Florida Senate - 2013                             CS for SB 1816
       
       
       
       By the Committees on Appropriations; and Appropriations
       
       
       
       
       576-04984-13                                          20131816c1
    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, managed care
   51         organizations, and provider service networks;
   52         encouraging the corporation to contract with insurers
   53         and managed care organizations that participate in
   54         more than one insurance affordability program under
   55         certain circumstances; requiring the corporation to
   56         establish a benefits package and a process for payment
   57         of services; authorizing the corporation to collect
   58         premiums and copayments; requiring the corporation to
   59         oversee the Healthy Florida program and to establish a
   60         grievance process and integrity process; providing
   61         applicability of certain state laws for administration
   62         of the Healthy Florida program; requiring the
   63         corporation to collect certain data and to submit
   64         enrollment reports and interim independent evaluations
   65         to the Legislature; providing for expiration of the
   66         program; providing an implementation and
   67         interpretation clause; amending s. 627.6474, F.S.;
   68         prohibiting a contract between a health insurer and a
   69         dentist from requiring the dentist to provide services
   70         at a fee set by the insurer under certain
   71         circumstances; providing that covered services are
   72         those services listed as a benefit that the insured is
   73         entitled to receive under a contract; prohibiting an
   74         insurer from providing merely de minimis reimbursement
   75         or coverage; requiring that fees for covered services
   76         be set in good faith and not be nominal; prohibiting a
   77         health insurer from requiring as a condition of a
   78         contract that a dentist participate in a discount
   79         medical plan; amending s. 636.035, F.S.; prohibiting a
   80         contract between a prepaid limited health service
   81         organization and a dentist from requiring the dentist
   82         to provide services at a fee set by the organization
   83         under certain circumstances; providing that covered
   84         services are those services listed as a benefit that a
   85         subscriber of a prepaid limited health service
   86         organization is entitled to receive under a contract;
   87         prohibiting a prepaid limited health service
   88         organization from providing merely de minimis
   89         reimbursement or coverage; requiring that fees for
   90         covered services be set in good faith and not be
   91         nominal; prohibiting the prepaid limited health
   92         service organization from requiring as a condition of
   93         a contract that a dentist participate in a discount
   94         medical plan; amending s. 641.315, F.S.; prohibiting a
   95         contract between a health maintenance organization and
   96         a dentist from requiring the dentist to provide
   97         services at a fee set by the organization under
   98         certain circumstances; providing that covered services
   99         are those services listed as a benefit that a
  100         subscriber of a health maintenance organization is
  101         entitled to receive under a contract; prohibiting a
  102         health maintenance organization from providing merely
  103         de minimis reimbursement or coverage; requiring that
  104         fees for covered services be set in good faith and not
  105         be nominal; prohibiting the health maintenance
  106         organization from requiring as a condition of a
  107         contract that a dentist participate in a discount
  108         medical plan; amending s. 766.1115, F.S.; revising a
  109         definition; requiring a contract with a governmental
  110         contractor for health care services to include a
  111         provision for a health care provider licensed under
  112         ch. 466, F.S., as an agent of the governmental
  113         contractor, to allow a patient or a parent or guardian
  114         of the patient to voluntarily contribute a fee to
  115         cover costs of dental laboratory work related to the
  116         services provided to the patient without forfeiting
  117         sovereign immunity; prohibiting the contribution from
  118         exceeding the actual amount of the dental laboratory
  119         charges; providing that the contribution complies with
  120         the requirements of s. 766.1115, F.S.; providing for
  121         applicability; providing appropriations; providing an
  122         effective date.
  123  
  124  Be It Enacted by the Legislature of the State of Florida:
  125  
  126         Section 1. Section 409.811, Florida Statutes, is amended to
  127  read:
  128         409.811 Definitions relating to Florida Kidcare Act.—As
  129  used in ss. 409.810-409.821, the term:
  130         (1) “Actuarially equivalent” means that:
  131         (a) The aggregate value of the benefits included in health
  132  benefits coverage is equal to the value of the benefits in the
  133  benchmark benefit plan; and
  134         (b) The benefits included in health benefits coverage are
  135  substantially similar to the benefits included in the benchmark
  136  benefit plan, except that preventive health services must be the
  137  same as in the benchmark benefit plan.
  138         (2) “Agency” means the Agency for Health Care
  139  Administration.
  140         (3) “Applicant” means a parent or guardian of a child or a
  141  child whose disability of nonage has been removed under chapter
  142  743, who applies for determination of eligibility for health
  143  benefits coverage under ss. 409.810-409.821.
  144         (4) “Child benchmark benefit plan” means the form and level
  145  of health benefits coverage established in s. 409.815.
  146         (5) “Child” means any person younger than under 19 years of
  147  age.
  148         (6) “Child with special health care needs” means a child
  149  whose serious or chronic physical or developmental condition
  150  requires extensive preventive and maintenance care beyond that
  151  required by typically healthy children. Health care utilization
  152  by such a child exceeds the statistically expected usage of the
  153  normal child adjusted for chronological age, and such a child
  154  often needs complex care requiring multiple providers,
  155  rehabilitation services, and specialized equipment in a number
  156  of different settings.
  157         (7) “Children’s Medical Services Network” or “network”
  158  means a statewide managed care service system as defined in s.
  159  391.021(1).
  160         (8) “CHIP” means the Children’s Health Insurance Program as
  161  authorized under Title XXI of the Social Security Act, and its
  162  regulations, ss. 409.810-409.820, and as administered in this
  163  state by the agency, the department, and the Florida Healthy
  164  Kids Corporation, as appropriate to their respective
  165  responsibilities.
  166         (9) “Combined eligibility notice” means an eligibility
  167  notice that informs an applicant, an enrollee, or multiple
  168  family members of a household, when feasible, of eligibility for
  169  each of the insurance affordability programs and enrollment into
  170  a program or exchange plan. A combined eligibility form must be
  171  issued by the last agency or department to make an eligibility,
  172  renewal or denial determination. The form must meet all of the
  173  federal and state law and regulatory requirements no later than
  174  January 1, 2014.
  175         (8) “Community rate” means a method used to develop
  176  premiums for a health insurance plan that spreads financial risk
  177  across a large population and allows adjustments only for age,
  178  gender, family composition, and geographic area.
  179         (10)(9) “Department” means the Department of Health.
  180         (11)(10) “Enrollee” means a child who has been determined
  181  eligible for and is receiving coverage under ss. 409.810
  182  409.821.
  183         (11) “Family” means the group or the individuals whose
  184  income is considered in determining eligibility for the Florida
  185  Kidcare program. The family includes a child with a parent or
  186  caretaker relative who resides in the same house or living unit
  187  or, in the case of a child whose disability of nonage has been
  188  removed under chapter 743, the child. The family may also
  189  include other individuals whose income and resources are
  190  considered in whole or in part in determining eligibility of the
  191  child.
  192         (12) “Family income” means cash received at periodic
  193  intervals from any source, such as wages, benefits,
  194  contributions, or rental property. Income also may include any
  195  money that would have been counted as income under the Aid to
  196  Families with Dependent Children (AFDC) state plan in effect
  197  prior to August 22, 1996.
  198         (12)(13) “Florida Kidcare program,” “Kidcare program,” or
  199  “program” means the health benefits program administered through
  200  ss. 409.810-409.821.
  201         (13)(14) “Guarantee issue” means that health benefits
  202  coverage must be offered to an individual regardless of the
  203  individual’s health status, preexisting condition, or claims
  204  history.
  205         (14)(15) “Health benefits coverage” means protection that
  206  provides payment of benefits for covered health care services or
  207  that otherwise provides, either directly or through arrangements
  208  with other persons, covered health care services on a prepaid
  209  per capita basis or on a prepaid aggregate fixed-sum basis.
  210         (15)(16) “Health insurance plan” means health benefits
  211  coverage under the following:
  212         (a) A health plan offered by any certified health
  213  maintenance organization or authorized health insurer, except a
  214  plan that is limited to the following: a limited benefit,
  215  specified disease, or specified accident; hospital indemnity;
  216  accident only; limited benefit convalescent care; Medicare
  217  supplement; credit disability; dental; vision; long-term care;
  218  disability income; coverage issued as a supplement to another
  219  health plan; workers’ compensation liability or other insurance;
  220  or motor vehicle medical payment only; or
  221         (b) An employee welfare benefit plan that includes health
  222  benefits established under the Employee Retirement Income
  223  Security Act of 1974, as amended.
  224         (16) “Household income” means the group or the individual
  225  whose income is considered in determining eligibility for the
  226  Florida Kidcare program. The term “household” has the same
  227  meaning as provided in s. 36B(d)(2) of the Internal Revenue Code
  228  of 1986.
  229         (17) “Medicaid” means the medical assistance program
  230  authorized by Title XIX of the Social Security Act, and
  231  regulations thereunder, and ss. 409.901-409.920, as administered
  232  in this state by the agency.
  233         (18) “Medically necessary” means the use of any medical
  234  treatment, service, equipment, or supply necessary to palliate
  235  the effects of a terminal condition, or to prevent, diagnose,
  236  correct, cure, alleviate, or preclude deterioration of a
  237  condition that threatens life, causes pain or suffering, or
  238  results in illness or infirmity and which is:
  239         (a) Consistent with the symptom, diagnosis, and treatment
  240  of the enrollee’s condition;
  241         (b) Provided in accordance with generally accepted
  242  standards of medical practice;
  243         (c) Not primarily intended for the convenience of the
  244  enrollee, the enrollee’s family, or the health care provider;
  245         (d) The most appropriate level of supply or service for the
  246  diagnosis and treatment of the enrollee’s condition; and
  247         (e) Approved by the appropriate medical body or health care
  248  specialty involved as effective, appropriate, and essential for
  249  the care and treatment of the enrollee’s condition.
  250         (19) “Medikids” means a component of the Florida Kidcare
  251  program of medical assistance authorized by Title XXI of the
  252  Social Security Act, and regulations thereunder, and s.
  253  409.8132, as administered in the state by the agency.
