, the
201	following:
202	(a)  Each applicant's Proof of family income, which must
203	shall be verified electronically to determine financial
204	eligibility for the Florida Kidcare program. Written
205	documentation, which may include wages and earnings statements
206	or pay stubs, W-2 forms, or a copy of the applicant's most
207	recent federal income tax return, is shall be required only if
208	the electronic verification is not available or does not
209	substantiate the applicant's income.
210	(b)  Each applicant shall provide A statement from all
211	applicable, employed family members that:
212	1.  Their employers do not sponsor health benefit plans for
213	employees;
214	2.  the potential enrollee is not covered by an employer-
215	sponsored health benefit plan; or
216	3.  The potential enrollee is covered by an employer-
217	sponsored health benefit plan and the cost of the employer-
218	sponsored health benefit plan is more than 5 percent of the
219	family's income.
220	(12)(10)  Subject to paragraph (6)(a) (4)(b), the Florida
221	Kidcare program shall withhold benefits from an enrollee if the
222	program obtains evidence that the enrollee is no longer
223	eligible, submitted incorrect or fraudulent information in order
224	to establish eligibility, or failed to provide verification of
225	eligibility. The applicant or enrollee shall be notified that
226	because of such evidence program benefits will be withheld
227	unless the applicant or enrollee contacts a designated
228	representative of the program by a specified date, which must be
229	within 10 working days after the date of notice, to discuss and
230	resolve the matter. The program shall make every effort to
231	resolve the matter within a timeframe that will not cause
232	benefits to be withheld from an eligible enrollee.
233	(13)(11)  The following individuals may be subject to
234	prosecution in accordance with s. 414.39:
235	(a)  An applicant obtaining or attempting to obtain
236	benefits for a potential enrollee under the Florida Kidcare
237	program if when the applicant knows or should have known that
238	the potential enrollee does not qualify for the Florida Kidcare
239	program.
240	(b)  An individual who assists an applicant in obtaining or
241	attempting to obtain benefits for a potential enrollee under the
242	Florida Kidcare program if when the individual knows or should
243	have known that the potential enrollee does not qualify for the
244	Florida Kidcare program.
245	Section 3.  Paragraph (f) of subsection (2) of section
246	409.815, Florida Statutes, is amended to read:
247	409.815  Health benefits coverage; limitations.-
248	(2)  BENCHMARK BENEFITS.-In order for health benefits
249	coverage to qualify for premium assistance payments for an
250	eligible child under ss. 409.810-409.821, the health benefits
251	coverage, except for coverage under Medicaid and Medikids, must
252	include the following minimum benefits, as medically necessary.
253	(f)  Outpatient services.-Covered services include
254	preventive, diagnostic, therapeutic, palliative care, and other
255	services authorized by the enrollee's health benefits coverage
256	provider and provided to an enrollee in the outpatient portion
257	of a health facility licensed under chapter 395, except for the
258	following limitations:
259	1.  Services must be authorized by the enrollee's health
260	benefits coverage provider; and
261	2.  Treatment for temporomandibular joint disease (TMJ) is
262	specifically excluded.
263	Section 4.  Subsection (3) of section 409.816, Florida
264	Statutes, is amended to read:
265	409.816  Limitations on premiums and cost-sharing.-The
266	following limitations on premiums and cost-sharing are
267	established for the program.
268	(3)  Enrollees in families with a family income above 150
269	percent of the federal poverty level who are not receiving
270	coverage under the Medicaid program or who are not eligible
271	under s. 409.814(8) 409.814(6) may be required to pay enrollment
272	fees, premiums, copayments, deductibles, coinsurance, or similar
273	charges on a sliding scale related to income, except that the
274	total annual aggregate cost-sharing with respect to all children
275	in a family may not exceed 5 percent of the family's income.
276	However, copayments, deductibles, coinsurance, or similar
277	charges may not be imposed for preventive services, including
278	well-baby and well-child care, age-appropriate immunizations,
279	and routine hearing and vision screenings.
280	Section 5.  Paragraph (b) of subsection (1) of section
281	409.818, Florida Statutes, is amended to read:
282	409.818  Administration.-In order to implement ss. 409.810-
283	409.821, the following agencies shall have the following duties:
284	(1)  The Department of Children and Family Services shall:
285	(b)  Establish and maintain the eligibility determination
286	process under the program except as specified in subsection (5).
