Bill Text: FL S0710 | 2014 | Regular Session | Introduced
Bill Title: Health Care
Spectrum: Bipartisan Bill
Status: (Failed) 2014-05-02 - Died in Health Policy, companion bill(s) passed, see HB 97 (Ch. 2014-108), CS/SB 86 (Ch. 2014-64) [S0710 Detail]
Download: Florida-2014-S0710-Introduced.html
Florida Senate - 2014 SB 710
By Senator Garcia
38-00386-14 2014710__
1 A bill to be entitled
2 An act relating to health care; providing a directive
3 to the Division of Law Revision and Information;
4 amending s. 409.811, F.S.; revising and providing
5 definitions; transferring, renumbering, and amending
6 s. 624.91, F.S.; revising the Florida Healthy Kids
7 Corporation Act to include the Healthy Florida
8 program; revising participation guidelines for
9 nonsubsidized enrollees in the Healthy Kids program;
10 revising the medical loss ratio requirements for
11 contracts for the Florida Healthy Kids Corporation;
12 modifying the membership of the corporation’s board of
13 directors; creating an executive steering committee;
14 requiring additional corporate compliance
15 requirements; amending s. 409.813, F.S.; revising the
16 components of Florida Kidcare; prohibiting a cause of
17 action from arising against the Florida Healthy Kids
18 Corporation for failure to make health services
19 available; amending s. 409.8132, F.S.; revising the
20 eligibility of the Medikids program component;
21 revising the enrollment requirements for Medikids;
22 amending s. 409.8134, F.S., relating to Florida
23 Kidcare; conforming provisions to changes made by the
24 act; amending s. 409.814, F.S.; revising eligibility
25 requirements for Florida Kidcare; amending s. 409.815,
26 F.S.; revising certain minimum health benefits
27 coverage under Florida Kidcare; deleting obsolete
28 provisions; amending s. 409.816, F.S.; conforming
29 provisions to changes made by the act; repealing s.
30 409.817, F.S., relating to the approval of health
31 benefits coverage and financial assistance under the
32 Kidcare program; repealing s. 409.8175, F.S., relating
33 to the delivery of services in rural counties;
34 amending s. 409.8177, F.S.; conforming provisions to
35 changes made by the act; amending s. 409.818, F.S.;
36 revising the duties of the Department of Children and
37 Families and the Agency for Health Care Administration
38 with regard to the Kidcare program; deleting the
39 duties of the Department of Health and the Office of
40 Insurance Regulation with regard to the Kidcare
41 program; amending s. 409.820, F.S.; requiring the
42 Department of Health, in consultation with the agency
43 and the Florida Healthy Kids Corporation, to develop a
44 minimum set of pediatric and adolescent quality
45 assurance and access standards for all program
46 components; creating s. 409.822, F.S.; creating the
47 Healthy Florida program; providing eligibility and
48 enrollment requirements; authorizing the corporation
49 to contract with certain insurers, managed care
50 organizations, and provider service networks;
51 encouraging the corporation to contract with insurers
52 and managed care organizations that participate in
53 more than one affordable insurance program under
54 certain circumstances; requiring the corporation to
55 establish a benefits package and a process for payment
56 of services; authorizing the corporation to collect
57 premiums and copayments; requiring the corporation to
58 oversee the Healthy Florida program and to establish a
59 grievance process and integrity process; providing for
60 the applicability of certain state laws for
61 administering the program; requiring the corporation
62 to collect certain data and to submit enrollment
63 reports and interim independent evaluations to the
64 Legislature; providing for expiration of the program;
65 authorizing the corporation to comply with federal
66 requirements upon giving notice to the Legislature;
67 amending ss. 154.503, 408.910, and 408.915, F.S.;
68 conforming cross-references; repealing s. 624.915,
69 F.S., relating to the operating fund of the Florida
70 Healthy Kids Corporation; amending ss. 627.6474,
71 636.035, and 641.315, F.S.; prohibiting a contract
72 between a health insurer, a prepaid health service
73 organization, or a health maintenance organization and
74 a dentist from requiring the dentist to provide
75 services at a set fee under certain circumstances or
76 to participate in a discount medical plan; amending s.
77 766.1115, F.S.; revising a definition; requiring a
78 contract with a governmental contractor for health
79 care services to include a provision that a health
80 care provider licensed under ch. 466, F.S., as an
81 agent of the governmental contractor, may allow a
82 patient or a parent or guardian of the patient to
83 voluntarily contribute a fee to cover costs of dental
84 laboratory work related to the services provided to
85 the patient without forfeiting the provider’s
86 sovereign immunity; prohibiting the contribution from
87 exceeding the actual amount of the dental laboratory
88 charges; providing that the contribution complies with
89 the requirements of s. 766.1115, F.S.; providing
90 applicability; providing appropriations; providing an
91 effective date.
92
93 Be It Enacted by the Legislature of the State of Florida:
94
95 Section 1. The Division of Law Revision and Information is
96 directed to rename part II of chapter 409, Florida Statutes, as
97 the “Florida Kidcare and Healthy Florida Programs.”
98 Section 2. Section 409.811, Florida Statutes, is reordered
99 and amended to read:
100 409.811 Definitions relating to Florida Kidcare Act.—As
101 used in this part ss. 409.810-409.821, the term:
102 (1) “Actuarially equivalent” means that:
103 (a) The aggregate value of the benefits included in health
104 benefits coverage is equal to the value of the benefits in the
105 benchmark benefit plan; and
106 (b) The benefits included in health benefits coverage are
107 substantially similar to the benefits included in the child
108 benchmark benefit plan, except that preventive health services
109 must be the same as in the benchmark benefit plan.