  254         (20)“Modified adjusted gross income” means the
  255  individual’s or household’s annual adjusted gross income as
  256  defined in s. 36B(d)(2) of the Internal Revenue Code of 1986
  257  which is used to determine eligibility under the Florida Kidcare
  258  program.
  259         (21) “Patient Protection and Affordable Care Act” or “Act”
  260  means the federal law enacted as Pub. L. No. 111-148, as further
  261  amended by the federal Health Care and Education Reconciliation
  262  Act of 2010, Pub. L. No. 111-152, and any amendments,
  263  regulations, or guidance issued under those acts.
  264         (22)(20) “Preexisting condition exclusion” means, with
  265  respect to coverage, a limitation or exclusion of benefits
  266  relating to a condition based on the fact that the condition was
  267  present before the date of enrollment for such coverage, whether
  268  or not any medical advice, diagnosis, care, or treatment was
  269  recommended or received before such date.
  270         (23)(21) “Premium” means the entire cost of a health
  271  insurance plan, including the administration fee or the risk
  272  assumption charge.
  273         (24)(22) “Premium assistance payment” means the monthly
  274  consideration paid by the agency per enrollee in the Florida
  275  Kidcare program towards health insurance premiums.
  276         (25)(23) “Qualified alien” means an alien as defined in 8
  277  U.S.C. s. 1641 (b) and (c) s. 431 of the Personal Responsibility
  278  and Work Opportunity Reconciliation Act of 1996, as amended,
  279  Pub. L. No. 104-193.
  280         (26)(24) “Resident” means a United States citizen, or
  281  qualified alien, who is domiciled in this state.
  282         (27)(25) “Rural county” means a county having a population
  283  density of less than 100 persons per square mile, or a county
  284  defined by the most recent United States Census as rural, in
  285  which there is no prepaid health plan participating in the
  286  Medicaid program as of July 1, 1998.
  287         (26) “Substantially similar” means that, with respect to
  288  additional services as defined in s. 2103(c)(2) of Title XXI of
  289  the Social Security Act, these services must have an actuarial
  290  value equal to at least 75 percent of the actuarial value of the
  291  coverage for that service in the benchmark benefit plan and,
  292  with respect to the basic services as defined in s. 2103(c)(1)
  293  of Title XXI of the Social Security Act, these services must be
  294  the same as the services in the benchmark benefit plan.
  295         Section 2. Section 409.813, Florida Statutes, is amended to
  296  read:
  297         409.813 Health benefits coverage; program components;
  298  entitlement and nonentitlement.—
  299         (1) The Florida Kidcare program includes health benefits
  300  coverage provided to children through the following program
  301  components, which shall be marketed as the Florida Kidcare
  302  program:
  303         (a) Medicaid;
  304         (b) Medikids as created in s. 409.8132;
  305         (c) The Florida Healthy Kids Corporation as created in s.
  306  624.91; and
  307         (d) Employer-sponsored group health insurance plans
  308  approved under ss. 409.810-409.821; and
  309         (d)(e) The Children’s Medical Services network established
  310  in chapter 391.
  311         (2) Except for Title XIX-funded Florida Kidcare program
  312  coverage under the Medicaid program, coverage under the Florida
  313  Kidcare program is not an entitlement. No cause of action shall
  314  arise against the state, the department, the Department of
  315  Children and Families Family Services, or the agency, or the
  316  Florida Healthy Kids Corporation for failure to make health
  317  services available to any person under ss. 409.810-409.821.
  318         Section 3. Subsections (6) and (7) of section 409.8132,
  319  Florida Statutes, are amended to read:
  320         409.8132 Medikids program component.—
  321         (6) ELIGIBILITY.—
  322         (a) A child who has attained the age of 1 year but who is
  323  under the age of 5 years is eligible to enroll in the Medikids
  324  program component of the Florida Kidcare program, if the child
  325  is a member of a family that has a family income which exceeds
  326  the Medicaid applicable income level as specified in s. 409.903,
  327  but which is equal to or below 200 percent of the current
  328  federal poverty level. In determining the eligibility of such a
  329  child, an assets test is not required. A child who is eligible
  330  for Medikids may elect to enroll in Florida Healthy Kids
  331  coverage or employer-sponsored group coverage. However, a child
  332  who is eligible for Medikids may participate in the Florida
  333  Healthy Kids program only if the child has a sibling
  334  participating in the Florida Healthy Kids program and the
  335  child’s county of residence permits such enrollment.
  336         (b) The provisions of s. 409.814 apply to the Medikids
  337  program.
  338         (7) ENROLLMENT.—Enrollment in the Medikids program
  339  component may occur at any time throughout the year. A child may
  340  not receive services under the Medikids program until the child
  341  is enrolled in a managed care plan or MediPass. Once determined
  342  eligible, an applicant may receive choice counseling and select
  343  a managed care plan or MediPass. The agency may initiate
  344  mandatory assignment for a Medikids applicant who has not chosen
  345  a managed care plan or MediPass provider after the applicant’s
  346  voluntary choice period ends. An applicant may select MediPass
  347  under the Medikids program component only in counties that have
  348  fewer than two managed care plans available to serve Medicaid
  349  recipients and only if the federal Health Care Financing
  350  Administration determines that MediPass constitutes “health
  351  insurance coverage” as defined in Title XXI of the Social
  352  Security Act.
  353         Section 4. Subsection (2) of section 409.8134, Florida
  354  Statutes, is amended to read:
  355         409.8134 Program expenditure ceiling; enrollment.—
  356         (2) The Florida Kidcare program may conduct enrollment
  357  continuously throughout the year.
  358         (a) Children eligible for coverage under the Title XXI
  359  funded Florida Kidcare program shall be enrolled on a first
  360  come, first-served basis using the date the enrollment
  361  application is received. Enrollment shall immediately cease when
  362  the expenditure ceiling is reached. Year-round enrollment shall
  363  only be held if the Social Services Estimating Conference
  364  determines that sufficient federal and state funds will be
  365  available to finance the increased enrollment.
  366         (b) The application for the Florida Kidcare program is
  367  valid for a period of 120 days after the date it was received.
  368  At the end of the 120-day period, if the applicant has not been
  369  enrolled in the program, the application is invalid and the
  370  applicant shall be notified of the action. The applicant may
  371  reactivate the application after notification of the action
  372  taken by the program.
  373         (c) Except for the Medicaid program, whenever the Social
  374  Services Estimating Conference determines that there are
  375  presently, or will be by the end of the current fiscal year,
  376  insufficient funds to finance the current or projected
  377  enrollment in the Florida Kidcare program, all additional
  378  enrollment must cease and additional enrollment may not resume
  379  until sufficient funds are available to finance such enrollment.
  380         Section 5. Section 409.814, Florida Statutes, is amended to
  381  read:
  382         409.814 Eligibility.—A child who has not reached 19 years
  383  of age whose household family income is equal to or below 200
  384  percent of the federal poverty level is eligible for the Florida
  385  Kidcare program as provided in this section. If an enrolled
  386  individual is determined to be ineligible for coverage, he or
  387  she must be immediately disenrolled from the respective Florida
  388  Kidcare program component and referred to another insurance
  389  affordability program, if appropriate, through a combined
  390  eligibility notice.
  391         (1) A child who is eligible for Medicaid coverage under s.
  392  409.903 or s. 409.904 must be offered the opportunity to enroll
  393  enrolled in Medicaid and is not eligible to receive health
  394  benefits under any other health benefits coverage authorized
  395  under the Florida Kidcare program. A child who is eligible for
  396  Medicaid and opts to enroll in CHIP may disenroll from CHIP at
  397  any time and transition to Medicaid. This transition must occur
  398  without any break in coverage.
  399         (2) A child who is not eligible for Medicaid, but who is
  400  eligible for the Florida Kidcare program, may obtain health
  401  benefits coverage under any of the other components listed in s.
  402  409.813 if such coverage is approved and available in the county
  403  in which the child resides.
  404         (3) A Title XXI-funded child who is eligible for the
  405  Florida Kidcare program who is a child with special health care
  406  needs, as determined through a medical or behavioral screening
  407  instrument, is eligible for health benefits coverage from and
  408  shall be assigned to and may opt out of the Children’s Medical
  409  Services Network.
  410         (4) The following children are not eligible to receive
  411  Title XXI-funded premium assistance for health benefits coverage
  412  under the Florida Kidcare program, except under Medicaid if the
  413  child would have been eligible for Medicaid under s. 409.903 or
  414  s. 409.904 as of June 1, 1997:
  415         (a) A child who is covered under a family member’s group
  416  health benefit plan or under other private or employer health
  417  insurance coverage, if the cost of the child’s participation is
  418  not greater than 5 percent of the household’s family’s income.
  419  If a child is otherwise eligible for a subsidy under the Florida
  420  Kidcare program and the cost of the child’s participation in the
  421  family member’s health insurance benefit plan is greater than 5
  422  percent of the household’s family’s income, the child may enroll
  423  in the appropriate subsidized Kidcare program.
  424         (b) A child who is seeking premium assistance for the
  425  Florida Kidcare program through employer-sponsored group
  426  coverage, if the child has been covered by the same employer’s
  427  group coverage during the 60 days before the family submitted an
  428  application for determination of eligibility under the program.
  429         (b)(c) A child who is an alien, but who does not meet the
  430  definition of qualified alien, in the United States.
  431         (c)(d) A child who is an inmate of a public institution or
  432  a patient in an institution for mental diseases.