287	The department shall directly, or through the services of a
288	contracted third-party administrator, establish and maintain a
289	process for determining eligibility of children for coverage
290	under the program. The eligibility determination process must be
291	used solely for determining eligibility of applicants for health
292	benefits coverage under the program. The eligibility
293	determination process must include an initial determination of
294	eligibility for any coverage offered under the program, as well
295	as a redetermination or reverification of eligibility each
296	subsequent 6 months. Effective January 1, 1999, a child who has
297	not attained the age of 5 and who has been determined eligible
298	for the Medicaid program is eligible for coverage for 12 months
299	without a redetermination or reverification of eligibility. In
300	conducting an eligibility determination, the department shall
301	determine if the child has special health care needs. The
302	department, in consultation with the Agency for Health Care
303	Administration and the Florida Healthy Kids Corporation, shall
304	develop procedures for redetermining eligibility which enable a
305	family to easily update any change in circumstances which could
306	affect eligibility. The department may accept changes in a
307	family's status as reported to the department by the Florida
308	Healthy Kids Corporation without requiring a new application
309	from the family. Redetermination of a child's eligibility for
310	Medicaid may not be linked to a child's eligibility
311	determination for other programs.
312	Section 6.  Subsections (6) and (7) of section 409.904,
313	Florida Statutes, are amended to read:
314	409.904  Optional payments for eligible persons.-The agency
315	may make payments for medical assistance and related services on
316	behalf of the following persons who are determined to be
317	eligible subject to the income, assets, and categorical
318	eligibility tests set forth in federal and state law. Payment on
319	behalf of these Medicaid eligible persons is subject to the
320	availability of moneys and any limitations established by the
321	General Appropriations Act or chapter 216.
322	(6)  A child who has not attained the age of 19 who has
323	been determined eligible for the Medicaid program is deemed to
324	be eligible for a total of 6 months, regardless of changes in
325	circumstances other than attainment of the maximum age.
326	Effective January 1, 1999, a child who has not attained the age
327	of 5 and who has been determined eligible for the Medicaid
328	program is deemed to be eligible for a total of 12 months
329	regardless of changes in circumstances other than attainment of
330	the maximum age. Subject to federal regulations, a child who is
331	eligible under this subsection must be offered the opportunity
332	to be made presumptively eligible.
333	(7)  A pregnant woman for the duration of her pregnancy and
334	for the postpartum period as defined in federal law and rule or
335	a child under 1 year of age who lives in a family that has an
336	income above 185 percent of the most recently published federal
337	poverty level, but that which is at or below 200 percent of such
338	poverty level. In determining the eligibility of such child, an
339	assets test is not required. An individual A child who is
340	eligible for Medicaid under this subsection must be offered the
341	opportunity, subject to federal rules, to be made presumptively
342	eligible.
343	Section 7.  Paragraph (b) of subsection (5) and paragraph
344	(a) of subsection (6) of section 624.91, Florida Statutes, are
345	amended to read:
346	624.91  The Florida Healthy Kids Corporation Act.-
347	(5)  CORPORATION AUTHORIZATION, DUTIES, POWERS.-
348	(b)  The Florida Healthy Kids Corporation shall:
349	1.  Arrange for the collection of any family, local
350	contributions, or employer payment or premium, in an amount to
351	be determined by the board of directors, to provide for payment
352	of premiums for comprehensive insurance coverage and for the
353	actual or estimated administrative expenses.
354	2.  Arrange for the collection of any voluntary
355	contributions to provide for payment of Florida Kidcare program
356	premiums for children who are not eligible for medical
357	assistance under Title XIX or Title XXI of the Social Security
358	Act.
359	3.  Subject to the provisions of s. 409.8134, accept
360	voluntary supplemental local match contributions that comply
361	with the requirements of Title XXI of the Social Security Act
362	for the purpose of providing additional Florida Kidcare coverage
363	in contributing counties under Title XXI.
364	4.  Establish the administrative and accounting procedures
365	for the operation of the corporation.
366	5.  Establish, with consultation from appropriate
367	professional organizations, standards for preventive health
368	services and providers and comprehensive insurance benefits
369	appropriate to children if, provided that such standards for
370	rural areas do shall not limit primary care providers to board-
371	certified pediatricians.
372	6.  Determine eligibility for children seeking to
373	participate in the Title XXI-funded components of the Florida
374	Kidcare program consistent with the requirements specified in s.
375	409.814, as well as the non-Title-XXI-eligible children as
376	provided in subsection (3).
377	7.  Establish procedures under which providers of local
378	match to, applicants to, and participants in the program may
379	have grievances reviewed by an impartial body and reported to
380	the board of directors of the corporation.
381	8.  Establish participation criteria and, if appropriate,
382	contract with an authorized insurer, health maintenance
383	organization, or third-party administrator to provide
384	administrative services to the corporation.
385	9.  Establish enrollment criteria that include penalties or
386	30-day waiting periods of 30 days for reinstatement of coverage
387	upon voluntary cancellation for nonpayment of family premiums.
