Florida Senate - 2013                                    SB 1816
       
       
       
       By the Committee on Appropriations
       
       
       
       
       576-02875-13                                          20131816__
    1                        A bill to be entitled                      
    2         An act relating to health care; amending s. 409.811,
    3         F.S.; revising and providing definitions; amending s.
    4         409.813, F.S.; revising the components of the Florida
    5         Kidcare program; prohibiting a cause of action from
    6         arising against the Florida Healthy Kids Corporation
    7         for failure to make health services available;
    8         amending s. 409.8132, F.S.; revising the eligibility
    9         of the Medikids program component; revising the
   10         enrollment requirements of the Medikids program
   11         component; amending s. 409.8134, F.S.; conforming
   12         provisions to changes made by the act; amending s.
   13         409.814, F.S.; revising eligibility requirements for
   14         the Florida Kidcare program; amending s. 409.815,
   15         F.S.; revising the minimum health benefits coverage
   16         under the Florida Kidcare Act; deleting obsolete
   17         provisions; amending ss. 409.816 and 409.8177, F.S.;
   18         conforming provisions to changes made by the act;
   19         repealing s. 409.817, F.S., relating to the approval
   20         of health benefits coverage and financial assistance;
   21         repealing s. 409.8175, F.S., relating to delivery of
   22         services in rural counties; amending s. 409.818, F.S.;
   23         revising the duties of the Department of Children and
   24         Families and the Agency for Health Care Administration
   25         with regard to the Florida Kidcare Act; deleting the
   26         duties of the Department of Health and the Office of
   27         Insurance Regulation with regard to the Florida
   28         Kidcare Act; amending s. 409.820, F.S.; requiring the
   29         Department of Health, in consultation with the agency
   30         and the Florida Healthy Kids Corporation, to develop a
   31         minimum set of pediatric and adolescent quality
   32         assurance and access standards for all program
   33         components; amending s. 624.91, F.S.; revising the
   34         legislative intent of the Florida Healthy Kids
   35         Corporation Act to include the Healthy Florida
   36         program; revising participation guidelines for
   37         nonsubsidized enrollees in the Healthy Kids program;
   38         revising the medical loss ratio requirements for the
   39         contracts for the Florida Healthy Kids Corporation;
   40         modifying the membership of the Florida Healthy Kids
   41         Corporation’s board of directors; creating an
   42         executive steering committee; requiring additional
   43         corporate compliance requirements for the Florida
   44         Healthy Kids Corporation; repealing s. 624.915, F.S.,
   45         relating to the operating fund of the Florida Healthy
   46         Kids Corporation; creating s. 624.917, F.S.; creating
   47         the Healthy Florida program; providing definitions;
   48         providing eligibility and enrollment requirements;
   49         authorizing the Florida Healthy Kids Corporation to
   50         contract with certain insurers; requiring the
   51         corporation to establish a benefits package and a
   52         process for payment of services; authorizing the
   53         corporation to collect premiums and copayments;
   54         requiring the corporation to oversee the Healthy
   55         Florida program and to establish a grievance process
   56         and integrity process; providing applicability of
   57         certain state laws for administration of the Healthy
   58         Florida program; requiring the corporation to collect
   59         certain data and to submit enrollment reports and
   60         interim independent evaluations to the Legislature;
   61         providing for expiration of the program; providing an
   62         implementation and interpretation clause; providing an
   63         effective date.
   64  
   65  Be It Enacted by the Legislature of the State of Florida:
   66  
   67         Section 1. Section 409.811, Florida Statutes, is amended to
   68  read:
   69         409.811 Definitions relating to Florida Kidcare Act.—As
   70  used in ss. 409.810-409.821, the term:
   71         (1) “Actuarially equivalent” means that:
   72         (a) The aggregate value of the benefits included in health
   73  benefits coverage is equal to the value of the benefits in the
   74  benchmark benefit plan; and
   75         (b) The benefits included in health benefits coverage are
   76  substantially similar to the benefits included in the benchmark
   77  benefit plan, except that preventive health services must be the
   78  same as in the benchmark benefit plan.
   79         (2) “Agency” means the Agency for Health Care
   80  Administration.
   81         (3) “Applicant” means a parent or guardian of a child or a
   82  child whose disability of nonage has been removed under chapter
   83  743, who applies for determination of eligibility for health
   84  benefits coverage under ss. 409.810-409.821.
   85         (4) “Child benchmark benefit plan” means the form and level
   86  of health benefits coverage established in s. 409.815.
   87         (5) “Child” means any person younger than under 19 years of
   88  age.
   89         (6) “Child with special health care needs” means a child
   90  whose serious or chronic physical or developmental condition
   91  requires extensive preventive and maintenance care beyond that
   92  required by typically healthy children. Health care utilization
   93  by such a child exceeds the statistically expected usage of the
   94  normal child adjusted for chronological age, and such a child
   95  often needs complex care requiring multiple providers,
   96  rehabilitation services, and specialized equipment in a number
   97  of different settings.
   98         (7) “Children’s Medical Services Network” or “network”
   99  means a statewide managed care service system as defined in s.
  100  391.021(1).
  101         (8) “CHIP” means the Children’s Health Insurance Program as
  102  authorized under Title XXI of the Social Security Act, and its
  103  regulations, ss. 409.810-409.820, and as administered in this
  104  state by the agency, the department, and the Florida Healthy
  105  Kids Corporation, as appropriate to their respective
  106  responsibilities.
  107         (9) “Combined eligibility notice” means an eligibility
  108  notice that informs an applicant, an enrollee, or multiple
  109  family members of a household, when feasible, of eligibility for
  110  each of the insurance affordability programs and enrollment into
  111  a program or exchange plan. A combined eligibility form must be
  112  issued by the last agency or department to make an eligibility,
  113  renewal or denial determination. The form must meet all of the
  114  federal and state law and regulatory requirements no later than
  115  January 1, 2014.
  116         (8) “Community rate” means a method used to develop
  117  premiums for a health insurance plan that spreads financial risk
  118  across a large population and allows adjustments only for age,
  119  gender, family composition, and geographic area.
  120         (10)(9) “Department” means the Department of Health.
  121         (11)(10) “Enrollee” means a child who has been determined
  122  eligible for and is receiving coverage under ss. 409.810
  123  409.821.
  124         (11) “Family” means the group or the individuals whose
  125  income is considered in determining eligibility for the Florida
  126  Kidcare program. The family includes a child with a parent or
  127  caretaker relative who resides in the same house or living unit
  128  or, in the case of a child whose disability of nonage has been
  129  removed under chapter 743, the child. The family may also
  130  include other individuals whose income and resources are
  131  considered in whole or in part in determining eligibility of the
  132  child.
  133         (12) “Family income” means cash received at periodic
  134  intervals from any source, such as wages, benefits,
  135  contributions, or rental property. Income also may include any
  136  money that would have been counted as income under the Aid to
  137  Families with Dependent Children (AFDC) state plan in effect
  138  prior to August 22, 1996.
  139         (12)(13) “Florida Kidcare program,” “Kidcare program,” or
  140  “program” means the health benefits program administered through
  141  ss. 409.810-409.821.
  142         (13)(14) “Guarantee issue” means that health benefits
  143  coverage must be offered to an individual regardless of the
  144  individual’s health status, preexisting condition, or claims
  145  history.
  146         (14)(15) “Health benefits coverage” means protection that
  147  provides payment of benefits for covered health care services or
  148  that otherwise provides, either directly or through arrangements
  149  with other persons, covered health care services on a prepaid
  150  per capita basis or on a prepaid aggregate fixed-sum basis.
  151         (15)(16) “Health insurance plan” means health benefits
  152  coverage under the following:
  153         (a) A health plan offered by any certified health
  154  maintenance organization or authorized health insurer, except a
  155  plan that is limited to the following: a limited benefit,
  156  specified disease, or specified accident; hospital indemnity;
  157  accident only; limited benefit convalescent care; Medicare
  158  supplement; credit disability; dental; vision; long-term care;
  159  disability income; coverage issued as a supplement to another
  160  health plan; workers’ compensation liability or other insurance;
  161  or motor vehicle medical payment only; or
  162         (b) An employee welfare benefit plan that includes health
  163  benefits established under the Employee Retirement Income
  164  Security Act of 1974, as amended.
  165         (16) “Household income” means the group or the individual
  166  whose income is considered in determining eligibility for the
  167  Florida Kidcare program. The term “household” has the same
  168  meaning as provided in s. 36B(d)(2) of the Internal Revenue Code
  169  of 1986.
  170         (17) “Medicaid” means the medical assistance program
  171  authorized by Title XIX of the Social Security Act, and
  172  regulations thereunder, and ss. 409.901-409.920, as administered
  173  in this state by the agency.