  433         (d)(e) A child who is otherwise eligible for premium
  434  assistance for the Florida Kidcare program and has had his or
  435  her coverage in an employer-sponsored or private health benefit
  436  plan voluntarily canceled in the last 60 days, except those
  437  children whose coverage was voluntarily canceled for good cause,
  438  including, but not limited to, the following circumstances:
  439         1. The cost of participation in an employer-sponsored
  440  health benefit plan is greater than 5 percent of the household’s
  441  modified adjusted gross family’s income;
  442         2. The parent lost a job that provided an employer
  443  sponsored health benefit plan for children;
  444         3. The parent who had health benefits coverage for the
  445  child is deceased;
  446         4. The child has a medical condition that, without medical
  447  care, would cause serious disability, loss of function, or
  448  death;
  449         5. The employer of the parent canceled health benefits
  450  coverage for children;
  451         6. The child’s health benefits coverage ended because the
  452  child reached the maximum lifetime coverage amount;
  453         7. The child has exhausted coverage under a COBRA
  454  continuation provision;
  455         8. The health benefits coverage does not cover the child’s
  456  health care needs; or
  457         9. Domestic violence led to loss of coverage.
  458         (5) A child who is otherwise eligible for the Florida
  459  Kidcare program and who has a preexisting condition that
  460  prevents coverage under another insurance plan as described in
  461  paragraph (4)(a) which would have disqualified the child for the
  462  Florida Kidcare program if the child were able to enroll in the
  463  plan is eligible for Florida Kidcare coverage when enrollment is
  464  possible.
  465         (5)(6) A child whose household’s modified adjusted gross
  466  family income is above 200 percent of the federal poverty level
  467  or a child who is excluded under the provisions of subsection
  468  (4) may participate in the Florida Kidcare program as provided
  469  in s. 409.8132 or, if the child is ineligible for Medikids by
  470  reason of age, in the Florida Healthy Kids program, subject to
  471  the following:
  472         (a) The family is not eligible for premium assistance
  473  payments and must pay the full cost of the premium, including
  474  any administrative costs.
  475         (b) The board of directors of the Florida Healthy Kids
  476  Corporation may offer a reduced benefit package to these
  477  children in order to limit program costs for such families.
  478         (c) By August 15, 2013, the Florida Healthy Kids
  479  Corporation shall notify all current full-pay enrollees of the
  480  availability of the exchange and how to access other insurance
  481  affordability options. New applications for full-pay coverage
  482  may not be accepted after September 30, 2013.
  483         (6)(7) Once a child is enrolled in the Florida Kidcare
  484  program, the child is eligible for coverage for 12 months
  485  without a redetermination or reverification of eligibility, if
  486  the family continues to pay the applicable premium. Eligibility
  487  for program components funded through Title XXI of the Social
  488  Security Act terminates when a child attains the age of 19. A
  489  child who has not attained the age of 5 and who has been
  490  determined eligible for the Medicaid program is eligible for
  491  coverage for 12 months without a redetermination or
  492  reverification of eligibility.
  493         (7)(8) When determining or reviewing a child’s eligibility
  494  under the Florida Kidcare program, the applicant shall be
  495  provided with reasonable notice of changes in eligibility which
  496  may affect enrollment in one or more of the program components.
  497  If a transition from one program component to another is
  498  authorized, there shall be cooperation between the program
  499  components and the affected family which promotes continuity of
  500  health care coverage. Any authorized transfers must be managed
  501  within the program’s overall appropriated or authorized levels
  502  of funding. Each component of the program shall establish a
  503  reserve to ensure that transfers between components will be
  504  accomplished within current year appropriations. These reserves
  505  shall be reviewed by each convening of the Social Services
  506  Estimating Conference to determine the adequacy of such reserves
  507  to meet actual experience.
  508         (8)(9) In determining the eligibility of a child, an assets
  509  test is not required. Each applicant shall provide documentation
  510  during the application process and the redetermination process,
  511  including, but not limited to, the following:
  512         (a) Proof of household family income, which must be
  513  verified electronically to determine financial eligibility for
  514  the Florida Kidcare program. Written documentation, which may
  515  include wages and earnings statements or pay stubs, W-2 forms,
  516  or a copy of the applicant’s most recent federal income tax
  517  return, is required only if the electronic verification is not
  518  available or does not substantiate the applicant’s income. This
  519  paragraph expires December 31, 2013.
  520         (b)  A statement from all applicable, employed household
  521  family members that:
  522         1. Their employers do not sponsor health benefit plans for
  523  employees;
  524         2. The potential enrollee is not covered by an employer
  525  sponsored health benefit plan; or
  526         3. The potential enrollee is covered by an employer
  527  sponsored health benefit plan and the cost of the employer
  528  sponsored health benefit plan is more than 5 percent of the
  529  household’s modified adjusted gross family’s income.
  530         (c) To enroll in the Children’s Medical Services Network, a
  531  completed application, including a clinical screening.
  532         (d) Effective January 1, 2014, eligibility shall be
  533  determined through electronic matching using the federally
  534  managed data services hub and other resources. Written
  535  documentation from the applicant may be accepted if the
  536  electronic verification does not substantiate the applicant’s
  537  income or if there has been a change in circumstances.
  538         (9)(10) Subject to paragraph (4)(a), the Florida Kidcare
  539  program shall withhold benefits from an enrollee if the program
  540  obtains evidence that the enrollee is no longer eligible,
  541  submitted incorrect or fraudulent information in order to
  542  establish eligibility, or failed to provide verification of
  543  eligibility. The applicant or enrollee shall be notified that
  544  because of such evidence program benefits will be withheld
  545  unless the applicant or enrollee contacts a designated
  546  representative of the program by a specified date, which must be
  547  within 10 working days after the date of notice, to discuss and
  548  resolve the matter. The program shall make every effort to
  549  resolve the matter within a timeframe that will not cause
  550  benefits to be withheld from an eligible enrollee.
  551         (10)(11) The following individuals may be subject to
  552  prosecution in accordance with s. 414.39:
  553         (a) An applicant obtaining or attempting to obtain benefits
  554  for a potential enrollee under the Florida Kidcare program when
  555  the applicant knows or should have known the potential enrollee
  556  does not qualify for the Florida Kidcare program.
  557         (b) An individual who assists an applicant in obtaining or
  558  attempting to obtain benefits for a potential enrollee under the
  559  Florida Kidcare program when the individual knows or should have
  560  known the potential enrollee does not qualify for the Florida
  561  Kidcare program.
  562         Section 6. Paragraphs (g), (k), (q), and (w) of subsection
  563  (2) of section 409.815, Florida Statutes, are amended to read:
  564         409.815 Health benefits coverage; limitations.—
  565         (2) BENCHMARK BENEFITS.—In order for health benefits
  566  coverage to qualify for premium assistance payments for an
  567  eligible child under ss. 409.810-409.821, the health benefits
  568  coverage, except for coverage under Medicaid and Medikids, must
  569  include the following minimum benefits, as medically necessary.
  570         (g) Behavioral health services.—
  571         1. Mental health benefits include:
  572         a. Inpatient services, limited to 30 inpatient days per
  573  contract year for psychiatric admissions, or residential
  574  services in facilities licensed under s. 394.875(6) or s.
  575  395.003 in lieu of inpatient psychiatric admissions; however, a
  576  minimum of 10 of the 30 days shall be available only for
  577  inpatient psychiatric services if authorized by a physician; and
  578         b. Outpatient services, including outpatient visits for
  579  psychological or psychiatric evaluation, diagnosis, and
  580  treatment by a licensed mental health professional, limited to
  581  40 outpatient visits each contract year.
  582         2. Substance abuse services include:
  583         a. Inpatient services, limited to 7 inpatient days per
  584  contract year for medical detoxification only and 30 days of
  585  residential services; and
  586         b. Outpatient services, including evaluation, diagnosis,
  587  and treatment by a licensed practitioner, limited to 40
  588  outpatient visits per contract year.
  589  
  590  Effective October 1, 2009, Covered services include inpatient
  591  and outpatient services for mental and nervous disorders as
  592  defined in the most recent edition of the Diagnostic and
  593  Statistical Manual of Mental Disorders published by the American
  594  Psychiatric Association. Such benefits include psychological or
  595  psychiatric evaluation, diagnosis, and treatment by a licensed
  596  mental health professional and inpatient, outpatient, and
  597  residential treatment of substance abuse disorders. Any benefit
  598  limitations, including duration of services, number of visits,
  599  or number of days for hospitalization or residential services,
  600  shall not be any less favorable than those for physical
  601  illnesses generally. The program may also implement appropriate
  602  financial incentives, peer review, utilization requirements, and
  603  other methods used for the management of benefits provided for
  604  other medical conditions in order to reduce service costs and
  605  utilization without compromising quality of care.
  606         (k) Hospice services.—Covered services include reasonable
  607  and necessary services for palliation or management of an
  608  enrollee’s terminal illness, with the following exceptions:
  609         1. Once a family elects to receive hospice care for an
  610  enrollee, other services that treat the terminal condition will
  611  not be covered; and
  612         2. Services required for conditions totally unrelated to
  613  the terminal condition are covered to the extent that the
  614  services are included in this section.
  615         (q) Dental services.Effective October 1, 2009, Dental
  616  services shall be covered as required under federal law and may
  617  also include those dental benefits provided to children by the
  618  Florida Medicaid program under s. 409.906(6).
  619         (w) Reimbursement of federally qualified health centers and
  620  rural health clinics.Effective October 1, 2009, Payments for
  621  services provided to enrollees by federally qualified health
  622  centers and rural health clinics under this section shall be
  623  reimbursed using the Medicaid Prospective Payment System as
  624  provided for under s. 2107(e)(1)(D) of the Social Security Act.
  625  If such services are paid for by health insurers or health care
  626  providers under contract with the Florida Healthy Kids
  627  Corporation, such entities are responsible for this payment. The
  628  agency may seek any available federal grants to assist with this
  629  transition.
  630         Section 7. Section 409.816, Florida Statutes, is amended to
  631  read:
  632         409.816 Limitations on premiums and cost-sharing.—The
  633  following limitations on premiums and cost-sharing are
  634  established for the program.
  635         (1) Enrollees who receive coverage under the Medicaid
  636  program may not be required to pay:
  637         (a) Enrollment fees, premiums, or similar charges; or
  638         (b) Copayments, deductibles, coinsurance, or similar
  639  charges.