110 (2) “Agency” means the Agency for Health Care
111 Administration.
112 (3) “Applicant” means:
113 (a) A parent or guardian of a child or a child whose
114 disability of nonage has been removed under chapter 743, who
115 applies for a determination of eligibility for health benefits
116 coverage under Florida Kidcare; or
117 (b) An individual who applies for a determination of
118 eligibility under Healthy Florida ss. 409.810-409.821.
119 (5)(4) “Child benchmark benefit plan” means the form and
120 level of health benefits coverage established under in s.
121 409.815.
122 (4)(5) “Child” means a any person younger than under 19
123 years of age.
124 (6) “Child with special health care needs” means a child
125 whose serious or chronic physical or developmental condition
126 requires extensive preventive and maintenance care beyond that
127 required by typically healthy children. Health care utilization
128 by such a child exceeds the statistically expected usage of the
129 normal child adjusted for chronological age, and such a child
130 often needs complex care requiring multiple providers,
131 rehabilitation services, and specialized equipment in a number
132 of different settings.
133 (7) “Children’s Medical Services Network” or “network” has
134 the same meaning means a statewide managed care service system
135 as defined in s. 391.021(1).
136 (8) “CHIP” means the Children’s Health Insurance Program as
137 authorized under Title XXI of the Social Security Act,
138 regulations adopted thereunder, and this part, and as
139 administered in this state by the agency, the department, and
140 the corporation pursuant to their respective jurisdictions.
141 (8) “Community rate” means a method used to develop
142 premiums for a health insurance plan that spreads financial risk
143 across a large population and allows adjustments only for age,
144 gender, family composition, and geographic area.
145 (9) “Corporation” means the Florida Healthy Kids
146 Corporation established under s. 409.8125.
147 (10)(9) “Department” means the Department of Health.
148 (11)(10) “Enrollee” means a child or adult who has been
149 determined eligible for and is receiving coverage under this
150 part ss. 409.810-409.821.
151 (11) “Family” means the group or the individuals whose
152 income is considered in determining eligibility for the Florida
153 Kidcare program. The family includes a child with a parent or
154 caretaker relative who resides in the same house or living unit
155 or, in the case of a child whose disability of nonage has been
156 removed under chapter 743, the child. The family may also
157 include other individuals whose income and resources are
158 considered in whole or in part in determining eligibility of the
159 child.
160 (12) “Family income” means cash received at periodic
161 intervals from any source, such as wages, benefits,
162 contributions, or rental property. Income also may include any
163 money that would have been counted as income under the Aid to
164 Families with Dependent Children (AFDC) state plan in effect
165 prior to August 22, 1996.
166 (12)(13) “Florida Kidcare Program,” “Kidcare program,” or
167 “program” means the health benefits program described in s.
168 409.813 and administered under this part through ss. 409.810
169 409.821.
170 (13)(14) “Guarantee issue” means that health benefits
171 coverage must be offered to an individual regardless of the
172 individual’s health status, preexisting condition, or claims
173 history.
174 (14)(15) “Health benefits coverage” means protection that
175 provides payment of benefits for covered health care services or
176 that otherwise provides, either directly or through arrangements
177 with other persons, covered health care services on a prepaid
178 per capita basis or on a prepaid aggregate fixed-sum basis.
179 (15)(16) “Health insurance plan” means health benefits
180 coverage under the following:
181 (a) A health plan offered by a any certified health
182 maintenance organization or authorized health insurer, except
183 for a plan that is limited to the following: a limited benefit,
184 specified disease, or specified accident; hospital indemnity;
185 accident only; limited benefit convalescent care; Medicare
186 supplement; credit disability; dental; vision; long-term care;
187 disability income; coverage issued as a supplement to another
188 health plan; workers’ compensation liability or other insurance;
189 or motor vehicle medical payment only; or
190 (b) An employee welfare benefit plan that includes health
191 benefits established under the Employee Retirement Income
192 Security Act of 1974, as amended.
193 (16) “Healthy Florida” means the program established under
194 s. 409.822.
195 (17) “Healthy Kids” means a component of Florida Kidcare
196 created under s. 409.8125 for children who are 5 through 18
197 years of age.
198 (18) “Household income” has the same meaning as in s.
199 36B(d)(2)(A) of the Internal Revenue Code of 1986 and applies to
200 the individual or household whose income is being considered in
201 determining eligibility for Florida Kidcare or Healthy Florida.
202 (19)(17) “Medicaid” means the medical assistance program
203 authorized by Title XIX of the Social Security Act, and
204 regulations thereunder, and ss. 409.901-409.920, as administered
205 in this state by the agency.
206 (20)(18) “Medically necessary” means the use of any medical
207 treatment, service, equipment, or supply necessary to palliate
208 the effects of a terminal condition, or to prevent, diagnose,
209 correct, cure, alleviate, or preclude deterioration of a
210 condition that threatens life, causes pain or suffering, or
211 results in illness or infirmity and which is:
212 (a) Consistent with the symptom, diagnosis, and treatment
213 of the enrollee’s condition;
214 (b) Provided in accordance with generally accepted
215 standards of medical practice;
216 (c) Not primarily intended for the convenience of the
217 enrollee, the enrollee’s family, or the health care provider;
218 (d) The most appropriate level of supply or service for the
219 diagnosis and treatment of the enrollee’s condition; and
220 (e) Approved by the appropriate medical body or health care
221 specialty involved as effective, appropriate, and essential for
222 the care and treatment of the enrollee’s condition.
223 (21)(19) “Medikids” means a component of the Florida
224 Kidcare program of medical assistance authorized by Title XXI of
225 the Social Security Act, and regulations thereunder, and s.
226 409.8132, as administered in the state by the agency.
227 (22) “Modified adjusted gross income” has the same meaning
228 as in s. 36B(d)(2)(B) of the Internal Revenue Code of 1986 and
229 applies to the individual or household whose income is being
230 considered in determining eligibility for Florida Kidcare or
231 Healthy Florida.
232 (23) “Patient Protection and Affordable Care Act” means the
233 federal law enacted as Pub. L. No. 111-148, as amended by the
234 Health Care and Education Reconciliation Act of 2010, Pub. L.
235 No. 111-152, and any regulations or guidance adopted or issued
236 pursuant to those acts.