  174         (18) “Medically necessary” means the use of any medical
  175  treatment, service, equipment, or supply necessary to palliate
  176  the effects of a terminal condition, or to prevent, diagnose,
  177  correct, cure, alleviate, or preclude deterioration of a
  178  condition that threatens life, causes pain or suffering, or
  179  results in illness or infirmity and which is:
  180         (a) Consistent with the symptom, diagnosis, and treatment
  181  of the enrollee’s condition;
  182         (b) Provided in accordance with generally accepted
  183  standards of medical practice;
  184         (c) Not primarily intended for the convenience of the
  185  enrollee, the enrollee’s family, or the health care provider;
  186         (d) The most appropriate level of supply or service for the
  187  diagnosis and treatment of the enrollee’s condition; and
  188         (e) Approved by the appropriate medical body or health care
  189  specialty involved as effective, appropriate, and essential for
  190  the care and treatment of the enrollee’s condition.
  191         (19) “Medikids” means a component of the Florida Kidcare
  192  program of medical assistance authorized by Title XXI of the
  193  Social Security Act, and regulations thereunder, and s.
  194  409.8132, as administered in the state by the agency.
  195         (20)“Modified adjusted gross income” means the
  196  individual’s or household’s annual adjusted gross income as
  197  defined in s. 36B(d)(2) of the Internal Revenue Code of 1986
  198  which is used to determine eligibility under the Florida Kidcare
  199  program.
  200         (21) “Patient Protection and Affordable Care Act” or “Act”
  201  means the federal law enacted as Pub. L. No. 111-148, as further
  202  amended by the federal Health Care and Education Reconciliation
  203  Act of 2010, Pub. L. No. 111-152, and any amendments,
  204  regulations, or guidance issued under those acts.
  205         (22)(20) “Preexisting condition exclusion” means, with
  206  respect to coverage, a limitation or exclusion of benefits
  207  relating to a condition based on the fact that the condition was
  208  present before the date of enrollment for such coverage, whether
  209  or not any medical advice, diagnosis, care, or treatment was
  210  recommended or received before such date.
  211         (23)(21) “Premium” means the entire cost of a health
  212  insurance plan, including the administration fee or the risk
  213  assumption charge.
  214         (24)(22) “Premium assistance payment” means the monthly
  215  consideration paid by the agency per enrollee in the Florida
  216  Kidcare program towards health insurance premiums.
  217         (25)(23) “Qualified alien” means an alien as defined in 8
  218  U.S.C. s. 1641 (b) and (c) s. 431 of the Personal Responsibility
  219  and Work Opportunity Reconciliation Act of 1996, as amended,
  220  Pub. L. No. 104-193.
  221         (26)(24) “Resident” means a United States citizen, or
  222  qualified alien, who is domiciled in this state.
  223         (27)(25) “Rural county” means a county having a population
  224  density of less than 100 persons per square mile, or a county
  225  defined by the most recent United States Census as rural, in
  226  which there is no prepaid health plan participating in the
  227  Medicaid program as of July 1, 1998.
  228         (26) “Substantially similar” means that, with respect to
  229  additional services as defined in s. 2103(c)(2) of Title XXI of
  230  the Social Security Act, these services must have an actuarial
  231  value equal to at least 75 percent of the actuarial value of the
  232  coverage for that service in the benchmark benefit plan and,
  233  with respect to the basic services as defined in s. 2103(c)(1)
  234  of Title XXI of the Social Security Act, these services must be
  235  the same as the services in the benchmark benefit plan.
  236         Section 2. Section 409.813, Florida Statutes, is amended to
  237  read:
  238         409.813 Health benefits coverage; program components;
  239  entitlement and nonentitlement.—
  240         (1) The Florida Kidcare program includes health benefits
  241  coverage provided to children through the following program
  242  components, which shall be marketed as the Florida Kidcare
  243  program:
  244         (a) Medicaid;
  245         (b) Medikids as created in s. 409.8132;
  246         (c) The Florida Healthy Kids Corporation as created in s.
  247  624.91; and
  248         (d) Employer-sponsored group health insurance plans
  249  approved under ss. 409.810-409.821; and
  250         (d)(e) The Children’s Medical Services network established
  251  in chapter 391.
  252         (2) Except for Title XIX-funded Florida Kidcare program
  253  coverage under the Medicaid program, coverage under the Florida
  254  Kidcare program is not an entitlement. No cause of action shall
  255  arise against the state, the department, the Department of
  256  Children and Families Family Services, or the agency, or the
  257  Florida Healthy Kids Corporation for failure to make health
  258  services available to any person under ss. 409.810-409.821.
  259         Section 3. Subsections (6) and (7) of section 409.8132,
  260  Florida Statutes, are amended to read:
  261         409.8132 Medikids program component.—
  262         (6) ELIGIBILITY.—
  263         (a) A child who has attained the age of 1 year but who is
  264  under the age of 5 years is eligible to enroll in the Medikids
  265  program component of the Florida Kidcare program, if the child
  266  is a member of a family that has a family income which exceeds
  267  the Medicaid applicable income level as specified in s. 409.903,
  268  but which is equal to or below 200 percent of the current
  269  federal poverty level. In determining the eligibility of such a
  270  child, an assets test is not required. A child who is eligible
  271  for Medikids may elect to enroll in Florida Healthy Kids
  272  coverage or employer-sponsored group coverage. However, a child
  273  who is eligible for Medikids may participate in the Florida
  274  Healthy Kids program only if the child has a sibling
  275  participating in the Florida Healthy Kids program and the
  276  child’s county of residence permits such enrollment.
  277         (b) The provisions of s. 409.814 apply to the Medikids
  278  program.
  279         (7) ENROLLMENT.—Enrollment in the Medikids program
  280  component may occur at any time throughout the year. A child may
  281  not receive services under the Medikids program until the child
  282  is enrolled in a managed care plan or MediPass. Once determined
  283  eligible, an applicant may receive choice counseling and select
  284  a managed care plan or MediPass. The agency may initiate
  285  mandatory assignment for a Medikids applicant who has not chosen
  286  a managed care plan or MediPass provider after the applicant’s
  287  voluntary choice period ends. An applicant may select MediPass
  288  under the Medikids program component only in counties that have
  289  fewer than two managed care plans available to serve Medicaid
  290  recipients and only if the federal Health Care Financing
  291  Administration determines that MediPass constitutes “health
  292  insurance coverage” as defined in Title XXI of the Social
  293  Security Act.
  294         Section 4. Subsection (2) of section 409.8134, Florida
  295  Statutes, is amended to read:
  296         409.8134 Program expenditure ceiling; enrollment.—
  297         (2) The Florida Kidcare program may conduct enrollment
  298  continuously throughout the year.
  299         (a) Children eligible for coverage under the Title XXI
  300  funded Florida Kidcare program shall be enrolled on a first
  301  come, first-served basis using the date the enrollment
  302  application is received. Enrollment shall immediately cease when
  303  the expenditure ceiling is reached. Year-round enrollment shall
  304  only be held if the Social Services Estimating Conference
  305  determines that sufficient federal and state funds will be
  306  available to finance the increased enrollment.
  307         (b) The application for the Florida Kidcare program is
  308  valid for a period of 120 days after the date it was received.
  309  At the end of the 120-day period, if the applicant has not been
  310  enrolled in the program, the application is invalid and the
  311  applicant shall be notified of the action. The applicant may
  312  reactivate the application after notification of the action
  313  taken by the program.
  314         (c) Except for the Medicaid program, whenever the Social
  315  Services Estimating Conference determines that there are
  316  presently, or will be by the end of the current fiscal year,
  317  insufficient funds to finance the current or projected
  318  enrollment in the Florida Kidcare program, all additional
  319  enrollment must cease and additional enrollment may not resume
  320  until sufficient funds are available to finance such enrollment.
  321         Section 5. Section 409.814, Florida Statutes, is amended to
  322  read:
  323         409.814 Eligibility.—A child who has not reached 19 years
  324  of age whose household family income is equal to or below 200
  325  percent of the federal poverty level is eligible for the Florida
  326  Kidcare program as provided in this section. If an enrolled
  327  individual is determined to be ineligible for coverage, he or
  328  she must be immediately disenrolled from the respective Florida
  329  Kidcare program component and referred to another insurance
  330  affordability program, if appropriate, through a combined
  331  eligibility notice.
  332         (1) A child who is eligible for Medicaid coverage under s.
  333  409.903 or s. 409.904 must be offered the opportunity to enroll
  334  enrolled in Medicaid and is not eligible to receive health
  335  benefits under any other health benefits coverage authorized
  336  under the Florida Kidcare program. A child who is eligible for
  337  Medicaid and opts to enroll in CHIP may disenroll from CHIP at
  338  any time and transition to Medicaid. This transition must occur
  339  without any break in coverage.