  640         (2) Enrollees in households that have families with a
  641  modified adjusted gross family income equal to or below 150
  642  percent of the federal poverty level, who are not receiving
  643  coverage under the Medicaid program, may not be required to pay:
  644         (a) Enrollment fees, premiums, or similar charges that
  645  exceed the maximum monthly charge permitted under s. 1916(b)(1)
  646  of the Social Security Act; or
  647         (b) Copayments, deductibles, coinsurance, or similar
  648  charges that exceed a nominal amount, as determined consistent
  649  with regulations referred to in s. 1916(a)(3) of the Social
  650  Security Act. However, such charges may not be imposed for
  651  preventive services, including well-baby and well-child care,
  652  age-appropriate immunizations, and routine hearing and vision
  653  screenings.
  654         (3) Enrollees in households that have families with a
  655  modified adjusted gross family income above 150 percent of the
  656  federal poverty level who are not receiving coverage under the
  657  Medicaid program or who are not eligible under s. 409.814(5) s.
  658  409.814(6) may be required to pay enrollment fees, premiums,
  659  copayments, deductibles, coinsurance, or similar charges on a
  660  sliding scale related to income, except that the total annual
  661  aggregate cost-sharing with respect to all children in a
  662  household family may not exceed 5 percent of the household’s
  663  modified adjusted family’s income. However, copayments,
  664  deductibles, coinsurance, or similar charges may not be imposed
  665  for preventive services, including well-baby and well-child
  666  care, age-appropriate immunizations, and routine hearing and
  667  vision screenings.
  668         Section 8. Section 409.817, Florida Statutes, is repealed.
  669         Section 9. Section 409.8175, Florida Statutes, is repealed.
  670         Section 10. Paragraph (c) of subsection (1) of section
  671  409.8177, Florida Statutes, is amended to read:
  672         409.8177 Program evaluation.—
  673         (1) The agency, in consultation with the Department of
  674  Health, the Department of Children and Families Family Services,
  675  and the Florida Healthy Kids Corporation, shall contract for an
  676  evaluation of the Florida Kidcare program and shall by January 1
  677  of each year submit to the Governor, the President of the
  678  Senate, and the Speaker of the House of Representatives a report
  679  of the program. In addition to the items specified under s. 2108
  680  of Title XXI of the Social Security Act, the report shall
  681  include an assessment of crowd-out and access to health care, as
  682  well as the following:
  683         (c) The characteristics of the children and families
  684  assisted under the program, including ages of the children,
  685  household family income, and access to or coverage by other
  686  health insurance prior to the program and after disenrollment
  687  from the program.
  688         Section 11. Section 409.818, Florida Statutes, is amended
  689  to read:
  690         409.818 Administration.—In order to implement ss. 409.810
  691  409.821, the following agencies shall have the following duties:
  692         (1) The Department of Children and Families Family Services
  693  shall:
  694         (a) Maintain Develop a simplified eligibility determination
  695  and renewal process application mail-in form to be used for
  696  determining the eligibility of children for coverage under the
  697  Florida Kidcare program, in consultation with the agency, the
  698  Department of Health, and the Florida Healthy Kids Corporation.
  699  The simplified eligibility process application form must include
  700  an item that provides an opportunity for the applicant to
  701  indicate whether coverage is being sought for a child with
  702  special health care needs. Families applying for children’s
  703  Medicaid coverage must also be able to use the simplified
  704  application process form without having to pay a premium.
  705         (b) Establish and maintain the eligibility determination
  706  process under the program except as specified in subsection (3),
  707  which includes the following: (5).
  708         1. The department shall directly, or through the services
  709  of a contracted third-party administrator, establish and
  710  maintain a process for determining eligibility of children for
  711  coverage under the program. The eligibility determination
  712  process must be used solely for determining eligibility of
  713  applicants for health benefits coverage under the program. The
  714  eligibility determination process must include an initial
  715  determination of eligibility for any coverage offered under the
  716  program, as well as a redetermination or reverification of
  717  eligibility each subsequent 6 months. Effective January 1, 1999,
  718  A child who has not attained the age of 5 and who has been
  719  determined eligible for the Medicaid program is eligible for
  720  coverage for 12 months without a redetermination or
  721  reverification of eligibility. In conducting an eligibility
  722  determination, the department shall determine if the child has
  723  special health care needs.
  724         2. The department, in consultation with the Agency for
  725  Health Care Administration and the Florida Healthy Kids
  726  Corporation, shall develop procedures for redetermining
  727  eligibility which enable applicants and enrollees a family to
  728  easily update any change in circumstances which could affect
  729  eligibility.
  730         3. The department may accept changes in a family’s status
  731  as reported to the department by the Florida Healthy Kids
  732  Corporation or the exchange without requiring a new application
  733  from the family. Redetermination of a child’s eligibility for
  734  Medicaid may not be linked to a child’s eligibility
  735  determination for other programs.
  736         4. The department, in consultation with the agency and the
  737  Florida Healthy Kids Corporation, shall develop a combined
  738  eligibility notice to inform applicants and enrollees of their
  739  application or renewal status, as appropriate. The content must
  740  be coordinated to meet all federal and state requirements under
  741  the federal Patient Protection and Affordable Care Act.
  742         (c) Inform program applicants about eligibility
  743  determinations and provide information about eligibility of
  744  applicants to the Florida Kidcare program and to insurers and
  745  their agents, through a centralized coordinating office.
  746         (d) Adopt rules necessary for conducting program
  747  eligibility functions.
  748         (2) The Department of Health shall:
  749         (a) Design an eligibility intake process for the program,
  750  in coordination with the Department of Children and Family
  751  Services, the agency, and the Florida Healthy Kids Corporation.
  752  The eligibility intake process may include local intake points
  753  that are determined by the Department of Health in coordination
  754  with the Department of Children and Family Services.
  755         (b) Chair a state-level Florida Kidcare coordinating
  756  council to review and make recommendations concerning the
  757  implementation and operation of the program. The coordinating
  758  council shall include representatives from the department, the
  759  Department of Children and Family Services, the agency, the
  760  Florida Healthy Kids Corporation, the Office of Insurance
  761  Regulation of the Financial Services Commission, local
  762  government, health insurers, health maintenance organizations,
  763  health care providers, families participating in the program,
  764  and organizations representing low-income families.
  765         (c) In consultation with the Florida Healthy Kids
  766  Corporation and the Department of Children and Family Services,
  767  establish a toll-free telephone line to assist families with
  768  questions about the program.
  769         (d) Adopt rules necessary to implement outreach activities.
  770         (2)(3) The Agency for Health Care Administration, under the
  771  authority granted in s. 409.914(1), shall:
  772         (a) Calculate the premium assistance payment necessary to
  773  comply with the premium and cost-sharing limitations specified
  774  in s. 409.816 and the federal Patient Protection and Affordable
  775  Care Act. The premium assistance payment for each enrollee in a
  776  health insurance plan participating in the Florida Healthy Kids
  777  Corporation shall equal the premium approved by the Florida
  778  Healthy Kids Corporation and the Office of Insurance Regulation
  779  of the Financial Services Commission pursuant to ss. 627.410 and
  780  641.31, less any enrollee’s share of the premium established
  781  within the limitations specified in s. 409.816. The premium
  782  assistance payment for each enrollee in an employer-sponsored
  783  health insurance plan approved under ss. 409.810-409.821 shall
  784  equal the premium for the plan adjusted for any benchmark
  785  benefit plan actuarial equivalent benefit rider approved by the
  786  Office of Insurance Regulation pursuant to ss. 627.410 and
  787  641.31, less any enrollee’s share of the premium established
  788  within the limitations specified in s. 409.816. In calculating
  789  the premium assistance payment levels for children with family
  790  coverage, the agency shall set the premium assistance payment
  791  levels for each child proportionately to the total cost of
  792  family coverage.
  793         (b) Make premium assistance payments to health insurance
  794  plans on a periodic basis. The agency may use its Medicaid
  795  fiscal agent or a contracted third-party administrator in making
  796  these payments. The agency may require health insurance plans
  797  that participate in the Medikids program or employer-sponsored
  798  group health insurance to collect premium payments from an
  799  enrollee’s family. Participating health insurance plans shall
  800  report premium payments collected on behalf of enrollees in the
  801  program to the agency in accordance with a schedule established
  802  by the agency.
  803         (c) Monitor compliance with quality assurance and access
  804  standards developed under s. 409.820 and in accordance with s.
  805  2103(f) of the Social Security Act, 42 U.S.C. s. 1397cc(f).
  806         (d) Establish a mechanism for investigating and resolving
  807  complaints and grievances from program applicants, enrollees,
  808  and health benefits coverage providers, and maintain a record of
  809  complaints and confirmed problems. In the case of a child who is
  810  enrolled in a managed care health maintenance organization, the
  811  agency must use the provisions of s. 641.511 to address
  812  grievance reporting and resolution requirements.
  813         (e) Approve health benefits coverage for participation in
  814  the program, following certification by the Office of Insurance
  815  Regulation under subsection (4).
  816         (e)(f) Adopt rules necessary for calculating premium
  817  assistance payment levels, making premium assistance payments,
  818  monitoring access and quality assurance standards and,
  819  investigating and resolving complaints and grievances,
  820  administering the Medikids program, and approving health
  821  benefits coverage.
  822         (f) Contract with the Florida Healthy Kids Corporation for
  823  the administration of the Florida Kidcare program and the
  824  Healthy Florida program and to facilitate the release of any
  825  federal and state funds.
  826  
  827  The agency is designated the lead state agency for Title XXI of
  828  the Social Security Act for purposes of receipt of federal
  829  funds, for reporting purposes, and for ensuring compliance with
  830  federal and state regulations and rules.