237 (24)(20) “Preexisting condition exclusion” means, with
238 respect to coverage, a limitation or exclusion of benefits
239 relating to a condition based on the fact that the condition was
240 present before the date of enrollment for such coverage,
241 regardless of whether or not any medical advice, diagnosis,
242 care, or treatment was recommended or received before such date.
243 (25)(21) “Premium” means the entire cost of a health
244 insurance plan, including the administration fee or the risk
245 assumption charge.
246 (26)(22) “Premium assistance payment” means the monthly
247 consideration paid toward health insurance premiums by the
248 agency per enrollee in the Florida Kidcare Program towards
249 health insurance premiums.
250 (27)(23) “Qualified alien” means an alien as defined in 8
251 U.S.C. s. 1641 (b) and (c) s. 431 of the Personal Responsibility
252 and Work Opportunity Reconciliation Act of 1996, as amended,
253 Pub. L. No. 104-193.
254 (28)(24) “Resident” means a United States citizen, or
255 qualified alien, who is domiciled in this state.
256 (29)(25) “Rural county” means a county having a population
257 density of less than 100 persons per square mile, or a county
258 defined by the most recent United States Census as rural, in
259 which there was is no prepaid health plan participating in the
260 Medicaid program as of July 1, 1998.
261 (26) “Substantially similar” means that, with respect to
262 additional services as defined in s. 2103(c)(2) of Title XXI of
263 the Social Security Act, these services must have an actuarial
264 value equal to at least 75 percent of the actuarial value of the
265 coverage for that service in the benchmark benefit plan and,
266 with respect to the basic services as defined in s. 2103(c)(1)
267 of Title XXI of the Social Security Act, these services must be
268 the same as the services in the benchmark benefit plan.
269 Section 3. Section 624.91, Florida Statutes, is transferred
270 and renumbered as section 409.8125, Florida Statutes, and is
271 reordered and amended to read:
272 409.8125 624.91 The Florida Healthy Kids Corporation Act.—
273 (1) SHORT TITLE.—This section may be cited as the “William
274 G. ‘Doc’ Myers Healthy Kids Corporation Act.”
275 (2) LEGISLATIVE INTENT.—
276 (a) The Legislature finds that increased access to health
277 care services could improve children’s health and reduce the
278 incidence and costs of childhood illness and disabilities among
279 children in this state. Many children do not have comprehensive,
280 affordable health care services available. It is the intent of
281 the Legislature that the Florida Healthy Kids Corporation
282 provide comprehensive health insurance coverage to such
283 children. The corporation is encouraged to cooperate with any
284 existing health service programs funded by the public or the
285 private sector.
286 (b) It is also the intent of the Legislature:
287 (a) That the Florida Healthy Kids program, established and
288 administered by the corporation, serve as one of several
289 providers of services to children eligible for medical
290 assistance under the federal Children’s Health Insurance Program
291 (CHIP) Title XXI of the Social Security Act. Although Healthy
292 Kids the corporation may serve other children, the Legislature
293 intends that the primary enrollees recipients of services
294 provided through the corporation be uninsured school-age
295 children eligible for CHIP with a family income below 200
296 percent of the federal poverty level, who do not qualify for
297 Medicaid. It is also the intent of the Legislature that state
298 and local government Florida Healthy Kids funds be used to
299 continue coverage, subject to specific appropriations in the
300 General Appropriations Act, to children not eligible for federal
301 matching funds under CHIP Title XXI.
302 (b) That the corporation administer and manage services for
303 Healthy Florida, a health care program for uninsured adults,
304 using a unique network of providers and contracts. Enrollees in
305 Healthy Florida shall receive comprehensive health care services
306 from private, licensed health insurers that meet standards
307 established by the corporation. It is further the intent of the
308 Legislature that these enrollees participate in their own health
309 care decisionmaking and contribute financially toward their
310 medical costs. The Legislature intends to provide an alternative
311 benefit package that includes a full range of services that meet
312 the needs of the residents of this state. As a new program, the
313 Legislature intends that a comprehensive analysis be conducted
314 to measure the overall impact of the program and evaluate
315 whether the program should be renewed after an initial 3-year
316 term.
317 (6)(3) ELIGIBILITY FOR STATE-FUNDED ASSISTANCE.—Only the
318 following individuals are eligible for state-funded assistance
319 in paying Florida Healthy Kids or Healthy Florida premiums:
320 (a) Residents of this state who are eligible for the
321 Florida Kidcare program pursuant to s. 409.814 or Healthy
322 Florida pursuant to s. 409.822.
323 (b) Notwithstanding s. 409.814, legal aliens who are
324 enrolled in the Florida Healthy Kids program as of January 31,
325 2004, who do not qualify for CHIP Title XXI federal funds
326 because they are not qualified aliens as defined in s. 409.811.
327 (7)(4) NONENTITLEMENT.—Nothing in This section does not
328 provide shall be construed as providing an individual with an
329 entitlement to health care services. No cause of action shall
330 arise against the state, the Florida Healthy Kids corporation,
331 or a unit of local government for failure to make health
332 services available under this section.
333 (3)(5) CORPORATION AUTHORIZATION, DUTIES, POWERS.—
334 (a) There is created The Florida Healthy Kids Corporation
335 is hereby established as, a not-for-profit corporation.
336 (b) The Florida Healthy Kids corporation shall:
337 1. Arrange for the collection of any family, individual, or
338 local contributions, or employer payment or premium, in an
339 amount to be determined by the board of directors, to provide
340 for payment of premiums for comprehensive insurance coverage and
341 for the actual or estimated administrative expenses.