  340         (2) A child who is not eligible for Medicaid, but who is
  341  eligible for the Florida Kidcare program, may obtain health
  342  benefits coverage under any of the other components listed in s.
  343  409.813 if such coverage is approved and available in the county
  344  in which the child resides.
  345         (3) A Title XXI-funded child who is eligible for the
  346  Florida Kidcare program who is a child with special health care
  347  needs, as determined through a medical or behavioral screening
  348  instrument, is eligible for health benefits coverage from and
  349  shall be assigned to and may opt out of the Children’s Medical
  350  Services Network.
  351         (4) The following children are not eligible to receive
  352  Title XXI-funded premium assistance for health benefits coverage
  353  under the Florida Kidcare program, except under Medicaid if the
  354  child would have been eligible for Medicaid under s. 409.903 or
  355  s. 409.904 as of June 1, 1997:
  356         (a) A child who is covered under a family member’s group
  357  health benefit plan or under other private or employer health
  358  insurance coverage, if the cost of the child’s participation is
  359  not greater than 5 percent of the household’s family’s income.
  360  If a child is otherwise eligible for a subsidy under the Florida
  361  Kidcare program and the cost of the child’s participation in the
  362  family member’s health insurance benefit plan is greater than 5
  363  percent of the household’s family’s income, the child may enroll
  364  in the appropriate subsidized Kidcare program.
  365         (b) A child who is seeking premium assistance for the
  366  Florida Kidcare program through employer-sponsored group
  367  coverage, if the child has been covered by the same employer’s
  368  group coverage during the 60 days before the family submitted an
  369  application for determination of eligibility under the program.
  370         (b)(c) A child who is an alien, but who does not meet the
  371  definition of qualified alien, in the United States.
  372         (c)(d) A child who is an inmate of a public institution or
  373  a patient in an institution for mental diseases.
  374         (d)(e) A child who is otherwise eligible for premium
  375  assistance for the Florida Kidcare program and has had his or
  376  her coverage in an employer-sponsored or private health benefit
  377  plan voluntarily canceled in the last 60 days, except those
  378  children whose coverage was voluntarily canceled for good cause,
  379  including, but not limited to, the following circumstances:
  380         1. The cost of participation in an employer-sponsored
  381  health benefit plan is greater than 5 percent of the household’s
  382  modified adjusted gross family’s income;
  383         2. The parent lost a job that provided an employer
  384  sponsored health benefit plan for children;
  385         3. The parent who had health benefits coverage for the
  386  child is deceased;
  387         4. The child has a medical condition that, without medical
  388  care, would cause serious disability, loss of function, or
  389  death;
  390         5. The employer of the parent canceled health benefits
  391  coverage for children;
  392         6. The child’s health benefits coverage ended because the
  393  child reached the maximum lifetime coverage amount;
  394         7. The child has exhausted coverage under a COBRA
  395  continuation provision;
  396         8. The health benefits coverage does not cover the child’s
  397  health care needs; or
  398         9. Domestic violence led to loss of coverage.
  399         (5) A child who is otherwise eligible for the Florida
  400  Kidcare program and who has a preexisting condition that
  401  prevents coverage under another insurance plan as described in
  402  paragraph (4)(a) which would have disqualified the child for the
  403  Florida Kidcare program if the child were able to enroll in the
  404  plan is eligible for Florida Kidcare coverage when enrollment is
  405  possible.
  406         (5)(6) A child whose household’s modified adjusted gross
  407  family income is above 200 percent of the federal poverty level
  408  or a child who is excluded under the provisions of subsection
  409  (4) may participate in the Florida Kidcare program as provided
  410  in s. 409.8132 or, if the child is ineligible for Medikids by
  411  reason of age, in the Florida Healthy Kids program, subject to
  412  the following:
  413         (a) The family is not eligible for premium assistance
  414  payments and must pay the full cost of the premium, including
  415  any administrative costs.
  416         (b) The board of directors of the Florida Healthy Kids
  417  Corporation may offer a reduced benefit package to these
  418  children in order to limit program costs for such families.
  419         (c) By August 15, 2013, the Florida Healthy Kids
  420  Corporation shall notify all current full-pay enrollees of the
  421  availability of the exchange and how to access other insurance
  422  affordability options. New applications for full-pay coverage
  423  may not be accepted after September 30, 2013.
  424         (6)(7) Once a child is enrolled in the Florida Kidcare
  425  program, the child is eligible for coverage for 12 months
  426  without a redetermination or reverification of eligibility, if
  427  the family continues to pay the applicable premium. Eligibility
  428  for program components funded through Title XXI of the Social
  429  Security Act terminates when a child attains the age of 19. A
  430  child who has not attained the age of 5 and who has been
  431  determined eligible for the Medicaid program is eligible for
  432  coverage for 12 months without a redetermination or
  433  reverification of eligibility.
  434         (7)(8) When determining or reviewing a child’s eligibility
  435  under the Florida Kidcare program, the applicant shall be
  436  provided with reasonable notice of changes in eligibility which
  437  may affect enrollment in one or more of the program components.
  438  If a transition from one program component to another is
  439  authorized, there shall be cooperation between the program
  440  components and the affected family which promotes continuity of
  441  health care coverage. Any authorized transfers must be managed
  442  within the program’s overall appropriated or authorized levels
  443  of funding. Each component of the program shall establish a
  444  reserve to ensure that transfers between components will be
  445  accomplished within current year appropriations. These reserves
  446  shall be reviewed by each convening of the Social Services
  447  Estimating Conference to determine the adequacy of such reserves
  448  to meet actual experience.
  449         (8)(9) In determining the eligibility of a child, an assets
  450  test is not required. Each applicant shall provide documentation
  451  during the application process and the redetermination process,
  452  including, but not limited to, the following:
  453         (a) Proof of household family income, which must be
  454  verified electronically to determine financial eligibility for
  455  the Florida Kidcare program. Written documentation, which may
  456  include wages and earnings statements or pay stubs, W-2 forms,
  457  or a copy of the applicant’s most recent federal income tax
  458  return, is required only if the electronic verification is not
  459  available or does not substantiate the applicant’s income. This
  460  paragraph expires December 31, 2013.
  461         (b)  A statement from all applicable, employed household
  462  family members that:
  463         1. Their employers do not sponsor health benefit plans for
  464  employees;
  465         2. The potential enrollee is not covered by an employer
  466  sponsored health benefit plan; or
  467         3. The potential enrollee is covered by an employer
  468  sponsored health benefit plan and the cost of the employer
  469  sponsored health benefit plan is more than 5 percent of the
  470  household’s modified adjusted gross family’s income.
  471         (c) To enroll in the Children’s Medical Services Network, a
  472  completed application, including a clinical screening.
  473         (d) Effective January 1, 2014, eligibility shall be
  474  determined through electronic matching using the federally
  475  managed data services hub and other resources. Written
  476  documentation from the applicant may be accepted if the
  477  electronic verification does not substantiate the applicant’s
  478  income or if there has been a change in circumstances.
  479         (9)(10) Subject to paragraph (4)(a), the Florida Kidcare
  480  program shall withhold benefits from an enrollee if the program
  481  obtains evidence that the enrollee is no longer eligible,
  482  submitted incorrect or fraudulent information in order to
  483  establish eligibility, or failed to provide verification of
  484  eligibility. The applicant or enrollee shall be notified that
  485  because of such evidence program benefits will be withheld
  486  unless the applicant or enrollee contacts a designated
  487  representative of the program by a specified date, which must be
  488  within 10 working days after the date of notice, to discuss and
  489  resolve the matter. The program shall make every effort to
  490  resolve the matter within a timeframe that will not cause
  491  benefits to be withheld from an eligible enrollee.
  492         (10)(11) The following individuals may be subject to
  493  prosecution in accordance with s. 414.39:
  494         (a) An applicant obtaining or attempting to obtain benefits
  495  for a potential enrollee under the Florida Kidcare program when
  496  the applicant knows or should have known the potential enrollee
  497  does not qualify for the Florida Kidcare program.
  498         (b) An individual who assists an applicant in obtaining or
  499  attempting to obtain benefits for a potential enrollee under the
  500  Florida Kidcare program when the individual knows or should have
  501  known the potential enrollee does not qualify for the Florida
  502  Kidcare program.
  503         Section 6. Paragraphs (g), (k), (q), and (w) of subsection
  504  (2) of section 409.815, Florida Statutes, are amended to read:
  505         409.815 Health benefits coverage; limitations.—
  506         (2) BENCHMARK BENEFITS.—In order for health benefits
  507  coverage to qualify for premium assistance payments for an
  508  eligible child under ss. 409.810-409.821, the health benefits
  509  coverage, except for coverage under Medicaid and Medikids, must
  510  include the following minimum benefits, as medically necessary.