  831         (4) The Office of Insurance Regulation shall certify that
  832  health benefits coverage plans that seek to provide services
  833  under the Florida Kidcare program, except those offered through
  834  the Florida Healthy Kids Corporation or the Children’s Medical
  835  Services Network, meet, exceed, or are actuarially equivalent to
  836  the benchmark benefit plan and that health insurance plans will
  837  be offered at an approved rate. In determining actuarial
  838  equivalence of benefits coverage, the Office of Insurance
  839  Regulation and health insurance plans must comply with the
  840  requirements of s. 2103 of Title XXI of the Social Security Act.
  841  The department shall adopt rules necessary for certifying health
  842  benefits coverage plans.
  843         (3)(5) The Florida Healthy Kids Corporation shall retain
  844  its functions as authorized in s. 624.91, including eligibility
  845  determination for participation in the Healthy Kids program.
  846         (4)(6) The agency, the Department of Health, the Department
  847  of Children and Families Family Services, and the Florida
  848  Healthy Kids Corporation, and the Office of Insurance
  849  Regulation, after consultation with and approval of the Speaker
  850  of the House of Representatives and the President of the Senate,
  851  may are authorized to make program modifications that are
  852  necessary to overcome any objections of the United States
  853  Department of Health and Human Services to obtain approval of
  854  the state’s child health insurance plan under Title XXI of the
  855  Social Security Act.
  856         Section 12. Section 409.820, Florida Statutes, is amended
  857  to read:
  858         409.820 Quality assurance and access standards.—Except for
  859  Medicaid, the Department of Health, in consultation with the
  860  agency and the Florida Healthy Kids Corporation, shall develop a
  861  minimum set of pediatric and adolescent quality assurance and
  862  access standards for all program components. The standards must
  863  include a process for granting exceptions to specific
  864  requirements for quality assurance and access. Compliance with
  865  the standards shall be a condition of program participation by
  866  health benefits coverage providers. These standards shall comply
  867  with the provisions of this chapter and chapter 641 and Title
  868  XXI of the Social Security Act.
  869         Section 13. Section 624.91, Florida Statutes, is amended to
  870  read:
  871         624.91 The Florida Healthy Kids Corporation Act.—
  872         (1) SHORT TITLE.—This section may be cited as the “William
  873  G. ‘Doc’ Myers Healthy Kids Corporation Act.”
  874         (2) LEGISLATIVE INTENT.—
  875         (a) The Legislature finds that increased access to health
  876  care services could improve children’s health and reduce the
  877  incidence and costs of childhood illness and disabilities among
  878  children in this state. Many children do not have comprehensive,
  879  affordable health care services available. It is the intent of
  880  the Legislature that the Florida Healthy Kids Corporation
  881  provide comprehensive health insurance coverage to such
  882  children. The corporation is encouraged to cooperate with any
  883  existing health service programs funded by the public or the
  884  private sector.
  885         (b) It is the intent of the Legislature that the Florida
  886  Healthy Kids Corporation serve as one of several providers of
  887  services to children eligible for medical assistance under Title
  888  XXI of the Social Security Act. Although the corporation may
  889  serve other children, the Legislature intends the primary
  890  recipients of services provided through the corporation be
  891  school-age children with a family income below 200 percent of
  892  the federal poverty level, who do not qualify for Medicaid. It
  893  is also the intent of the Legislature that state and local
  894  government Florida Healthy Kids funds be used to continue
  895  coverage, subject to specific appropriations in the General
  896  Appropriations Act, to children not eligible for federal
  897  matching funds under Title XXI.
  898         (c) It is further the intent of the Legislature that the
  899  Florida Healthy Kids Corporation administer and manage services
  900  for Healthy Florida, a health care program for uninsured adults
  901  using a unique network of providers and contracts. Enrollees in
  902  Healthy Florida will receive comprehensive health care services
  903  from private, licensed health insurers who meet standards
  904  established by the corporation. It is further the intent of the
  905  Legislature that these enrollees participate in their own health
  906  care decisionmaking and contribute financially toward their
  907  medical costs. The Legislature intends to provide an alternative
  908  benefit package that includes a full range of services which
  909  meet the needs of residents of this state. As a new program, the
  910  Legislature shall also ensure that a comprehensive evaluation is
  911  conducted to measure the overall impact of the program and
  912  identify whether to renew the program after an initial 3-year
  913  term.
  914         (3) ELIGIBILITY FOR STATE-FUNDED ASSISTANCE.—Only the
  915  following individuals are eligible for state-funded assistance
  916  in paying premiums for Healthy Florida or Florida Healthy Kids
  917  premiums:
  918         (a) Residents of this state who are eligible for the
  919  Florida Kidcare program pursuant to s. 409.814 or the Healthy
  920  Florida pursuant to s. 624.917.
  921         (b) Notwithstanding s. 409.814, legal aliens who are
  922  enrolled in the Florida Healthy Kids program as of January 31,
  923  2004, who do not qualify for Title XXI federal funds because
  924  they are not qualified aliens as defined in s. 409.811.
  925         (4) NONENTITLEMENT.—Nothing in this section shall be
  926  construed as providing an individual with an entitlement to
  927  health care services. No cause of action shall arise against the
  928  state, the Florida Healthy Kids Corporation, or a unit of local
  929  government for failure to make health services available under
  930  this section.
  931         (5) CORPORATION AUTHORIZATION, DUTIES, POWERS.—
  932         (a) There is created the Florida Healthy Kids Corporation,
  933  a not-for-profit corporation.
  934         (b) The Florida Healthy Kids Corporation shall:
  935         1. Arrange for the collection of any family, individual, or
  936  local contributions, or employer payment or premium, in an
  937  amount to be determined by the board of directors, to provide
  938  for payment of premiums for comprehensive insurance coverage and
  939  for the actual or estimated administrative expenses.
  940         2. Arrange for the collection of any voluntary
  941  contributions to provide for payment of premiums for enrollees
  942  in the Florida Kidcare program or Healthy Florida premiums for
  943  children who are not eligible for medical assistance under Title
  944  XIX or Title XXI of the Social Security Act.
  945         3. Subject to the provisions of s. 409.8134, accept
  946  voluntary supplemental local match contributions that comply
  947  with the requirements of Title XXI of the Social Security Act
  948  for the purpose of providing additional Florida Kidcare coverage
  949  in contributing counties under Title XXI.
  950         4. Establish the administrative and accounting procedures
  951  for the operation of the corporation.
  952         5. Establish, with consultation from appropriate
  953  professional organizations, standards for preventive health
  954  services and providers and comprehensive insurance benefits
  955  appropriate to children, provided that such standards for rural
  956  areas shall not limit primary care providers to board-certified
  957  pediatricians.
  958         6. Determine eligibility for children seeking to
  959  participate in the Title XXI-funded components of the Florida
  960  Kidcare program consistent with the requirements specified in s.
  961  409.814, as well as the non-Title-XXI-eligible children as
  962  provided in subsection (3).
  963         7. Establish procedures under which providers of local
  964  match to, applicants to and participants in the program may have
  965  grievances reviewed by an impartial body and reported to the
  966  board of directors of the corporation.
  967         8. Establish participation criteria and, if appropriate,
  968  contract with an authorized insurer, health maintenance
  969  organization, or third-party administrator to provide
  970  administrative services to the corporation.
  971         9. Establish enrollment criteria that include penalties or
  972  waiting periods of 30 days for reinstatement of coverage upon
  973  voluntary cancellation for nonpayment of family and individual
  974  premiums under the programs.
  975         10. Contract with authorized insurers or any provider of
  976  health care services, meeting standards established by the
  977  corporation, for the provision of comprehensive insurance
  978  coverage to participants. Such standards shall include criteria
  979  under which the corporation may contract with more than one
  980  provider of health care services in program sites.
  981         a. Health plans shall be selected through a competitive bid
  982  process.
  983         b. The Florida Healthy Kids Corporation shall purchase
  984  goods and services in the most cost-effective manner consistent
  985  with the delivery of quality medical care. The maximum
  986  administrative cost for a Florida Healthy Kids Corporation
  987  contract shall be 15 percent. For all health care contracts, the
  988  minimum medical loss ratio is for a Florida Healthy Kids
  989  Corporation contract shall be 85 percent. The calculations must
  990  use uniform financial data collected from all plans in a format
  991  established by the corporation and shall be computed for each
  992  insurer on a statewide basis. Funds shall be classified in a
  993  manner consistent with 45 C.F.R. part 158 For dental contracts,
  994  the remaining compensation to be paid to the authorized insurer
  995  or provider under a Florida Healthy Kids Corporation contract
  996  shall be no less than an amount which is 85 percent of premium;
  997  to the extent any contract provision does not provide for this
  998  minimum compensation, this section shall prevail.
  999         c. The health plan selection criteria and scoring system,
 1000  and the scoring results, shall be available upon request for
 1001  inspection after the bids have been awarded.
 1002         11. Establish disenrollment criteria in the event local
 1003  matching funds are insufficient to cover enrollments.
 1004         12. Develop and implement a plan to publicize the Florida
 1005  Kidcare program and Healthy Florida, the eligibility
 1006  requirements of the programs program, and the procedures for
 1007  enrollment in the program and to maintain public awareness of
 1008  the corporation and the programs program.
 1009         13. Secure staff necessary to properly administer the
 1010  corporation. Staff costs shall be funded from state and local
 1011  matching funds and such other private or public funds as become
 1012  available. The board of directors shall determine the number of
 1013  staff members necessary to administer the corporation.
 1014         14. In consultation with the partner agencies, annually
 1015  provide a report on the Florida Kidcare program annually to the
 1016  Governor, the Chief Financial Officer, the Commissioner of
 1017  Education, the President of the Senate, the Speaker of the House
 1018  of Representatives, and the Minority Leaders of the Senate and
 1019  the House of Representatives.