342 2. Arrange for the collection of any voluntary
343 contributions to provide for the payment of premiums for
344 enrollees in Florida Kidcare or Healthy Florida program premiums
345 for children who are not eligible for medical assistance under
346 Title XIX or Title XXI of the Social Security Act.
347 3. Subject to the provisions of s. 409.8134, accept
348 voluntary supplemental local match contributions that comply
349 with CHIP the requirements of Title XXI of the Social Security
350 Act for the purpose of providing additional Florida Kidcare
351 coverage in contributing counties under CHIP Title XXI.
352 4. Establish the administrative and accounting procedures
353 for the operation of the corporation.
354 5. Establish, with consultation from appropriate
355 professional organizations, standards for preventive health
356 services and providers and comprehensive insurance benefits
357 appropriate to children., provided that Such standards for rural
358 areas may shall not require that limit primary care providers be
359 to board-certified pediatricians.
360 6. Determine eligibility for children seeking to
361 participate in CHIP the Title XXI-funded components of the
362 Florida Kidcare program consistent with the requirements
363 specified in s. 409.814, as well as the non-Title-XXI-eligible
364 children not eligible under CHIP as provided in subsection (6)
365 (3).
366 7. Establish procedures under which providers of local
367 match to, applicants to, and participants in Healthy Kids or
368 Healthy Families the program may have grievances reviewed by an
369 impartial body and reported to the board of directors of the
370 corporation.
371 8. Establish participation criteria and, if appropriate,
372 contract with an authorized insurer, health maintenance
373 organization, or third-party administrator to provide
374 administrative services to the corporation.
375 9. Establish enrollment criteria that include penalties or
376 30-day waiting periods of 30 days for reinstatement of coverage
377 upon voluntary cancellation for nonpayment of family and
378 individual premiums under the programs.
379 10. Contract with authorized insurers or providers any
380 provider of health care services who meet the, meeting standards
381 established by the corporation, for the provision of
382 comprehensive insurance coverage to participants. Such standards
383 must shall include criteria under which the corporation may
384 contract with more than one provider of health care services in
385 program sites.
386 a. Health plans shall be selected through a competitive bid
387 process.
388 b. The Florida Healthy Kids corporation shall purchase
389 goods and services in the most cost-effective manner consistent
390 with the delivery of quality medical care. The maximum
391 administrative cost for a Florida Healthy Kids corporation
392 contract is shall be 15 percent. For all health care contracts,
393 the minimum medical loss ratio is for a Florida Healthy Kids
394 Corporation contract shall be 85 percent. The calculations must
395 use uniform financial data collected from all plans in a format
396 established by the corporation and computed for each insurer on
397 a statewide basis. Funds shall be classified in a manner
398 consistent with 45 C.F.R. part 158 For dental contracts, the
399 remaining compensation to be paid to the authorized insurer or
400 provider under a Florida Healthy Kids Corporation contract shall
401 be no less than an amount which is 85 percent of premium; to the
402 extent any contract provision does not provide for this minimum
403 compensation, this section shall prevail.
404 c. The health plan selection criteria, and scoring system,
405 and the scoring results must, shall be available upon request
406 for inspection after the bids have been awarded.
407 11. Establish disenrollment criteria if in the event local
408 matching funds are insufficient to cover enrollments.
409 12. Develop and implement a plan to publicize the Florida
410 Kidcare and Healthy Florida program, the eligibility
411 requirements of the programs program, and the procedures for
412 enrollment in the programs program and to maintain public
413 awareness of the corporation and the programs program.
414 13. Secure staff necessary to properly administer the
415 corporation. Staff costs shall be funded from state and local
416 matching funds and such other private or public funds as become
417 available. The board of directors shall determine the number of
418 staff members necessary to administer the corporation.
419 14. In consultation with the partner agencies, provide an
420 annual a report on the Florida Kidcare program annually to the
421 Governor, the Chief Financial Officer, the Commissioner of
422 Education, the President of the Senate, the Speaker of the House
423 of Representatives, and the Minority Leaders of the Senate and
424 the House of Representatives.
425 15. Provide information on a quarterly basis to the
426 Legislature and the Governor which compares the costs and
427 utilization of the full-pay enrolled population and the CHIP
428 subsidized Title XXI-subsidized enrolled population in the
429 Florida Kidcare program. The information, At a minimum, the
430 information must include:
431 a. The monthly enrollment and expenditure for full-pay
432 enrollees in the Medikids and Florida Healthy Kids programs
433 compared to the CHIP-subsidized Title XXI-subsidized enrolled
434 population; and
435 b. The costs and utilization by service of the full-pay
436 enrollees in the Medikids and Florida Healthy Kids programs and
437 the CHIP-subsidized Title XXI-subsidized enrolled population.
438
439 By February 1, 2010, the Florida Healthy Kids Corporation shall
440 provide a study to the Legislature and the Governor on premium
441 impacts to the subsidized portion of the program from the
442 inclusion of the full-pay program, which shall include
443 recommendations on how to eliminate or mitigate possible impacts
444 to the subsidized premiums.
445 16. Notify all current full-pay enrollees of the
446 availability of the exchange, as defined in the federal Patient
447 Protection and Affordable Care Act, and how to access other
448 affordable insurance options. New applications for full-pay
449 coverage may not be accepted after September 30, 2014.
450 17.16. Establish benefit packages that conform to the
451 provisions of the Florida Kidcare program, as created under this
452 part in ss. 409.810-409.821.
453 (c) Coverage under the corporation’s programs program is
454 secondary to any other available private coverage held by, or
455 applicable to, the participant child or family member. Insurers
456 under contract with the corporation are the payors of last
457 resort and must coordinate benefits with any other third-party
458 payor that may be liable for the participant’s medical care.