  511         (g) Behavioral health services.—
  512         1. Mental health benefits include:
  513         a. Inpatient services, limited to 30 inpatient days per
  514  contract year for psychiatric admissions, or residential
  515  services in facilities licensed under s. 394.875(6) or s.
  516  395.003 in lieu of inpatient psychiatric admissions; however, a
  517  minimum of 10 of the 30 days shall be available only for
  518  inpatient psychiatric services if authorized by a physician; and
  519         b. Outpatient services, including outpatient visits for
  520  psychological or psychiatric evaluation, diagnosis, and
  521  treatment by a licensed mental health professional, limited to
  522  40 outpatient visits each contract year.
  523         2. Substance abuse services include:
  524         a. Inpatient services, limited to 7 inpatient days per
  525  contract year for medical detoxification only and 30 days of
  526  residential services; and
  527         b. Outpatient services, including evaluation, diagnosis,
  528  and treatment by a licensed practitioner, limited to 40
  529  outpatient visits per contract year.
  530  
  531  Effective October 1, 2009, Covered services include inpatient
  532  and outpatient services for mental and nervous disorders as
  533  defined in the most recent edition of the Diagnostic and
  534  Statistical Manual of Mental Disorders published by the American
  535  Psychiatric Association. Such benefits include psychological or
  536  psychiatric evaluation, diagnosis, and treatment by a licensed
  537  mental health professional and inpatient, outpatient, and
  538  residential treatment of substance abuse disorders. Any benefit
  539  limitations, including duration of services, number of visits,
  540  or number of days for hospitalization or residential services,
  541  shall not be any less favorable than those for physical
  542  illnesses generally. The program may also implement appropriate
  543  financial incentives, peer review, utilization requirements, and
  544  other methods used for the management of benefits provided for
  545  other medical conditions in order to reduce service costs and
  546  utilization without compromising quality of care.
  547         (k) Hospice services.—Covered services include reasonable
  548  and necessary services for palliation or management of an
  549  enrollee’s terminal illness, with the following exceptions:
  550         1. Once a family elects to receive hospice care for an
  551  enrollee, other services that treat the terminal condition will
  552  not be covered; and
  553         2. Services required for conditions totally unrelated to
  554  the terminal condition are covered to the extent that the
  555  services are included in this section.
  556         (q) Dental services.Effective October 1, 2009, Dental
  557  services shall be covered as required under federal law and may
  558  also include those dental benefits provided to children by the
  559  Florida Medicaid program under s. 409.906(6).
  560         (w) Reimbursement of federally qualified health centers and
  561  rural health clinics.Effective October 1, 2009, Payments for
  562  services provided to enrollees by federally qualified health
  563  centers and rural health clinics under this section shall be
  564  reimbursed using the Medicaid Prospective Payment System as
  565  provided for under s. 2107(e)(1)(D) of the Social Security Act.
  566  If such services are paid for by health insurers or health care
  567  providers under contract with the Florida Healthy Kids
  568  Corporation, such entities are responsible for this payment. The
  569  agency may seek any available federal grants to assist with this
  570  transition.
  571         Section 7. Section 409.816, Florida Statutes, is amended to
  572  read:
  573         409.816 Limitations on premiums and cost-sharing.—The
  574  following limitations on premiums and cost-sharing are
  575  established for the program.
  576         (1) Enrollees who receive coverage under the Medicaid
  577  program may not be required to pay:
  578         (a) Enrollment fees, premiums, or similar charges; or
  579         (b) Copayments, deductibles, coinsurance, or similar
  580  charges.
  581         (2) Enrollees in households that have families with a
  582  modified adjusted gross family income equal to or below 150
  583  percent of the federal poverty level, who are not receiving
  584  coverage under the Medicaid program, may not be required to pay:
  585         (a) Enrollment fees, premiums, or similar charges that
  586  exceed the maximum monthly charge permitted under s. 1916(b)(1)
  587  of the Social Security Act; or
  588         (b) Copayments, deductibles, coinsurance, or similar
  589  charges that exceed a nominal amount, as determined consistent
  590  with regulations referred to in s. 1916(a)(3) of the Social
  591  Security Act. However, such charges may not be imposed for
  592  preventive services, including well-baby and well-child care,
  593  age-appropriate immunizations, and routine hearing and vision
  594  screenings.
  595         (3) Enrollees in households that have families with a
  596  modified adjusted gross family income above 150 percent of the
  597  federal poverty level who are not receiving coverage under the
  598  Medicaid program or who are not eligible under s. 409.814(5) s.
  599  409.814(6) may be required to pay enrollment fees, premiums,
  600  copayments, deductibles, coinsurance, or similar charges on a
  601  sliding scale related to income, except that the total annual
  602  aggregate cost-sharing with respect to all children in a
  603  household family may not exceed 5 percent of the household’s
  604  modified adjusted family’s income. However, copayments,
  605  deductibles, coinsurance, or similar charges may not be imposed
  606  for preventive services, including well-baby and well-child
  607  care, age-appropriate immunizations, and routine hearing and
  608  vision screenings.
  609         Section 8. Section 409.817, Florida Statutes, is repealed.
  610         Section 9. Section 409.8175, Florida Statutes, is repealed.
  611         Section 10. Paragraph (c) of subsection (1) of section
  612  409.8177, Florida Statutes, is amended to read:
  613         409.8177 Program evaluation.—
  614         (1) The agency, in consultation with the Department of
  615  Health, the Department of Children and Families Family Services,
  616  and the Florida Healthy Kids Corporation, shall contract for an
  617  evaluation of the Florida Kidcare program and shall by January 1
  618  of each year submit to the Governor, the President of the
  619  Senate, and the Speaker of the House of Representatives a report
  620  of the program. In addition to the items specified under s. 2108
  621  of Title XXI of the Social Security Act, the report shall
  622  include an assessment of crowd-out and access to health care, as
  623  well as the following:
  624         (c) The characteristics of the children and families
  625  assisted under the program, including ages of the children,
  626  household family income, and access to or coverage by other
  627  health insurance prior to the program and after disenrollment
  628  from the program.
  629         Section 11. Section 409.818, Florida Statutes, is amended
  630  to read:
  631         409.818 Administration.—In order to implement ss. 409.810
  632  409.821, the following agencies shall have the following duties:
  633         (1) The Department of Children and Families Family Services
  634  shall:
  635         (a) Maintain Develop a simplified eligibility determination
  636  and renewal process application mail-in form to be used for
  637  determining the eligibility of children for coverage under the
  638  Florida Kidcare program, in consultation with the agency, the
  639  Department of Health, and the Florida Healthy Kids Corporation.
  640  The simplified eligibility process application form must include
  641  an item that provides an opportunity for the applicant to
  642  indicate whether coverage is being sought for a child with
  643  special health care needs. Families applying for children’s
  644  Medicaid coverage must also be able to use the simplified
  645  application process form without having to pay a premium.
  646         (b) Establish and maintain the eligibility determination
  647  process under the program except as specified in subsection (3),
  648  which includes the following: (5).
  649         1. The department shall directly, or through the services
  650  of a contracted third-party administrator, establish and
  651  maintain a process for determining eligibility of children for
  652  coverage under the program. The eligibility determination
  653  process must be used solely for determining eligibility of
  654  applicants for health benefits coverage under the program. The
  655  eligibility determination process must include an initial
  656  determination of eligibility for any coverage offered under the
  657  program, as well as a redetermination or reverification of
  658  eligibility each subsequent 6 months. Effective January 1, 1999,
  659  A child who has not attained the age of 5 and who has been
  660  determined eligible for the Medicaid program is eligible for
  661  coverage for 12 months without a redetermination or
  662  reverification of eligibility. In conducting an eligibility
  663  determination, the department shall determine if the child has
  664  special health care needs.
  665         2. The department, in consultation with the Agency for
  666  Health Care Administration and the Florida Healthy Kids
  667  Corporation, shall develop procedures for redetermining
  668  eligibility which enable applicants and enrollees a family to
  669  easily update any change in circumstances which could affect
  670  eligibility.
  671         3. The department may accept changes in a family’s status
  672  as reported to the department by the Florida Healthy Kids
  673  Corporation or the exchange without requiring a new application
  674  from the family. Redetermination of a child’s eligibility for
  675  Medicaid may not be linked to a child’s eligibility
  676  determination for other programs.
  677         4. The department, in consultation with the agency and the
  678  Florida Healthy Kids Corporation, shall develop a combined
  679  eligibility notice to inform applicants and enrollees of their
  680  application or renewal status, as appropriate. The content must
  681  be coordinated to meet all federal and state requirements under
  682  the federal Patient Protection and Affordable Care Act.
  683         (c) Inform program applicants about eligibility
  684  determinations and provide information about eligibility of
  685  applicants to the Florida Kidcare program and to insurers and
  686  their agents, through a centralized coordinating office.