 1020         15. Provide information on a quarterly basis to the
 1021  Legislature and the Governor which compares the costs and
 1022  utilization of the full-pay enrolled population and the Title
 1023  XXI-subsidized enrolled population in the Florida Kidcare
 1024  program. The information, at a minimum, must include:
 1025         a. The monthly enrollment and expenditure for full-pay
 1026  enrollees in the Medikids and Florida Healthy Kids programs
 1027  compared to the Title XXI-subsidized enrolled population; and
 1028         b. The costs and utilization by service of the full-pay
 1029  enrollees in the Medikids and Florida Healthy Kids programs and
 1030  the Title XXI-subsidized enrolled population. This subparagraph
 1031  is repealed effective December 31, 2013.
 1032  
 1033  By February 1, 2010, the Florida Healthy Kids Corporation shall
 1034  provide a study to the Legislature and the Governor on premium
 1035  impacts to the subsidized portion of the program from the
 1036  inclusion of the full-pay program, which shall include
 1037  recommendations on how to eliminate or mitigate possible impacts
 1038  to the subsidized premiums.
 1039         16. By August 15, 2013, the corporation shall notify all
 1040  current full-pay enrollees of the availability of the exchange,
 1041  as defined in the federal Patient Protection and Affordable Care
 1042  Act, and how to access other insurance affordability options.
 1043  New applications for full-pay coverage may not be accepted after
 1044  September 30, 2013.
 1045         17.16. Establish benefit packages that conform to the
 1046  provisions of the Florida Kidcare program, as created in ss.
 1047  409.810-409.821.
 1048         (c) Coverage under the corporation’s program is secondary
 1049  to any other available private coverage held by, or applicable
 1050  to, the participant child or family member. Insurers under
 1051  contract with the corporation are the payors of last resort and
 1052  must coordinate benefits with any other third-party payor that
 1053  may be liable for the participant’s medical care.
 1054         (d) The Florida Healthy Kids Corporation shall be a private
 1055  corporation not for profit, registered, incorporated, and
 1056  organized pursuant to chapter 617, and shall have all powers
 1057  necessary to carry out the purposes of this act, including, but
 1058  not limited to, the power to receive and accept grants, loans,
 1059  or advances of funds from any public or private agency and to
 1060  receive and accept from any source contributions of money,
 1061  property, labor, or any other thing of value, to be held, used,
 1062  and applied for the purposes of this act. The corporation and
 1063  any committees it forms shall act in compliance with part III of
 1064  chapter 112, and chapters 119 and 286.
 1065         (6) BOARD OF DIRECTORS AND MANAGEMENT SUPERVISION.—
 1066         (a) The Florida Healthy Kids Corporation shall operate
 1067  subject to the supervision and approval of a board of directors
 1068  chaired by an appointee designated by the Governor Chief
 1069  Financial Officer or her or his designee, and composed of 15 12
 1070  other members. The Senate shall confirm the designated chair and
 1071  other board appointees selected for 3-year terms of office as
 1072  follows:
 1073         1. The Secretary of Health Care Administration, or his or
 1074  her designee, as an ex-officio member.
 1075         2. The State Surgeon General, or his or her designee, as an
 1076  ex-officio member One member appointed by the Commissioner of
 1077  Education from the Office of School Health Programs of the
 1078  Florida Department of Education.
 1079         3. The Secretary of Children and Families, or his or her
 1080  designee, as an ex-officio member One member appointed by the
 1081  Chief Financial Officer from among three members nominated by
 1082  the Florida Pediatric Society.
 1083         4. Four members One member, appointed by the Governor, who
 1084  represents the Children’s Medical Services Program.
 1085         5. Two members One member appointed by the President of the
 1086  Senate Chief Financial Officer from among three members
 1087  nominated by the Florida Hospital Association.
 1088         6. Two members One member, appointed by the Senate Minority
 1089  Leader Governor, who is an expert on child health policy.
 1090         7. Two members One member, appointed by the Speaker of the
 1091  House of Representatives Chief Financial Officer, from among
 1092  three members nominated by the Florida Academy of Family
 1093  Physicians.
 1094         8. Two members One member, appointed by the House Minority
 1095  Leader Governor, who represents the state Medicaid program.
 1096         9. One member, appointed by the Chief Financial Officer,
 1097  from among three members nominated by the Florida Association of
 1098  Counties.
 1099         10. The State Health Officer or her or his designee.
 1100         11. The Secretary of Children and Family Services, or his
 1101  or her designee.
 1102         12. One member, appointed by the Governor, from among three
 1103  members nominated by the Florida Dental Association.
 1104         (b) A member of the board of directors may be removed by
 1105  the official who appointed that member. The board shall appoint
 1106  an executive director, who is responsible for other staff
 1107  authorized by the board.
 1108         (c) Board members are entitled to receive, from funds of
 1109  the corporation, reimbursement for per diem and travel expenses
 1110  as provided by s. 112.061.
 1111         (d) There shall be no liability on the part of, and no
 1112  cause of action shall arise against, any member of the board of
 1113  directors, or its employees or agents, for any action they take
 1114  in the performance of their powers and duties under this act.
 1115         (e) Board members who are serving on or before the date of
 1116  enactment of this act or similar legislation may remain until
 1117  July 1, 2013.
 1118         (f) An executive steering committee is created to provide
 1119  management direction and support and to make recommendations to
 1120  the board on the programs. The steering committee is composed of
 1121  the Secretary of Health Care Administration, the Secretary of
 1122  Children and Families, and the State Surgeon General. Committee
 1123  members may not delegate their membership or attendance.
 1124         (7) LICENSING NOT REQUIRED; FISCAL OPERATION.—
 1125         (a) The corporation shall not be deemed an insurer. The
 1126  officers, directors, and employees of the corporation shall not
 1127  be deemed to be agents of an insurer. Neither the corporation
 1128  nor any officer, director, or employee of the corporation is
 1129  subject to the licensing requirements of the insurance code or
 1130  the rules of the Department of Financial Services or Office of
 1131  Insurance Regulation. However, any marketing representative
 1132  utilized and compensated by the corporation must be appointed as
 1133  a representative of the insurers or health services providers
 1134  with which the corporation contracts.
 1135         (b) The board has complete fiscal control over the
 1136  corporation and is responsible for all corporate operations.
 1137         (c) The Department of Financial Services shall supervise
 1138  any liquidation or dissolution of the corporation and shall
 1139  have, with respect to such liquidation or dissolution, all power
 1140  granted to it pursuant to the insurance code.
 1141         Section 14. Section 624.915, Florida Statutes, is repealed.
 1142         Section 15. Section 624.917, Florida Statutes, is created
 1143  to read:
 1144         624.917Healthy Florida program.—
 1145         (1) PROGRAM CREATION.—There is created Healthy Florida, a
 1146  health care program for lower income, uninsured adults who meet
 1147  the eligibility guidelines established under s. 624.91. The
 1148  Florida Healthy Kids Corporation shall administer the program
 1149  under its existing corporate governance and structure.
 1150         (2) DEFINITIONS.—As used in this section, the term:
 1151         (a) “Actuarially equivalent” means:
 1152         1. The aggregate value of the benefits included in health
 1153  benefits coverage is equal to the value of the benefits in the
 1154  child benchmark benefit plan as defined in s. 409.811; and
 1155         2. The benefits included in health benefits coverage are
 1156  substantially similar to the benefits included in the child
 1157  benchmark benefit plan, except that preventive health services
 1158  do not include dental services.
 1159         (b) “Agency” means the Agency for Health Care
 1160  Administration.
 1161         (c) “Applicant” means the individual who applies for
 1162  determination of eligibility for health benefits coverage under
 1163  this section.
 1164         (d) “Child benchmark benefit plan” means the form and level
 1165  of health benefits coverage established in s. 409.815.
 1166         (e) “Child” means any person younger than 19 years of age.
 1167         (f) “Corporation” means the Florida Healthy Kids
 1168  Corporation.
 1169         (g) “Enrollee” means an individual who has been determined
 1170  eligible for and is receiving coverage under this section.
 1171         (h) “Florida Kidcare program” or “Kidcare program,” means
 1172  the health benefits program administered through ss. 409.810
 1173  409.821.
 1174         (i)“Health benefits coverage” means protection that
 1175  provides payment of benefits for covered health care services or
 1176  that otherwise provides, either directly or through arrangements
 1177  with other persons, covered health care services on a prepaid
 1178  per capita basis or on a prepaid aggregate fixed-sum basis.
 1179         (j) “Healthy Florida” means the program created by this
 1180  section which is administered by the Florida Healthy Kids
 1181  Corporation.
 1182         (k) “Healthy Kids” means the Florida Kidcare program
 1183  component created under s. 624.91 for children who are 5 through
 1184  18 years of age.
 1185         (l) “Household income” means the group or the individual
 1186  whose income is considered in determining eligibility for the
 1187  Healthy Florida program. The term “household” has the same
 1188  meaning as provided in s. 36B(d)(2) of the Internal Revenue Code
 1189  of 1986.
 1190         (m) “Medicaid” means the medical assistance program
 1191  authorized by Title XIX of the Social Security Act, and
 1192  regulations thereunder, and ss. 409.901-409.920, as administered
 1193  in this state by the agency.
 1194         (n) “Medically necessary” means the use of any medical
 1195  treatment, service, equipment, or supply necessary to palliate
 1196  the effects of a terminal condition, or to prevent, diagnose,
 1197  correct, cure, alleviate, or preclude deterioration of a
 1198  condition that threatens life, causes pain or suffering, or
 1199  results in illness or infirmity and which is:
 1200         1. Consistent with the symptom, diagnosis, and treatment of
 1201  the enrollee’s condition;
 1202         2. Provided in accordance with generally accepted standards
 1203  of medical practice;
 1204         3. Not primarily intended for the convenience of the
 1205  enrollee, the enrollee’s family, or the health care provider;
 1206         4. The most appropriate level of supply or service for the
 1207  diagnosis and treatment of the enrollee’s condition; and
 1208         5. Approved by the appropriate medical body or health care
 1209  specialty involved as effective, appropriate, and essential for
 1210  the care and treatment of the enrollee’s condition.