459 (d) The Florida Healthy Kids corporation shall be a private
460 corporation not for profit, registered, incorporated, and
461 organized pursuant to chapter 617, and shall have all powers
462 necessary to carry out the purposes of this section act,
463 including, but not limited to, the power to receive and accept
464 grants, loans, or advances of funds from any public or private
465 agency and to receive and accept from any source contributions
466 of money, property, labor, or any other thing of value, to be
467 held, used, and applied for the purposes of this section act.
468 The corporation and any committees it forms shall comply with
469 part III of chapter 112 and chapters 119 and 286.
470 (4)(6) BOARD OF DIRECTORS AND MANAGEMENT SUPERVISION.—
471 (a) The Florida Healthy Kids corporation shall operate
472 subject to the supervision and approval of a board of directors
473 chaired by an appointee designated by the Governor Chief
474 Financial Officer or her or his designee, and composed of 15 12
475 other members. The Senate shall confirm the designated chair and
476 other board appointees selected for 3-year terms of office as
477 follows:
478 1. The Secretary of Health Care Administration, or his or
479 her designee, as an ex-officio member.
480 2. The State Surgeon General, or his or her designee, as an
481 ex-officio member One member appointed by the Commissioner of
482 Education from the Office of School Health Programs of the
483 Florida Department of Education.
484 3. The Secretary of Children and Families, or his or her
485 designee, as an ex-officio member One member appointed by the
486 Chief Financial Officer from among three members nominated by
487 the Florida Pediatric Society.
488 4. Four members One member, appointed by the Governor, who
489 represents the Children’s Medical Services Program.
490 5. Two members One member appointed by the President of the
491 Senate Chief Financial Officer from among three members
492 nominated by the Florida Hospital Association.
493 6. Two members One member, appointed by the Senate Minority
494 Leader Governor, who is an expert on child health policy.
495 7. Two members One member, appointed by the Speaker of the
496 House of Representatives Chief Financial Officer, from among
497 three members nominated by the Florida Academy of Family
498 Physicians.
499 8. Two members One member, appointed by the House Minority
500 Leader Governor, who represents the state Medicaid program.
501 9. One member, appointed by the Chief Financial Officer,
502 from among three members nominated by the Florida Association of
503 Counties.
504 10. The State Health Officer or her or his designee.
505 11. The Secretary of Children and Family Services, or his
506 or her designee.
507 12. One member, appointed by the Governor, from among three
508 members nominated by the Florida Dental Association.
509 (b) A member of the board of directors may be removed by
510 the official who made the appointment appointed that member. The
511 board shall appoint an executive director, who is responsible
512 for other staff authorized by the board.
513 (c) Board members are entitled to receive, from funds of
514 the corporation, reimbursement for per diem and travel expenses
515 as provided by s. 112.061.
516 (d) There is shall be no liability on the part of, and no
517 cause of action shall arise against, any member of the board of
518 directors, or its employees or agents, for any action they take
519 in the performance of their powers and duties under this act.
520 (e) Board members who are serving on or before the
521 effective date of this act or similar legislation may remain
522 until July 1, 2015.
523 (f) An executive steering committee is created to provide
524 direction and support to management and to make recommendations
525 to the board on programs. The steering committee consists of the
526 Secretary of Health Care Administration, the Secretary of
527 Children and Families, and the State Surgeon General, who may
528 not delegate their membership or attendance.
529 (5)(7) LICENSING NOT REQUIRED; FISCAL OPERATION.—
530 (a) The corporation is shall not be deemed an insurer. The
531 officers, directors, and employees of the corporation may shall
532 not be deemed to be agents of an insurer. Neither the
533 corporation nor any officer, director, or employee of the
534 corporation is subject to the licensing requirements of the
535 insurance code or the rules of the Department of Financial
536 Services or the Office of Insurance Regulation. However, any
537 marketing representative used utilized and compensated by the
538 corporation must be appointed as a representative of the
539 insurers or health services providers with which the corporation
540 contracts.
541 (b) The board has complete fiscal control over the
542 corporation and is responsible for all corporate operations.
543 (c) The Department of Financial Services shall supervise
544 any liquidation or dissolution of the corporation and shall
545 have, with respect to such liquidation or dissolution, shall
546 have all power granted to it pursuant to the insurance code.
547 Section 4. Section 409.813, Florida Statutes, is amended to
548 read:
549 409.813 Health benefits coverage; program components;
550 entitlement and nonentitlement.—
551 (1) The Florida Kidcare program includes health benefits
552 coverage provided to children through the following program
553 components, which shall be marketed as the Florida Kidcare
554 program:
555 (a) Medicaid;
556 (b) Medikids as created in s. 409.8132;
557 (c) The Florida Healthy Kids Corporation as created in s.
558 409.8125 s. 624.91; and
559 (d) Employer-sponsored group health insurance plans
560 approved under ss. 409.810-409.821; and
561 (d)(e) The Children’s Medical Services network established
562 in chapter 391.
563 (2) Except for CHIP-funded Title XIX-funded Florida Kidcare
564 program coverage under the Medicaid program, coverage under the
565 Florida Kidcare program is not an entitlement. No cause of
566 action shall arise against the state, the department, the
567 Department of Children and Families Family Services, or the
568 agency, or the corporation for failure to make health services
569 available to any person under this part ss. 409.810-409.821.
570 Section 5. Subsections (6) and (7) of section 409.8132,
571 Florida Statutes, are amended to read:
572 409.8132 Medikids program component.—
573 (6) ELIGIBILITY.—
574 (a) A child who has attained the age of 1 year but who is
575 under the age of 5 years is eligible to enroll in the Medikids
576 program component of the Florida Kidcare program, if the child
577 is a member of a family that has a household family income
578 greater than which exceeds the Medicaid applicable income level
579 as specified in s. 409.903, but which is equal to or below 200
580 percent of the current federal poverty level. In determining the
581 eligibility of such a child, an assets test is not required. A
582 child who is eligible for Medikids may elect to enroll in
583 Florida Healthy Kids coverage or employer-sponsored group
584 coverage. However, a child who is eligible for Medikids may
585 participate in the Florida Healthy Kids Program only if the
586 child has a sibling participating in the Florida Healthy Kids
587 Program and the child’s county of residence permits such
588 enrollment.