388	10.  Contract with authorized insurers or providers any
389	provider of health care services, who meet meeting standards
390	established by the corporation, for the provision of
391	comprehensive insurance coverage to participants. Such standards
392	must shall include criteria under which the corporation may
393	contract with more than one provider of health care services in
394	program sites. Health plans shall be selected through a
395	competitive bid process. The Florida Healthy Kids Corporation
396	shall purchase goods and services in the most cost-effective
397	manner consistent with the delivery of quality medical care. The
398	maximum administrative cost for a Florida Healthy Kids
399	Corporation contract is shall be 15 percent. For health care
400	contracts, the minimum medical loss ratio for a Florida Healthy
401	Kids Corporation contract is shall be 85 percent. For dental
402	contracts, the remaining compensation to be paid to the
403	authorized insurer or provider must be at least under a Florida
404	Healthy Kids Corporation contract shall be no less than an
405	amount which is 85 percent of the premium; to the extent any
406	contract provision does not provide for this minimum
407	compensation, this section prevails shall prevail. The health
408	plan selection criteria and scoring system, and the scoring
409	results, must shall be available upon request for inspection
410	after the bids have been awarded.
411	11.  Establish disenrollment criteria if in the event local
412	matching funds are insufficient to cover enrollments.
413	12.  Develop and implement a plan to publicize the Florida
414	Kidcare program, the eligibility requirements of the program,
415	and the procedures for enrollment in the program and to maintain
416	public awareness of the corporation and the program.
417	13.  Secure staff necessary to properly administer the
418	corporation. Staff costs shall be funded from state and local
419	matching funds and such other private or public funds as become
420	available. The board of directors shall determine the number of
421	staff members necessary to administer the corporation.
422	14.  In consultation with the partner agencies, provide a
423	report on the Florida Kidcare program annually to the Governor,
424	the Chief Financial Officer, the Commissioner of Education, the
425	President of the Senate, the Speaker of the House of
426	Representatives, and the Minority Leaders of the Senate and the
427	House of Representatives.
428	15.  Provide information on a quarterly basis to the
429	Legislature and the Governor which compares the costs and
430	utilization of the full-pay enrolled population and the Title
431	XXI-subsidized enrolled population in the Florida Kidcare
432	program. The information, At a minimum, the information must
433	include:
434	a.  The monthly enrollment and expenditure for full-pay
435	enrollees in the Medikids and Florida Healthy Kids programs
436	compared to the Title XXI-subsidized enrolled population; and
437	b.  The costs and utilization by service of the full-pay
438	enrollees in the Medikids and Florida Healthy Kids programs and
439	the Title XXI-subsidized enrolled population.
440
441	By February 1, 2010, the Florida Healthy Kids Corporation shall
442	provide a study to the Legislature and the Governor on premium
443	impacts to the subsidized portion of the program from the
444	inclusion of the full-pay program, which shall include
445	recommendations on how to eliminate or mitigate possible impacts
446	to the subsidized premiums.
447	16.  Establish benefit packages that conform to the
448	provisions of the Florida Kidcare program, as created in ss.
449	409.810-409.821.
450	(6)  BOARD OF DIRECTORS.-
451	(a)  The Florida Healthy Kids Corporation is shall operate
452	subject to the supervision and approval of a board of directors
453	chaired by the Chief Financial Officer or her or his designee,
454	and composed of 12 11 other members selected for 3-year terms of
455	office as follows:
456	1.  The Secretary of Health Care Administration, or his or
457	her designee.
458	2.  One member, appointed by the Commissioner of Education,
459	from the Office of School Health Programs of the Florida
460	Department of Education.
461	3.  One member, appointed by the Chief Financial Officer,
462	from among three members nominated by the Florida Pediatric
463	Society.
464	4.  One member, appointed by the Governor, who represents
465	the Children's Medical Services Program.
466	5.  One member, appointed by the Chief Financial Officer
467	from among three members nominated by the Florida Hospital
468	Association.
469	6.  One member, appointed by the Governor, who is an expert
470	on child health policy.
471	7.  One member, appointed by the Chief Financial Officer,
472	from among three members nominated by the Florida Academy of
473	Family Physicians.
474	8.  One member, appointed by the Governor, who represents
475	the state Medicaid program.
476	9.  One member, appointed by the Chief Financial Officer,
477	from among three members nominated by the Florida Association of
478	Counties.
479	10.  The State Health Officer, or her or his designee.
480	11.  The Secretary of Children and Family Services, or his
481	or her designee.
482	12.  One member, appointed by the Governor, from among
483	three members nominated by the Florida Dental Association.
484	Section 8.  Subject to appropriation, the Agency for Health
485	Care Administration shall implement the federal Family
486	Opportunity Act, ss. 6062-6071 of the Deficit Reduction Act of
487	2005, to allow families whose income is up to 300 percent of the
488	federal poverty level to buy Medicaid coverage for their
489	disabled children.
490	Section 9.  This act shall take effect October 1, 2011.

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