 1211         (o)“Modified adjusted gross income” means the individual
 1212  or household’s annual adjusted gross income as defined in s.
 1213  36B(d)(2) of the Internal Revenue Code of 1986 which is used to
 1214  determine eligibility under the Florida Kidcare program.
 1215         (p) “Patient Protection and Affordable Care Act” or “Act”
 1216  means the federal law enacted as Pub. L. No. 111-148, as further
 1217  amended by the federal Health Care and Education Reconciliation
 1218  Act of 2010, Pub. L. No. 111-152, and any amendments,
 1219  regulations or guidance thereunder, issued under those acts.
 1220         (q) “Premium” means the entire cost of a health insurance
 1221  plan, including the administration fee or the risk assumption
 1222  charge.
 1223         (r) “Premium assistance payment” means the monthly
 1224  consideration paid by the agency per enrollee in the Florida
 1225  Kidcare program towards health insurance premiums.
 1226         (s) “Qualified alien” means an alien as defined in 8 U.S.C.
 1227  s. 1641(b) and (c).
 1228         (t) “Resident” means a United States citizen or qualified
 1229  alien who is domiciled in this state.
 1230         (3) ELIGIBILITY.—To be eligible and remain eligible for the
 1231  Healthy Florida program, an individual must be a resident of
 1232  this state and meet the following additional criteria:
 1233         (a) Be identified as newly eligible, as defined in s.
 1234  1902(a)(10)(A)(i)(VIII) of the Social Security Act or s. 2001 of
 1235  the federal Patient Protection and Affordable Care Act, and as
 1236  may be further defined by federal regulation.
 1237         (b) Maintain eligibility with the corporation and meet all
 1238  renewal requirements as established by the corporation.
 1239         (c) Renew eligibility on at least an annual basis.
 1240         (4) ENROLLMENT.—The corporation may begin the enrollment of
 1241  applicants in the Healthy Florida program on October 1, 2013.
 1242  Enrollment may occur directly, through the services of a third
 1243  party administrator, referrals from the Department of Children
 1244  and Families, and the exchange as defined by the federal Patient
 1245  Protection and Affordable Care Act. As an enrollee disenrolls,
 1246  the corporation must also provide the enrollee with information
 1247  about other insurance affordability programs and electronically
 1248  refer the enrollee to the exchange or other programs, as
 1249  appropriate. The earliest coverage effective date under the
 1250  program shall be January 1, 2014.
 1251         (5) DELIVERY OF SERVICES.—The corporation shall contract
 1252  with authorized insurers licensed under chapter 627; managed
 1253  care organizations authorized under chapter 641; and provider
 1254  service networks authorized under ss. 409.912(4)(d) and
 1255  409.962(13) which are prepaid plans. These insurers, managed
 1256  care organizations, and provider service networks must meet
 1257  standards established by the corporation to provide
 1258  comprehensive health care services to enrollees who qualify for
 1259  services under this section. The corporation may contract for
 1260  such services on a statewide or regional basis. To encourage
 1261  continuity of care among enrollees who may transition across
 1262  multiple insurance affordability programs, the corporation is
 1263  encouraged to contract with those insurers and managed care
 1264  organizations that participate in more than one such program.
 1265         (a) The corporation shall establish access and network
 1266  standards for such contracts and ensure that contracted
 1267  providers have sufficient providers to meet enrollee needs.
 1268  Quality standards must be developed by the corporation, specific
 1269  to the adult population, which take into consideration
 1270  recommendations from the National Committee on Quality
 1271  Assurance, stakeholders, and other existing performance
 1272  indicators from both public and commercial populations. The
 1273  corporation and its contracted health plans shall develop
 1274  policies that minimize the disruption of enrollee medical homes
 1275  when enrollees transition between insurance affordability plans.
 1276         (b) The corporation shall provide an enrollee a choice of
 1277  plans. The corporation may select a plan if no selection has
 1278  been received before the coverage start date. Once enrolled, an
 1279  enrollee has an initial 90-day, free-look period before a lock
 1280  in period of not more than 12 months is applied. Exceptions to
 1281  the lock-in period must be offered to an enrollee for reasons
 1282  based upon good cause or qualifying events.
 1283         (c) The corporation may consider contracts that provide
 1284  family plans that would allow members from multiple state and
 1285  federally funded programs to remain together under the same
 1286  plan.
 1287         (d) All contracts must meet the medical loss ratio
 1288  requirements under s. 624.91.
 1289         (6) BENEFITS.—The corporation shall establish a benefits
 1290  package that is actuarially equivalent to the benchmark benefit
 1291  plan offered under s. 409.815(2), excluding dental, and meets
 1292  the alternative benefits package requirements under s. 1937 of
 1293  the Social Security Act. Benefits must be offered as an
 1294  integrated, single package.
 1295         (a) In addition to benchmark benefits, health reimbursement
 1296  accounts or a comparable health savings account for each
 1297  enrollee must be established through the corporation or the
 1298  contracts managed by the corporation. Enrollees must be rewarded
 1299  for healthy behaviors, wellness program adherence, and other
 1300  activities established by the corporation which demonstrate
 1301  compliance with preventive care or disease management
 1302  guidelines. Funds deposited into these accounts may be used to
 1303  pay cost-sharing obligations or to purchase over-the-counter
 1304  health-related items to the extent allowed under federal law or
 1305  regulation.
 1306         (b) Enhanced services may be offered if the cost of such
 1307  additional services provides savings to the overall plan.
 1308         (c) The corporation shall establish a process for the
 1309  payment of wrap-around services not covered by the benchmark
 1310  benefit plan through a separate subcapitation process to its
 1311  contracted providers if it is determined that such services are
 1312  required by federal law. Such services would be covered when
 1313  deemed medically necessary on an individual basis. The
 1314  subcapitation pool is subject to a separate reconciliation
 1315  process under the medical loss ratio provisions in s. 624.91.
 1316         (d) A prior authorization process and other utilization
 1317  controls may be established by the plan for any benefit if
 1318  approved by the corporation.
 1319         (7) COST SHARING.—The corporation may collect premiums and
 1320  copayments from enrollees in accordance with federal law.
 1321  Amounts to be collected for the Healthy Florida program must be
 1322  established annually in the General Appropriations Act.
 1323         (a) Payment of a monthly premium may be required before the
 1324  establishment of an enrollee’s coverage start date and to retain
 1325  monthly coverage.
 1326         (b) An enrollee who has a family income above the federal
 1327  poverty level may be required to make nominal copayments, in
 1328  accordance with federal rule, as a condition of receiving a
 1329  health care service.
 1330         (c) A provider is responsible for the collection of point
 1331  of-service cost-sharing obligations. The enrollee’s cost-sharing
 1332  contribution is considered part of the provider’s total
 1333  reimbursement. Failure to collect an enrollee’s cost sharing
 1334  reduces the provider’s share of the reimbursement.
 1335         (8) PROGRAM MANAGEMENT.—The corporation is responsible for
 1336  the oversight of the Healthy Florida program. The agency shall
 1337  seek a state plan amendment or other appropriate federal
 1338  approval to implement the Healthy Florida program. The agency
 1339  shall consult with the corporation in the amendment’s
 1340  development and submit by June 14, 2013, the state plan
 1341  amendment to the federal Department of Health and Human
 1342  Services. The agency shall contract with the corporation for the
 1343  administration of the Healthy Florida program and for the timely
 1344  release of federal and state funds. The agency retains its
 1345  authorities as provided in ss. 409.902 and 409.963.
 1346         (a) The corporation shall establish a process by which
 1347  grievances can be resolved and Healthy Florida recipients can be
 1348  informed of their rights under the Medicaid Fair Hearing
 1349  Process, as appropriate, or any alternative resolution process
 1350  adopted by the corporation.
 1351         (b) The corporation shall establish a program integrity
 1352  process to ensure compliance with program guidelines. At a
 1353  minimum, the corporation shall withhold benefits from an
 1354  applicant or enrollee if the corporation obtains evidence that
 1355  the applicant or enrollee is no longer eligible, submitted
 1356  incorrect or fraudulent information in order to establish
 1357  eligibility, or failed to provide verification of eligibility.
 1358  The corporation shall notify the applicant or enrollee that,
 1359  because of such evidence, program benefits must be withheld
 1360  unless the applicant or enrollee contacts a designated
 1361  representative of the corporation by a specified date, which
 1362  must be within 10 working days after the date of notice, to
 1363  discuss and resolve the matter. The corporation shall make every
 1364  effort to resolve the matter within a timeframe that will not
 1365  cause benefits to be withheld from an eligible enrollee. The
 1366  following individuals may be subject to specific prosecution in
 1367  accordance with s. 414.39:
 1368         1. An applicant who obtains or attempts to obtain benefits
 1369  for a potential enrollee under the Healthy Florida program when
 1370  the applicant knows or should have known that the potential
 1371  enrollee does not qualify for the Healthy Florida program.
 1372         2. An individual who assists an applicant in obtaining or
 1373  attempting to obtain benefits for a potential enrollee under the
 1374  Healthy Florida program when the individual knows or should have
 1375  known that the potential enrollee does not qualify for the
 1376  Healthy Florida program.
 1377         (9) APPLICABILITY OF LAWS RELATING TO MEDICAID.—The
 1378  provisions of ss. 409.902, 409.9128, and 409.920 apply to the
 1379  administration of the Healthy Florida program.
 1380         (10) PROGRAM EVALUATION.—The corporation shall collect both
 1381  eligibility and enrollment data from program applicants and
 1382  enrollees as well as encounter and utilization data from all
 1383  contracted entities during the program term. The corporation
 1384  shall submit monthly enrollment reports to the President of the
 1385  Senate, the Speaker of the House of Representative, and the
 1386  Minority Leaders of the Senate and the House of Representatives.
 1387  The corporation shall submit an interim independent evaluation
 1388  of the Healthy Florida program to the presiding officers no
 1389  later than July 1, 2015, with annual evaluations due July 1 each
 1390  year thereafter. The evaluations must address, at a minimum,
 1391  application and enrollment trends and issues, utilization and
 1392  cost data, and customer satisfaction.