589 (b) The provisions of s. 409.814 apply to the Medikids
590 program.
591 (7) ENROLLMENT.—Enrollment in the Medikids program
592 component may occur at any time throughout the year. A child may
593 not receive services under the Medikids program until the child
594 is enrolled in a managed care plan or MediPass. Once determined
595 eligible, an applicant may receive choice counseling and select
596 a managed care plan or MediPass. The agency may initiate
597 mandatory assignment for a Medikids applicant who has not chosen
598 a managed care plan or MediPass provider after the applicant’s
599 voluntary choice period ends. An applicant may select MediPass
600 under the Medikids program component only in counties that have
601 fewer than two managed care plans available to serve Medicaid
602 recipients and only if the federal Health Care Financing
603 Administration determines that MediPass constitutes “health
604 insurance coverage” as defined in Title XXI of the Social
605 Security Act.
606 Section 6. Subsection (2) of section 409.8134, Florida
607 Statutes, is amended to read:
608 409.8134 Program expenditure ceiling; enrollment.—
609 (2) The Florida Kidcare program may conduct enrollment
610 continuously throughout the year.
611 (a) Children eligible for coverage under the CHIP-funded
612 Title XXI-funded Florida Kidcare program shall be enrolled on a
613 first-come, first-served basis using the date the enrollment
614 application is received. Enrollment shall immediately cease when
615 the expenditure ceiling is reached. Year-round enrollment shall
616 only be held only if the Social Services Estimating Conference
617 determines that sufficient federal and state funds will be
618 available to finance the increased enrollment.
619 (b) An The application for the Florida Kidcare program is
620 valid for a period of 120 days after the date it was received.
621 At the end of the 120-day period, If the applicant has not been
622 enrolled in the program by the end of the 120-day period, the
623 application is invalid and the applicant shall be notified of
624 the action. The applicant may reactivate the application after
625 notification of the action taken by the program.
626 (c) Except for the Medicaid program, if whenever the Social
627 Services Estimating Conference determines that there are
628 presently, or will be by the end of the current fiscal year will
629 be, insufficient funds to finance the current or projected
630 enrollment in the Florida Kidcare program, all additional
631 enrollment must cease and additional enrollment may not resume
632 until sufficient funds are available to finance such enrollment.
633 Section 7. Section 409.814, Florida Statutes, is amended to
634 read:
635 409.814 Eligibility.—A child who has not reached 19 years
636 of age whose household family income is equal to or below 200
637 percent of the federal poverty level is eligible for the Florida
638 Kidcare program as provided in this section. If an enrolled
639 individual is determined to be ineligible for coverage, he or
640 she must be immediately disenrolled from the respective Florida
641 Kidcare program component and referred to another affordable
642 insurance program.
643 (1) A child who is eligible for Medicaid coverage under s.
644 409.903 or s. 409.904 must be offered an opportunity to enroll
645 enrolled in Medicaid and is not eligible to receive health
646 benefits under any other health benefits coverage authorized
647 under the Florida Kidcare program. A child who is eligible for
648 Medicaid and opts to enroll in CHIP may disenroll from CHIP at
649 any time and transition to Medicaid. Such transition must occur
650 without a break in coverage.
651 (2) A child who is not eligible for Medicaid, but who is
652 eligible for another component of the Florida Kidcare program,
653 may obtain health benefits coverage under any of the other
654 components listed in s. 409.813 if such coverage is approved and
655 available in the county in which the child resides.
656 (3) A CHIP-funded Title XXI-funded child who is eligible
657 for the Florida Kidcare program who is a child with special
658 health care needs, as determined through a medical or behavioral
659 screening instrument, is eligible for health benefits coverage
660 from, and shall be assigned to, and may opt out of the
661 Children’s Medical Services Network.
662 (4) The following children are not eligible to receive
663 CHIP-funded Title XXI-funded premium assistance for health
664 benefits coverage under the Florida Kidcare program, except
665 under Medicaid if the child would have been eligible for
666 Medicaid under s. 409.903 or s. 409.904 as of June 1, 1997:
667 (a) A child who is covered under a family member’s group
668 health benefit plan or under other private or employer health
669 insurance coverage, if the cost of the child’s participation is
670 not greater than 5 percent of the household family’s income. If
671 a child is otherwise eligible for a subsidy under the Florida
672 Kidcare program and the cost of the child’s participation in the
673 family member’s health insurance benefit plan is greater than 5
674 percent of the household family’s income, the child may enroll
675 in the appropriate subsidized Florida Kidcare program component.
676 (b) A child who is seeking premium assistance for the
677 Florida Kidcare program through employer-sponsored group
678 coverage, if the child has been covered by the same employer’s
679 group coverage during the 60 days before the family submitted an
680 application for determination of eligibility under the program.
681 (b)(c) A child who is an alien, but who does not meet the
682 definition of qualified alien, in the United States.
683 (c)(d) A child who is an inmate of a public institution or
684 a patient in an institution for mental diseases.