  687         (d) Adopt rules necessary for conducting program
  688  eligibility functions.
  689         (2) The Department of Health shall:
  690         (a) Design an eligibility intake process for the program,
  691  in coordination with the Department of Children and Family
  692  Services, the agency, and the Florida Healthy Kids Corporation.
  693  The eligibility intake process may include local intake points
  694  that are determined by the Department of Health in coordination
  695  with the Department of Children and Family Services.
  696         (b) Chair a state-level Florida Kidcare coordinating
  697  council to review and make recommendations concerning the
  698  implementation and operation of the program. The coordinating
  699  council shall include representatives from the department, the
  700  Department of Children and Family Services, the agency, the
  701  Florida Healthy Kids Corporation, the Office of Insurance
  702  Regulation of the Financial Services Commission, local
  703  government, health insurers, health maintenance organizations,
  704  health care providers, families participating in the program,
  705  and organizations representing low-income families.
  706         (c) In consultation with the Florida Healthy Kids
  707  Corporation and the Department of Children and Family Services,
  708  establish a toll-free telephone line to assist families with
  709  questions about the program.
  710         (d) Adopt rules necessary to implement outreach activities.
  711         (2)(3) The Agency for Health Care Administration, under the
  712  authority granted in s. 409.914(1), shall:
  713         (a) Calculate the premium assistance payment necessary to
  714  comply with the premium and cost-sharing limitations specified
  715  in s. 409.816 and the federal Patient Protection and Affordable
  716  Care Act. The premium assistance payment for each enrollee in a
  717  health insurance plan participating in the Florida Healthy Kids
  718  Corporation shall equal the premium approved by the Florida
  719  Healthy Kids Corporation and the Office of Insurance Regulation
  720  of the Financial Services Commission pursuant to ss. 627.410 and
  721  641.31, less any enrollee’s share of the premium established
  722  within the limitations specified in s. 409.816. The premium
  723  assistance payment for each enrollee in an employer-sponsored
  724  health insurance plan approved under ss. 409.810-409.821 shall
  725  equal the premium for the plan adjusted for any benchmark
  726  benefit plan actuarial equivalent benefit rider approved by the
  727  Office of Insurance Regulation pursuant to ss. 627.410 and
  728  641.31, less any enrollee’s share of the premium established
  729  within the limitations specified in s. 409.816. In calculating
  730  the premium assistance payment levels for children with family
  731  coverage, the agency shall set the premium assistance payment
  732  levels for each child proportionately to the total cost of
  733  family coverage.
  734         (b) Make premium assistance payments to health insurance
  735  plans on a periodic basis. The agency may use its Medicaid
  736  fiscal agent or a contracted third-party administrator in making
  737  these payments. The agency may require health insurance plans
  738  that participate in the Medikids program or employer-sponsored
  739  group health insurance to collect premium payments from an
  740  enrollee’s family. Participating health insurance plans shall
  741  report premium payments collected on behalf of enrollees in the
  742  program to the agency in accordance with a schedule established
  743  by the agency.
  744         (c) Monitor compliance with quality assurance and access
  745  standards developed under s. 409.820 and in accordance with s.
  746  2103(f) of the Social Security Act, 42 U.S.C. s. 1397cc(f).
  747         (d) Establish a mechanism for investigating and resolving
  748  complaints and grievances from program applicants, enrollees,
  749  and health benefits coverage providers, and maintain a record of
  750  complaints and confirmed problems. In the case of a child who is
  751  enrolled in a managed care health maintenance organization, the
  752  agency must use the provisions of s. 641.511 to address
  753  grievance reporting and resolution requirements.
  754         (e) Approve health benefits coverage for participation in
  755  the program, following certification by the Office of Insurance
  756  Regulation under subsection (4).
  757         (e)(f) Adopt rules necessary for calculating premium
  758  assistance payment levels, making premium assistance payments,
  759  monitoring access and quality assurance standards and,
  760  investigating and resolving complaints and grievances,
  761  administering the Medikids program, and approving health
  762  benefits coverage.
  763         (f) Contract with the Florida Healthy Kids Corporation for
  764  the administration of the Florida Kidcare program and the
  765  Healthy Florida program and to facilitate the release of any
  766  federal and state funds.
  767  
  768  The agency is designated the lead state agency for Title XXI of
  769  the Social Security Act for purposes of receipt of federal
  770  funds, for reporting purposes, and for ensuring compliance with
  771  federal and state regulations and rules.
  772         (4) The Office of Insurance Regulation shall certify that
  773  health benefits coverage plans that seek to provide services
  774  under the Florida Kidcare program, except those offered through
  775  the Florida Healthy Kids Corporation or the Children’s Medical
  776  Services Network, meet, exceed, or are actuarially equivalent to
  777  the benchmark benefit plan and that health insurance plans will
  778  be offered at an approved rate. In determining actuarial
  779  equivalence of benefits coverage, the Office of Insurance
  780  Regulation and health insurance plans must comply with the
  781  requirements of s. 2103 of Title XXI of the Social Security Act.
  782  The department shall adopt rules necessary for certifying health
  783  benefits coverage plans.
  784         (3)(5) The Florida Healthy Kids Corporation shall retain
  785  its functions as authorized in s. 624.91, including eligibility
  786  determination for participation in the Healthy Kids program.
  787         (4)(6) The agency, the Department of Health, the Department
  788  of Children and Families Family Services, and the Florida
  789  Healthy Kids Corporation, and the Office of Insurance
  790  Regulation, after consultation with and approval of the Speaker
  791  of the House of Representatives and the President of the Senate,
  792  may are authorized to make program modifications that are
  793  necessary to overcome any objections of the United States
  794  Department of Health and Human Services to obtain approval of
  795  the state’s child health insurance plan under Title XXI of the
  796  Social Security Act.
  797         Section 12. Section 409.820, Florida Statutes, is amended
  798  to read:
  799         409.820 Quality assurance and access standards.—Except for
  800  Medicaid, the Department of Health, in consultation with the
  801  agency and the Florida Healthy Kids Corporation, shall develop a
  802  minimum set of pediatric and adolescent quality assurance and
  803  access standards for all program components. The standards must
  804  include a process for granting exceptions to specific
  805  requirements for quality assurance and access. Compliance with
  806  the standards shall be a condition of program participation by
  807  health benefits coverage providers. These standards shall comply
  808  with the provisions of this chapter and chapter 641 and Title
  809  XXI of the Social Security Act.
  810         Section 13. Section 624.91, Florida Statutes, is amended to
  811  read:
  812         624.91 The Florida Healthy Kids Corporation Act.—
  813         (1) SHORT TITLE.—This section may be cited as the “William
  814  G. ‘Doc’ Myers Healthy Kids Corporation Act.”
  815         (2) LEGISLATIVE INTENT.—
  816         (a) The Legislature finds that increased access to health
  817  care services could improve children’s health and reduce the
  818  incidence and costs of childhood illness and disabilities among
  819  children in this state. Many children do not have comprehensive,
  820  affordable health care services available. It is the intent of
  821  the Legislature that the Florida Healthy Kids Corporation
  822  provide comprehensive health insurance coverage to such
  823  children. The corporation is encouraged to cooperate with any
  824  existing health service programs funded by the public or the
  825  private sector.
  826         (b) It is the intent of the Legislature that the Florida
  827  Healthy Kids Corporation serve as one of several providers of
  828  services to children eligible for medical assistance under Title
  829  XXI of the Social Security Act. Although the corporation may
  830  serve other children, the Legislature intends the primary
  831  recipients of services provided through the corporation be
  832  school-age children with a family income below 200 percent of
  833  the federal poverty level, who do not qualify for Medicaid. It
  834  is also the intent of the Legislature that state and local
  835  government Florida Healthy Kids funds be used to continue
  836  coverage, subject to specific appropriations in the General
  837  Appropriations Act, to children not eligible for federal
  838  matching funds under Title XXI.
  839         (c) It is further the intent of the Legislature that the
  840  Florida Healthy Kids Corporation administer and manage services
  841  for Healthy Florida, a health care program for uninsured adults
  842  using a unique network of providers and contracts. Enrollees in
  843  Healthy Florida will receive comprehensive health care services
  844  from private, licensed health insurers who meet standards
  845  established by the corporation. It is further the intent of the
  846  Legislature that these enrollees participate in their own health
  847  care decisionmaking and contribute financially toward their
  848  medical costs. The Legislature intends to provide an alternative
  849  benefit package that includes a full range of services which
  850  meet the needs of residents of this state. As a new program, the
  851  Legislature shall also ensure that a comprehensive evaluation is
  852  conducted to measure the overall impact of the program and
  853  identify whether to renew the program after an initial 3-year
  854  term.