 1393         (11) PROGRAM EXPIRATION.—The Healthy Florida program shall
 1394  expire at the end of the state fiscal year in which any of these
 1395  conditions occur, whichever occurs first:
 1396         (a) The federal match contribution falls below 90 percent.
 1397         (b) The federal match contribution falls below the
 1398  increased FMAP for medical assistance for newly eligible
 1399  mandatory individuals as specified in the federal Patient
 1400  Protection and Affordable Care Act, Pub. L. No. 111-148, as
 1401  amended by the federal Health Care and Education Reconciliation
 1402  Act of 2010, Pub. L. No. 111-152.
 1403         (c) The federal match for the Healthy Florida program and
 1404  the Medicaid program are blended under federal law or regulation
 1405  in such a way that causes the overall federal contribution to
 1406  diminish when compared to separate, nonblended federal
 1407  contributions.
 1408         Section 16. The Florida Healthy Kids Corporation may make
 1409  changes to comply with the objections of the federal Department
 1410  of Health and Human Services to gain approval of the Healthy
 1411  Florida program in compliance with the federal Patient
 1412  Protection and Affordable Care Act, upon giving notice to the
 1413  Senate and the House of Representatives of the proposed changes.
 1414  If there is a conflict between a provision in this section and
 1415  the federal Patient Protection and Affordable Care Act, Pub. L.
 1416  No. 111-148, as amended by the federal Health Care and Education
 1417  Reconciliation Act of 2010, Pub. L. No. 111-152, the provision
 1418  must be interpreted and applied so as to comply with the
 1419  requirement of the federal law.
 1420         Section 17. Section 627.6474, Florida Statutes, is amended
 1421  to read:
 1422         627.6474 Provider contracts.—
 1423         (1) A health insurer may shall not require a contracted
 1424  health care practitioner as defined in s. 456.001(4) to accept
 1425  the terms of other health care practitioner contracts with the
 1426  insurer or any other insurer, or health maintenance
 1427  organization, under common management and control with the
 1428  insurer, including Medicare and Medicaid practitioner contracts
 1429  and those authorized by s. 627.6471, s. 627.6472, s. 636.035, or
 1430  s. 641.315, except for a practitioner in a group practice as
 1431  defined in s. 456.053 who must accept the terms of a contract
 1432  negotiated for the practitioner by the group, as a condition of
 1433  continuation or renewal of the contract. Any contract provision
 1434  that violates this section is void. A violation of this
 1435  subsection section is not subject to the criminal penalty
 1436  specified in s. 624.15.
 1437         (2)(a)A contract between a health insurer and a dentist
 1438  licensed under chapter 466 for the provision of services to an
 1439  insured may not contain any provision that requires the dentist
 1440  to provide services to the insured under such contract at a fee
 1441  set by the health insurer unless such services are covered
 1442  services under the applicable contract.
 1443         (b) Covered services are those services that are listed as
 1444  a benefit that the insured is entitled to receive under the
 1445  contract. An insurer may not provide merely de minimis
 1446  reimbursement or coverage in order to avoid the requirements of
 1447  this section. Fees for covered services shall be set in good
 1448  faith and must not be nominal.
 1449         (c) A health insurer may not require as a condition of the
 1450  contract that the dentist participate in a discount medical plan
 1451  under part II of chapter 636.
 1452         Section 18. Subsection (13) is added to section 636.035,
 1453  Florida Statutes, to read:
 1454         636.035 Provider arrangements.—
 1455         (13)(a)A contract between a prepaid limited health service
 1456  organization and a dentist licensed under chapter 466 for the
 1457  provision of services to a subscriber of the prepaid limited
 1458  health service organization may not contain any provision that
 1459  requires the dentist to provide services to the subscriber of
 1460  the prepaid limited health service organization at a fee set by
 1461  the prepaid limited health service organization unless such
 1462  services are covered services under the applicable contract.
 1463         (b) Covered services are those services that are listed as
 1464  a benefit that the subscriber is entitled to receive under the
 1465  contract. A prepaid limited health service organization may not
 1466  provide merely de minimis reimbursement or coverage in order to
 1467  avoid the requirements of this section. Fees for covered
 1468  services shall be set in good faith and must not be nominal.
 1469         (c) A prepaid limited health service organization may not
 1470  require as a condition of the contract that the dentist
 1471  participate in a discount medical plan under part II of this
 1472  chapter.
 1473         Section 19. Subsection (11) is added to section 641.315,
 1474  Florida Statutes, to read:
 1475         641.315 Provider contracts.—
 1476         (11)(a)A contract between a health maintenance
 1477  organization and a dentist licensed under chapter 466 for the
 1478  provision of services to a subscriber of the health maintenance
 1479  organization may not contain any provision that requires the
 1480  dentist to provide services to the subscriber of the health
 1481  maintenance organization at a fee set by the health maintenance
 1482  organization unless such services are covered services under the
 1483  applicable contract.
 1484         (b) Covered services are those services that are listed as
 1485  a benefit that the subscriber is entitled to receive under the
 1486  contract. A health maintenance organization may not provide
 1487  merely de minimis reimbursement or coverage in order to avoid
 1488  the requirements of this section. Fees for covered services
 1489  shall be set in good faith and must not be nominal.
 1490         (c) A health maintenance organization may not require as a
 1491  condition of the contract that the dentist participate in a
 1492  discount medical plan under part II of chapter 636.
 1493         Section 20. Paragraph (a) of subsection (3) of section
 1494  766.1115, Florida Statutes, is amended, and paragraph (h) is
 1495  added to subsection (4) of that section, to read:
 1496         766.1115 Health care providers; creation of agency
 1497  relationship with governmental contractors.—
 1498         (3) DEFINITIONS.—As used in this section, the term:
 1499         (a) “Contract” means an agreement executed in compliance
 1500  with this section between a health care provider and a
 1501  governmental contractor which allows. This contract shall allow
 1502  the health care provider to deliver health care services to low
 1503  income recipients as an agent of the governmental contractor.
 1504  The contract must be for volunteer, uncompensated services. For
 1505  services to qualify as volunteer, uncompensated services under
 1506  this section, the health care provider must receive no
 1507  compensation from the governmental contractor for any services
 1508  provided under the contract and must not bill or accept
 1509  compensation from the recipient, or a any public or private
 1510  third-party payor, for the specific services provided to the
 1511  low-income recipients covered by the contract.
 1512         (4) CONTRACT REQUIREMENTS.—A health care provider that
 1513  executes a contract with a governmental contractor to deliver
 1514  health care services on or after April 17, 1992, as an agent of
 1515  the governmental contractor is an agent for purposes of s.
 1516  768.28(9), while acting within the scope of duties under the
 1517  contract, if the contract complies with the requirements of this
 1518  section and regardless of whether the individual treated is
 1519  later found to be ineligible. A health care provider under
 1520  contract with the state may not be named as a defendant in any
 1521  action arising out of medical care or treatment provided on or
 1522  after April 17, 1992, under contracts entered into under this
 1523  section. The contract must provide that:
 1524         (h) As an agent of the governmental contractor for purposes
 1525  of s. 768.28(9), while acting within the scope of duties under
 1526  the contract, a health care provider licensed under chapter 466
 1527  may allow a patient or a parent or guardian of the patient to
 1528  voluntarily contribute a fee to cover costs of dental laboratory
 1529  work related to the services provided to the patient. This
 1530  contribution may not exceed the actual cost of the dental
 1531  laboratory charges and is deemed in compliance with this
 1532  section.
 1533  
 1534  A governmental contractor that is also a health care provider is
 1535  not required to enter into a contract under this section with
 1536  respect to the health care services delivered by its employees.
 1537         Section 21. The amendments to ss. 627.6474, 636.035, and
 1538  641.315, Florida Statutes, apply to contracts entered into or
 1539  renewed on or after July 1, 2013.
 1540         Section 22. (1) The sum of $1,258,054,808 from the Medical
 1541  Care Trust Fund is appropriated to the Agency for Health Care
 1542  Administration beginning in the 2013-2014 fiscal year to provide
 1543  coverage for individuals who enroll in the Healthy Florida
 1544  Program.
 1545         (2) The sum of $254,151 from the General Revenue Fund and
 1546  $18,235,833 from the Medical Care Trust Fund is appropriated to
 1547  the Agency for Health Care Administration beginning in the 2013
 1548  2014 fiscal year to comply with federal regulations to
 1549  compensate insurers and managed care organizations that contract
 1550  with the Healthy Florida Program for the imposition of the
 1551  annual fee on health insurance providers under section 9010 of
 1552  the federal Patient Protection and Affordable Care Act, Pub. L.
 1553  No. 111-148, as amended by the federal Health Care and Education
 1554  Reconciliation Act of 2010, Pub. L. No. 111-152.
 1555         (3) The sum of $10,676,377 from the General Revenue Fund
 1556  and $10,676,377 from the Medical Care Trust Fund is appropriated
 1557  beginning in the 2013-2014 fiscal year to the Agency for Health
 1558  Care Administration to contract with the Florida Healthy Kids
 1559  Corporation under s. 409.818(2)(f), Florida Statutes, to fund
 1560  administrative costs necessary for implementing and operating
 1561  the Healthy Florida Program.
 1562         (4) The Agency for Health Care Administration may submit
 1563  budget amendments to the Legislative Budget Commission pursuant
 1564  to chapter 216, Florida Statutes, to fund the Healthy Florida
 1565  Program for the coverage of children who transfer from the
 1566  Florida Kidcare Program to the Healthy Florida Program, or to
 1567  provide additional spending authority from the Medical Care
 1568  Trust Fund under subsection (1) for the coverage of individuals
 1569  who enroll in the Healthy Florida Program, during the 2013-2014
 1570  fiscal year.
 1571         Section 23. This act shall take effect upon becoming a law.