685 (d)(e) A child who is otherwise eligible for premium
686 assistance for the Florida Kidcare program and has had his or
687 her coverage in an employer-sponsored or private health benefit
688 plan voluntarily canceled in the last 60 days, except those
689 children whose coverage was voluntarily canceled for good cause,
690 including, but not limited to, the following circumstances:
691 1. The cost of participation in an employer-sponsored
692 health benefit plan is greater than 5 percent of the household’s
693 modified adjusted gross family’s income;
694 2. The parent lost a job that provided an employer
695 sponsored health benefit plan for children;
696 3. The parent who had health benefits coverage for the
697 child is deceased;
698 4. The child has a medical condition that, without medical
699 care, would cause serious disability, loss of function, or
700 death;
701 5. The employer of the parent canceled health benefits
702 coverage for children;
703 6. The child’s health benefits coverage ended because the
704 child reached the maximum lifetime coverage amount;
705 7. The child has exhausted coverage under a COBRA
706 continuation provision;
707 8. The health benefits coverage does not cover the child’s
708 health care needs; or
709 9. Domestic violence led to loss of coverage.
710 (5) A child who is otherwise eligible for the Florida
711 Kidcare program and who has a preexisting condition that
712 prevents coverage under another insurance plan as described in
713 paragraph (4)(a) which would have disqualified the child for the
714 Florida Kidcare program if the child were able to enroll in the
715 plan is eligible for Florida Kidcare coverage when enrollment is
716 possible.
717 (5)(6) A child whose household’s modified adjusted gross
718 family income is above 200 percent of the federal poverty level
719 or a child who is excluded under the provisions of subsection
720 (4) may participate in the Florida Kidcare program as provided
721 in s. 409.8132 or, if the child is ineligible for Medikids by
722 reason of age, in the Florida Healthy Kids program, subject to
723 the following:
724 (a) The family is not eligible for premium assistance
725 payments and must pay the full cost of the premium, including
726 any administrative costs.
727 (b) The board of directors of the Florida Healthy Kids
728 Corporation may offer a reduced benefit package to these
729 children in order to limit program costs for such families.
730 (c) The corporation shall notify all current full-pay
731 enrollees of the availability of the exchange and how to access
732 other affordable insurance options.
733 (6)(7) Once a child is enrolled in the Florida Kidcare
734 program, the child is eligible for coverage for 12 months
735 without a redetermination or reverification of eligibility, if
736 the family continues to pay the applicable premium. Eligibility
737 for program components funded through CHIP Title XXI of the
738 Social Security Act terminates when a child attains the age of
739 19. A child who has not attained the age of 5 and who has been
740 determined eligible for the Medicaid program is eligible for
741 coverage for 12 months without a redetermination or
742 reverification of eligibility.
743 (7)(8) When determining or reviewing a child’s eligibility
744 under the Florida Kidcare Program, the applicant shall be
745 provided with reasonable notice of changes in eligibility which
746 may affect enrollment in one or more of the program components.
747 If a transition from one program component to another is
748 authorized, there must shall be cooperation between the program
749 components and the affected family which promotes continuity of
750 health care coverage. Any authorized transfers must be managed
751 within the program’s overall appropriated or authorized levels
752 of funding. Each component of the program shall establish a
753 reserve to ensure that transfers between components are will be
754 accomplished within current year appropriations. These reserves
755 shall be reviewed by each convening of the Social Services
756 Estimating Conference to determine their the adequacy of such
757 reserves to meet actual experience.
758 (8)(9) In determining the eligibility of a child, an assets
759 test is not required. Each applicant shall provide documentation
760 during the application process and the redetermination process,
761 including, but not limited to, the following:
762 (a) Proof of household family income, which must be
763 verified electronically to determine financial eligibility for
764 the Florida Kidcare program. Written documentation, which may
765 include wages and earnings statements or pay stubs, W-2 forms,
766 or a copy of the applicant’s most recent federal income tax
767 return, is required only if the electronic verification is not
768 available or does not substantiate the applicant’s income.
769 (b) A statement from all applicable, employed household
770 family members that:
771 1. Their employers do not sponsor health benefit plans for
772 employees;
773 2. The potential enrollee is not covered by an employer
774 sponsored health benefit plan; or
775 3. The potential enrollee is covered by an employer
776 sponsored health benefit plan and the cost of the employer
777 sponsored health benefit plan is more than 5 percent of the
778 household’s modified adjusted gross family’s income.
779 (c) To enroll in the Children’s Medical Services Network, a
780 completed application, including a clinical screening.
781 (d) Eligibility shall be determined through electronic
782 matching using the federally managed data services hub and other
783 resources. Written documentation from the applicant may be
784 accepted if the electronic verification does not substantiate
785 the applicant’s income or if there has been a change in
786 circumstances.
787 (9)(10) Subject to paragraph (4)(a), the Florida Kidcare
788 program shall withhold benefits from an enrollee if the program
789 obtains evidence that the enrollee is no longer eligible,
790 submitted incorrect or fraudulent information in order to
791 establish eligibility, or failed to provide verification of
792 eligibility. The applicant or enrollee shall be notified that
793 because of such evidence, program benefits will be withheld
794 unless the applicant or enrollee contacts a designated
795 representative of the program by a specified date, which must be
796 within 10 working days after the date of notice, to discuss and
797 resolve the matter. The program shall make every effort to
798 resolve the matter within a timeframe that does will not cause
799 benefits to be withheld from an eligible enrollee.
800 (10)(11) The following individuals may be subject to
801 prosecution in accordance with s. 414.39:
802 (a) An applicant obtaining or attempting to obtain benefits
803 for a potential enrollee under the Florida Kidcare if program
804 when the applicant knows or should have known the potential
805 enrollee does not qualify for the Florida Kidcare program.
806 (b) An individual who assists an applicant in obtaining or
807 attempting to obtain benefits for a potential enrollee under the
808 Florida Kidcare if program when the individual knows or should
809 have known the potential enrollee does not qualify for the
810 Florida Kidcare program.
811 Section 8. Subsection (2) of section 409.815, Florida
812 Statutes, is amended to read:
813 409.815 Health benefits coverage; limitations.—
814 (2) BENCHMARK BENEFITS.—In order for health benefits
815 coverage to qualify for premium assistance payments for an
816 eligible child under this part ss. 409.810-409.821, the health
817 benefits coverage, except for coverage under Medicaid and
818 Medikids, must include the following minimum benefits, as
819 medically necessary.