  855         (3) ELIGIBILITY FOR STATE-FUNDED ASSISTANCE.—Only the
  856  following individuals are eligible for state-funded assistance
  857  in paying premiums for Healthy Florida or Florida Healthy Kids
  858  premiums:
  859         (a) Residents of this state who are eligible for the
  860  Florida Kidcare program pursuant to s. 409.814 or the Healthy
  861  Florida pursuant to s. 624.917.
  862         (b) Notwithstanding s. 409.814, legal aliens who are
  863  enrolled in the Florida Healthy Kids program as of January 31,
  864  2004, who do not qualify for Title XXI federal funds because
  865  they are not qualified aliens as defined in s. 409.811.
  866         (4) NONENTITLEMENT.—Nothing in this section shall be
  867  construed as providing an individual with an entitlement to
  868  health care services. No cause of action shall arise against the
  869  state, the Florida Healthy Kids Corporation, or a unit of local
  870  government for failure to make health services available under
  871  this section.
  872         (5) CORPORATION AUTHORIZATION, DUTIES, POWERS.—
  873         (a) There is created the Florida Healthy Kids Corporation,
  874  a not-for-profit corporation.
  875         (b) The Florida Healthy Kids Corporation shall:
  876         1. Arrange for the collection of any family, individual, or
  877  local contributions, or employer payment or premium, in an
  878  amount to be determined by the board of directors, to provide
  879  for payment of premiums for comprehensive insurance coverage and
  880  for the actual or estimated administrative expenses.
  881         2. Arrange for the collection of any voluntary
  882  contributions to provide for payment of premiums for enrollees
  883  in the Florida Kidcare program or Healthy Florida premiums for
  884  children who are not eligible for medical assistance under Title
  885  XIX or Title XXI of the Social Security Act.
  886         3. Subject to the provisions of s. 409.8134, accept
  887  voluntary supplemental local match contributions that comply
  888  with the requirements of Title XXI of the Social Security Act
  889  for the purpose of providing additional Florida Kidcare coverage
  890  in contributing counties under Title XXI.
  891         4. Establish the administrative and accounting procedures
  892  for the operation of the corporation.
  893         5. Establish, with consultation from appropriate
  894  professional organizations, standards for preventive health
  895  services and providers and comprehensive insurance benefits
  896  appropriate to children, provided that such standards for rural
  897  areas shall not limit primary care providers to board-certified
  898  pediatricians.
  899         6. Determine eligibility for children seeking to
  900  participate in the Title XXI-funded components of the Florida
  901  Kidcare program consistent with the requirements specified in s.
  902  409.814, as well as the non-Title-XXI-eligible children as
  903  provided in subsection (3).
  904         7. Establish procedures under which providers of local
  905  match to, applicants to and participants in the program may have
  906  grievances reviewed by an impartial body and reported to the
  907  board of directors of the corporation.
  908         8. Establish participation criteria and, if appropriate,
  909  contract with an authorized insurer, health maintenance
  910  organization, or third-party administrator to provide
  911  administrative services to the corporation.
  912         9. Establish enrollment criteria that include penalties or
  913  waiting periods of 30 days for reinstatement of coverage upon
  914  voluntary cancellation for nonpayment of family and individual
  915  premiums under the programs.
  916         10. Contract with authorized insurers or any provider of
  917  health care services, meeting standards established by the
  918  corporation, for the provision of comprehensive insurance
  919  coverage to participants. Such standards shall include criteria
  920  under which the corporation may contract with more than one
  921  provider of health care services in program sites.
  922         a. Health plans shall be selected through a competitive bid
  923  process.
  924         b. The Florida Healthy Kids Corporation shall purchase
  925  goods and services in the most cost-effective manner consistent
  926  with the delivery of quality medical care. The maximum
  927  administrative cost for a Florida Healthy Kids Corporation
  928  contract shall be 15 percent. For all health care contracts, the
  929  minimum medical loss ratio is for a Florida Healthy Kids
  930  Corporation contract shall be 85 percent. The calculations must
  931  use uniform financial data collected from all plans in a format
  932  established by the corporation and shall be computed for each
  933  insurer on a statewide basis. Funds shall be classified in a
  934  manner consistent with 45 C.F.R. part 158 For dental contracts,
  935  the remaining compensation to be paid to the authorized insurer
  936  or provider under a Florida Healthy Kids Corporation contract
  937  shall be no less than an amount which is 85 percent of premium;
  938  to the extent any contract provision does not provide for this
  939  minimum compensation, this section shall prevail.
  940         c. The health plan selection criteria and scoring system,
  941  and the scoring results, shall be available upon request for
  942  inspection after the bids have been awarded.
  943         11. Establish disenrollment criteria in the event local
  944  matching funds are insufficient to cover enrollments.
  945         12. Develop and implement a plan to publicize the Florida
  946  Kidcare program and Healthy Florida, the eligibility
  947  requirements of the programs program, and the procedures for
  948  enrollment in the program and to maintain public awareness of
  949  the corporation and the programs program.
  950         13. Secure staff necessary to properly administer the
  951  corporation. Staff costs shall be funded from state and local
  952  matching funds and such other private or public funds as become
  953  available. The board of directors shall determine the number of
  954  staff members necessary to administer the corporation.
  955         14. In consultation with the partner agencies, annually
  956  provide a report on the Florida Kidcare program annually to the
  957  Governor, the Chief Financial Officer, the Commissioner of
  958  Education, the President of the Senate, the Speaker of the House
  959  of Representatives, and the Minority Leaders of the Senate and
  960  the House of Representatives.
  961         15. Provide information on a quarterly basis to the
  962  Legislature and the Governor which compares the costs and
  963  utilization of the full-pay enrolled population and the Title
  964  XXI-subsidized enrolled population in the Florida Kidcare
  965  program. The information, at a minimum, must include:
  966         a. The monthly enrollment and expenditure for full-pay
  967  enrollees in the Medikids and Florida Healthy Kids programs
  968  compared to the Title XXI-subsidized enrolled population; and
  969         b. The costs and utilization by service of the full-pay
  970  enrollees in the Medikids and Florida Healthy Kids programs and
  971  the Title XXI-subsidized enrolled population. This subparagraph
  972  is repealed effective December 31, 2013.
  973  
  974  By February 1, 2010, the Florida Healthy Kids Corporation shall
  975  provide a study to the Legislature and the Governor on premium
  976  impacts to the subsidized portion of the program from the
  977  inclusion of the full-pay program, which shall include
  978  recommendations on how to eliminate or mitigate possible impacts
  979  to the subsidized premiums.
  980         16. By August 15, 2013, the corporation shall notify all
  981  current full-pay enrollees of the availability of the exchange,
  982  as defined in the federal Patient Protection and Affordable Care
  983  Act, and how to access other insurance affordability options.
  984  New applications for full-pay coverage may not be accepted after
  985  September 30, 2013.
  986         17.16. Establish benefit packages that conform to the
  987  provisions of the Florida Kidcare program, as created in ss.
  988  409.810-409.821.
  989         (c) Coverage under the corporation’s program is secondary
  990  to any other available private coverage held by, or applicable
  991  to, the participant child or family member. Insurers under
  992  contract with the corporation are the payors of last resort and
  993  must coordinate benefits with any other third-party payor that
  994  may be liable for the participant’s medical care.
  995         (d) The Florida Healthy Kids Corporation shall be a private
  996  corporation not for profit, registered, incorporated, and
  997  organized pursuant to chapter 617, and shall have all powers
  998  necessary to carry out the purposes of this act, including, but
  999  not limited to, the power to receive and accept grants, loans,
 1000  or advances of funds from any public or private agency and to
 1001  receive and accept from any source contributions of money,
 1002  property, labor, or any other thing of value, to be held, used,
 1003  and applied for the purposes of this act. The corporation and
 1004  any committees it forms shall act in compliance with part III of
 1005  chapter 112, and chapters 119 and 286.
 1006         (6) BOARD OF DIRECTORS AND MANAGEMENT SUPERVISION.—
 1007         (a) The Florida Healthy Kids Corporation shall operate
 1008  subject to the supervision and approval of a board of directors
 1009  chaired by an appointee designated by the Governor Chief
 1010  Financial Officer or her or his designee, and composed of 12
 1011  other members. The Senate shall confirm the designated chair and
 1012  other board appointees selected for 3-year terms of office as
 1013  follows:
 1014         1. The Secretary of Health Care Administration, or his or
 1015  her designee.
 1016         2. One member appointed by the Commissioner of Education
 1017  from the Office of School Health Programs of the Florida
 1018  Department of Education.
 1019         3. One member appointed by the Chief Financial Officer from
 1020  among three members nominated by the Florida Pediatric Society.
 1021         4. One member, appointed by the Governor, who represents
 1022  the Children’s Medical Services Program.
 1023         5. One member appointed by the Chief Financial Officer from
 1024  among three members nominated by the Florida Hospital
 1025  Association.
 1026         6. One member, appointed by the Governor, who is an expert
 1027  on child health policy.
 1028         7. One member, appointed by the Chief Financial Officer,
 1029  from among three members nominated by the Florida Academy of
 1030  Family Physicians.
 1031         8. One member, appointed by the Governor, who represents
 1032  the state Medicaid program.
 1033         9. One member, appointed by the Chief Financial Officer,
 1034  from among three members nominated by the Florida Association of
 1035  Counties.
 1036         10. The State Health Officer or her or his designee.
 1037         11. The Secretary of Children and Family Services, or his
 1038  or her designee.
 1039         12. One member, appointed by the Governor, from among three
 1040  members nominated by the Florida Dental Association.
 1041         (b) A member of the board of directors serves at the
 1042  pleasure of the Governor may be removed by the official who
 1043  appointed that member. The board shall appoint an executive
 1044  director, who is responsible for other staff authorized by the
 1045  board.
 1046         (c) Board members are entitled to receive, from funds of
 1047  the corporation, reimbursement for per diem and travel expenses
 1048  as provided by s. 112.061.
 1049         (d) There shall be no liability on the part of, and no
 1050  cause of action shall arise against, any member of the board of
 1051  directors, or its employees or agents, for any action they take
 1052  in the performance of their powers and duties under this act.
 1053         (e) Board members who are serving on or before the date of
 1054  enactment of this act or similar legislation may remain until
 1055  July 1, 2013.
 1056         (f) An executive steering committee is created to provide
 1057  management direction and support and to make recommendations to
 1058  the board on the programs. The steering committee is composed of
 1059  the Secretary of Health Care Administration, the Secretary of
 1060  Children and Families, and the State Surgeon General. Committee
 1061  members may not delegate their membership or attendance.
 1062         (7) LICENSING NOT REQUIRED; FISCAL OPERATION.—
 1063         (a) The corporation shall not be deemed an insurer. The
 1064  officers, directors, and employees of the corporation shall not
 1065  be deemed to be agents of an insurer. Neither the corporation
 1066  nor any officer, director, or employee of the corporation is
 1067  subject to the licensing requirements of the insurance code or
 1068  the rules of the Department of Financial Services or Office of
 1069  Insurance Regulation. However, any marketing representative
 1070  utilized and compensated by the corporation must be appointed as
 1071  a representative of the insurers or health services providers
 1072  with which the corporation contracts.
 1073         (b) The board has complete fiscal control over the
 1074  corporation and is responsible for all corporate operations.
 1075         (c) The Department of Financial Services shall supervise
 1076  any liquidation or dissolution of the corporation and shall
 1077  have, with respect to such liquidation or dissolution, all power
 1078  granted to it pursuant to the insurance code.
 1079         Section 14. Section 624.915, Florida Statutes, is repealed.
 1080         Section 15. Section 624.917, Florida Statutes, is created
 1081  to read:
 1082         624.917Healthy Florida program.—
 1083         (1) PROGRAM CREATION.—There is created Healthy Florida, a
 1084  health care program for lower income, uninsured adults who meet
 1085  the eligibility guidelines established under s. 624.91. The
 1086  Florida Healthy Kids Corporation shall administer the program
 1087  under its existing corporate governance and structure.
 1088         (2) DEFINITIONS.—As used in this section, the term:
 1089         (a) “Actuarially equivalent” means:
 1090         1. The aggregate value of the benefits included in health
 1091  benefits coverage is equal to the value of the benefits in the
 1092  child benchmark benefit plan as defined in s. 409.811; and
 1093         2. The benefits included in health benefits coverage are
 1094  substantially similar to the benefits included in the child
 1095  benchmark benefit plan, except that preventive health services
 1096  do not include dental services.
 1097         (b) “Agency” means the Agency for Health Care
 1098  Administration.
 1099         (c) “Applicant” means the individual who applies for
 1100  determination of eligibility for health benefits coverage under
 1101  this section.
 1102         (d) “Child benchmark benefit plan” means the form and level
 1103  of health benefits coverage established in s. 409.815.
 1104         (e) “Child” means any person younger than 19 years of age.
 1105         (f) “Corporation” means the Florida Healthy Kids
 1106  Corporation.
 1107         (g) “Enrollee” means an individual who has been determined
 1108  eligible for and is receiving coverage under this section.
 1109         (h) “Florida Kidcare program” or “Kidcare program,” means
 1110  the health benefits program administered through ss. 409.810
 1111  409.821.
 1112         (i)“Health benefits coverage” means protection that
 1113  provides payment of benefits for covered health care services or
 1114  that otherwise provides, either directly or through arrangements
 1115  with other persons, covered health care services on a prepaid
 1116  per capita basis or on a prepaid aggregate fixed-sum basis.
 1117         (j) “Healthy Florida” means the program created by this
 1118  section which is administered by the Florida Healthy Kids
 1119  Corporation.
 1120         (k) “Healthy Kids” means the Florida Kidcare program
 1121  component created under s. 624.91 for children who are 5 through
 1122  18 years of age.
 1123         (l) “Household income” means the group or the individual
 1124  whose income is considered in determining eligibility for the
 1125  Healthy Florida program. The term “household” has the same
 1126  meaning as provided in s. 36B(d)(2) of the Internal Revenue Code
 1127  of 1986.
 1128         (m) “Medicaid” means the medical assistance program
 1129  authorized by Title XIX of the Social Security Act, and
 1130  regulations thereunder, and ss. 409.901-409.920, as administered
 1131  in this state by the agency.
 1132         (n) “Medically necessary” means the use of any medical
 1133  treatment, service, equipment, or supply necessary to palliate
 1134  the effects of a terminal condition, or to prevent, diagnose,
 1135  correct, cure, alleviate, or preclude deterioration of a
 1136  condition that threatens life, causes pain or suffering, or
 1137  results in illness or infirmity and which is:
 1138         1. Consistent with the symptom, diagnosis, and treatment of
 1139  the enrollee’s condition;
 1140         2. Provided in accordance with generally accepted standards
 1141  of medical practice;
 1142         3. Not primarily intended for the convenience of the
 1143  enrollee, the enrollee’s family, or the health care provider;
 1144         4. The most appropriate level of supply or service for the
 1145  diagnosis and treatment of the enrollee’s condition; and
 1146         5. Approved by the appropriate medical body or health care
 1147  specialty involved as effective, appropriate, and essential for
 1148  the care and treatment of the enrollee’s condition.
 1149         (o)“Modified adjusted gross income” means the individual
 1150  or household’s annual adjusted gross income as defined in s.
 1151  36B(d)(2) of the Internal Revenue Code of 1986 which is used to
 1152  determine eligibility under the Florida Kidcare program.
 1153         (p) “Patient Protection and Affordable Care Act” or “Act”
 1154  means the federal law enacted as Pub. L. No. 111-148, as further
 1155  amended by the federal Health Care and Education Reconciliation
 1156  Act of 2010, Pub. L. No. 111-152, and any amendments,
 1157  regulations or guidance thereunder, issued under those acts.
 1158         (q) “Premium” means the entire cost of a health insurance
 1159  plan, including the administration fee or the risk assumption
 1160  charge.
 1161         (r) “Premium assistance payment” means the monthly
 1162  consideration paid by the agency per enrollee in the Florida
 1163  Kidcare program towards health insurance premiums.
 1164         (s) “Qualified alien” means an alien as defined in 8 U.S.C.
 1165  s. 1641(b) and (c).
 1166         (t) “Resident” means a United States citizen or qualified
 1167  alien who is domiciled in this state.
 1168         (3) ELIGIBILITY.—To be eligible and remain eligible for the
 1169  Healthy Florida program, an individual must be a resident of
 1170  this state and meet the following additional criteria:
 1171         (a) Be identified as newly eligible, as defined in s.
 1172  1902(a)(10)(A)(i)(VIII) of the Social Security Act or s. 2001 of
 1173  the federal Patient Protection and Affordable Care Act, and as
 1174  may be further defined by federal regulation.
 1175         (b) Maintain eligibility with the corporation and meet all
 1176  renewal requirements as established by the corporation.
 1177         (c) Renew eligibility on at least an annual basis.
 1178         (4) ENROLLMENT.—The corporation may begin the enrollment of
 1179  applicants in the Healthy Florida program on October 1, 2013.
 1180  Enrollment may occur directly, through the services of a third
 1181  party administrator, referrals from the Department of Children
 1182  and Families, and the exchange as defined by the federal Patient
 1183  Protection and Affordable Care Act. As an enrollee disenrolls,
 1184  the corporation must also provide the enrollee with information
 1185  about other insurance affordability programs and electronically
 1186  refer the enrollee to the exchange or other programs, as
 1187  appropriate. The earliest coverage effective date under the
 1188  program shall be January 1, 2014.
 1189         (5) DELIVERY OF SERVICES.—The corporation shall contract
 1190  with authorized insurers licensed under chapter 627 and managed
 1191  care organizations under chapter 641 which meet standards
 1192  established by the corporation to provide comprehensive health
 1193  care services to enrollees who qualify for services under this
 1194  section. The corporation may contract for such services on a
 1195  statewide or regional basis.
 1196         (a) The corporation shall establish access and network
 1197  standards for such contracts and ensure that contracted
 1198  providers have sufficient providers to meet enrollee needs.
 1199  Quality standards must be developed by the corporation, specific
 1200  to the adult population, which take into consideration
 1201  recommendations from the National Committee on Quality
 1202  Assurance, stakeholders, and other existing performance
 1203  indicators from both public and commercial populations.
 1204         (b) The corporation shall provide an enrollee a choice of
 1205  plans. The corporation may select a plan if no selection has
 1206  been received before the coverage start date. Once enrolled, an
 1207  enrollee has an initial 90-day, free-look period before a lock
 1208  in period of not more than 12 months is applied. Exceptions to
 1209  the lock-in period must be offered to an enrollee for reasons
 1210  based upon good cause or qualifying events.
 1211         (c) The corporation may consider contracts that provide
 1212  family plans that would allow members from multiple state and
 1213  federally funded programs to remain together under the same
 1214  plan.
 1215         (d) All contracts must meet the medical loss ratio
 1216  requirements under s. 624.91.
 1217         (6) BENEFITS.—The corporation shall establish a benefits
 1218  package that is actuarially equivalent to the benchmark benefit
 1219  plan offered under s. 409.815(2), excluding dental, and meets
 1220  the alternative benefits package requirements under s. 1937 of
 1221  the Social Security Act. Benefits must be offered as an
 1222  integrated, single package.
 1223         (a) In addition to benchmark benefits, health reimbursement
 1224  accounts or a comparable health savings account for each
 1225  enrollee must be established through the corporation or the
 1226  contracts managed by the corporation. Enrollees must be rewarded
 1227  for healthy behaviors, wellness program adherence, and other
 1228  activities established by the corporation which demonstrate
 1229  compliance with preventive care or disease management
 1230  guidelines. Funds deposited into these accounts may be used to
 1231  pay cost-sharing obligations or to purchase over-the-counter
 1232  health-related items to the extent allowed under federal law or
 1233  regulation.
 1234         (b) Enhanced services may be offered if the cost of such
 1235  additional services provides savings to the overall plan.
 1236         (c) The corporation shall establish a process for the
 1237  payment of wrap-around services not covered by the benchmark
 1238  benefit plan through a separate subcapitation process to its
 1239  contracted providers if it is determined that such services are
 1240  required by federal law. Such services would be covered when
 1241  deemed medically necessary on an individual basis. The
 1242  subcapitation pool is subject to a separate reconciliation
 1243  process under the medical loss ratio provisions in s. 624.91.
 1244         (d) A prior authorization process and other utilization
 1245  controls may be established by the plan for any benefit if
 1246  approved by the corporation.
 1247         (7) COST SHARING.—The corporation may collect premiums and
 1248  copayments from enrollees in accordance with federal law.
 1249  Amounts to be collected for the Healthy Florida program must be
 1250  established annually in the General Appropriations Act.
 1251         (a) Payment of a monthly premium may be required before the
 1252  establishment of an enrollee’s coverage start date and to retain
 1253  monthly coverage.
 1254         (b) An enrollee may be required to make copayments as a
 1255  condition of receiving a health care service.
 1256         (c) A provider is responsible for the collection of point
 1257  of-service cost-sharing obligations. The enrollee’s cost-sharing
 1258  contribution is considered part of the provider’s total
 1259  reimbursement. Failure to collect an enrollee’s cost sharing
 1260  reduces the provider’s share of the reimbursement.
 1261         (8) PROGRAM MANAGEMENT.—The corporation is responsible for
 1262  the oversight of the Healthy Florida program. The agency shall
 1263  seek a state plan amendment or other appropriate federal
 1264  approval to implement the Healthy Florida program. The agency
 1265  shall consult with the corporation in the amendment’s
 1266  development and submit by June 14, 2013, the state plan
 1267  amendment to the federal Department of Health and Human
 1268  Services. The agency shall contract with the corporation for the
 1269  administration of the Healthy Florida program and for the timely
 1270  release of federal and state funds. The agency retains its
 1271  authorities as provided in ss. 409.902 and 409.963.
 1272         (a) The corporation shall establish a process by which
 1273  grievances can be resolved and Healthy Florida recipients can be
 1274  informed of their rights under the Medicaid Fair Hearing
 1275  Process, as appropriate, or any alternative resolution process
 1276  adopted by the corporation.
 1277         (b) The corporation shall establish a program integrity
 1278  process to ensure compliance with program guidelines. At a
 1279  minimum, the corporation shall withhold benefits from an
 1280  applicant or enrollee if the corporation obtains evidence that
 1281  the applicant or enrollee is no longer eligible, submitted
 1282  incorrect or fraudulent information in order to establish
 1283  eligibility, or failed to provide verification of eligibility.
 1284  The corporation shall notify the applicant or enrollee that,
 1285  because of such evidence, program benefits must be withheld
 1286  unless the applicant or enrollee contacts a designated
 1287  representative of the corporation by a specified date, which
 1288  must be within 10 working days after the date of notice, to
 1289  discuss and resolve the matter. The corporation shall make every
 1290  effort to resolve the matter within a timeframe that will not
 1291  cause benefits to be withheld from an eligible enrollee. The
 1292  following individuals may be subject to specific prosecution in
 1293  accordance with s. 414.39:
 1294         1. An applicant who obtains or attempts to obtain benefits
 1295  for a potential enrollee under the Healthy Florida program when
 1296  the applicant knows or should have known that the potential
 1297  enrollee does not qualify for the Healthy Florida program.
 1298         2. An individual who assists an applicant in obtaining or
 1299  attempting to obtain benefits for a potential enrollee under the
 1300  Healthy Florida program when the individual knows or should have
 1301  known that the potential enrollee does not qualify for the
 1302  Healthy Florida program.
 1303         (9) APPLICABILITY OF LAWS RELATING TO MEDICAID.—The
 1304  provisions of ss. 409.902, 409.9128, and 409.920 apply to the
 1305  administration of the Healthy Florida program.
 1306         (10) PROGRAM EVALUATION.—The corporation shall collect both
 1307  eligibility and enrollment data from program applicants and
 1308  enrollees as well as encounter and utilization data from all
 1309  contracted entities during the program term. The corporation
 1310  shall submit monthly enrollment reports to the President of the
 1311  Senate, the Speaker of the House of Representative, and the
 1312  Minority Leaders of the Senate and the House of Representatives.
 1313  The corporation shall submit an interim independent evaluation
 1314  of the Healthy Florida program to the presiding officers no
 1315  later than July 1, 2015, with annual evaluations due July 1 each
 1316  year thereafter. The evaluations must address, at a minimum,
 1317  application and enrollment trends and issues, utilization and
 1318  cost data, and customer satisfaction.
 1319         (11) PROGRAM EXPIRATION.—The Healthy Florida program shall
 1320  expire at the end of the state fiscal year in which any of these
 1321  conditions occur, whichever occurs first:
 1322         (a) The federal match contribution falls below 90 percent.
 1323         (b) The federal match contribution falls below the
 1324  increased FMAP for medical assistance for newly eligible
 1325  mandatory individuals as specified in the federal Patient
 1326  Protection and Affordable Care Act, Pub. L. No. 111-148, as
 1327  amended by the federal Health Care and Education Reconciliation
 1328  Act of 2010, Pub. L. No. 111-152.
 1329         (c) The federal match for the Healthy Florida program and
 1330  the Medicaid program are blended under federal law or regulation
 1331  in such a way that causes the overall federal contribution to
 1332  diminish when compared to separate, nonblended federal
 1333  contributions.
 1334         Section 16. The Florida Healthy Kids Corporation may make
 1335  changes to comply with the objections of the federal Department
 1336  of Health and Human Services to gain approval of the Healthy
 1337  Florida program in compliance with the federal Patient
 1338  Protection and Affordable Care Act, upon giving notice to the
 1339  Senate and the House of Representatives of the proposed changes.
 1340  If there is a conflict between a provision in this section and
 1341  the federal Patient Protection and Affordable Care Act, Pub. L.
 1342  No. 111-148, as amended by the federal Health Care and Education
 1343  Reconciliation Act of 2010, Pub. L. No. 111-152, the provision
 1344  must be interpreted and applied so as to comply with the
 1345  requirement of the federal law.
 1346         Section 17. This act shall take effect upon becoming a law.