820 (a) Preventive health services.—Covered services include:
821 1. Well-child care, including services recommended in the
822 Guidelines for Health Supervision of Children and Youth as
823 developed by the American Academy of Pediatrics;
824 2. Immunizations and injections;
825 3. Health education counseling and clinical services;
826 4. Vision screening; and
827 5. Hearing screening.
828 (b) Inpatient hospital services.—All covered services
829 provided for the medical care and treatment of an enrollee who
830 is admitted as an inpatient to a hospital licensed under part I
831 of chapter 395, with the following exceptions:
832 1. All admissions must be authorized by the enrollee’s
833 health benefits coverage provider.
834 2. The length of the patient stay shall be determined based
835 on the medical condition of the enrollee in relation to the
836 necessary and appropriate level of care.
837 3. Room and board may be limited to semiprivate
838 accommodations, unless a private room is considered medically
839 necessary or semiprivate accommodations are not available.
840 4. Admissions for rehabilitation and physical therapy are
841 limited to 15 days per contract year.
842 (c) Emergency services.—Covered services include visits to
843 an emergency room or other licensed facility if needed
844 immediately due to an injury or illness and delay means risk of
845 permanent damage to the enrollee’s health. Health maintenance
846 organizations must shall comply with the provisions of s.
847 641.513.
848 (d) Maternity services.—Covered services include maternity
849 and newborn care, including prenatal and postnatal care, with
850 the following limitations:
851 1. Coverage may be limited to the fee for vaginal
852 deliveries; and
853 2. Initial inpatient care for newborn infants of enrolled
854 adolescents is shall be covered, including normal newborn care,
855 nursery charges, and the initial pediatric or neonatal
856 examination, and the infant may be covered for up to 3 days
857 following birth.
858 (e) Organ transplantation services.—Covered services
859 include pretransplant, transplant, and postdischarge services
860 and treatment of complications after transplantation if for
861 transplants deemed necessary and appropriate within the
862 guidelines set by the Organ Transplant Advisory Council under s.
863 765.53 or the Bone Marrow Transplant Advisory Panel under s.
864 627.4236.
865 (f) Outpatient services.—Covered services include
866 preventive, diagnostic, therapeutic, palliative care, and other
867 services provided to an enrollee in the outpatient portion of a
868 health facility licensed under chapter 395, except for the
869 following limitations:
870 1. Services must be authorized by the enrollee’s health
871 benefits coverage provider; and
872 2. Treatment for temporomandibular joint disease (TMJ) is
873 specifically excluded.
874 (g) Behavioral health services.—
875 1. Mental health benefits include:
876 a. Inpatient services, limited to 30 inpatient days per
877 contract year for psychiatric admissions, or residential
878 services in facilities licensed under s. 394.875(6) or s.
879 395.003 in lieu of inpatient psychiatric admissions; however, a
880 minimum of 10 of the 30 days shall be available only for
881 inpatient psychiatric services if authorized by a physician; and
882 b. Outpatient services, including outpatient visits for
883 psychological or psychiatric evaluation, diagnosis, and
884 treatment by a licensed mental health professional, limited to
885 40 outpatient visits each contract year.
886 2. Substance abuse services include:
887 a. Inpatient services, limited to 7 inpatient days per
888 contract year for medical detoxification only and 30 days of
889 residential services; and
890 b. Outpatient services, including evaluation, diagnosis,
891 and treatment by a licensed practitioner, limited to 40
892 outpatient visits per contract year.
893
894 Effective October 1, 2009, Covered services include inpatient
895 and outpatient services for mental and nervous disorders as
896 defined in the most recent edition of the Diagnostic and
897 Statistical Manual of Mental Disorders published by the American
898 Psychiatric Association. Such benefits include psychological or
899 psychiatric evaluation, diagnosis, and treatment by a licensed
900 mental health professional and inpatient, outpatient, and
901 residential treatment of substance abuse disorders. Any benefit
902 limitations, including duration of services, number of visits,
903 or number of days for hospitalization or residential services,
904 may shall not be any less favorable than those for physical
905 illnesses generally. The program may also implement appropriate
906 financial incentives, peer review, utilization requirements, and
907 other methods used for the management of benefits provided for
908 other medical conditions in order to reduce service costs and
909 utilization without compromising quality of care.
910 (h) Durable medical equipment.—Covered services include
911 equipment and devices that are medically indicated to assist in
912 the treatment of a medical condition and specifically prescribed
913 as medically necessary, with the following limitations:
914 1. Low-vision and telescopic aids aides are not included.
915 2. Corrective lenses and frames may be limited to one pair
916 every 2 years, unless the prescription or head size of the
917 enrollee changes.
918 3. Hearing aids are shall be covered only if when medically
919 indicated to assist in the treatment of a medical condition.
920 4. Covered prosthetic devices include artificial eyes and
921 limbs, braces, and other artificial aids.
922 (i) Health practitioner services.—Covered services include
923 services and procedures rendered to an enrollee if when
924 performed to diagnose and treat diseases, injuries, or other
925 conditions, including care rendered by health practitioners
926 acting within the scope of their practice, with the following
927 exceptions:
928 1. Chiropractic services shall be provided in the same
929 manner as under in the Florida Medicaid program.
930 2. Podiatric services may be limited to one visit per day
931 totaling two visits per month for specific foot disorders.
932 (j) Home health services.—Covered services include
933 prescribed home visits by both registered and licensed practical
934 nurses to provide skilled nursing services on a part-time
935 intermittent basis, subject to the following limitations:
936 1. Coverage may be limited to include skilled nursing
937 services only;
938 2. Meals, housekeeping, and personal comfort items may be
939 excluded; and
940 3. Private duty nursing is limited to circumstances where
941 such care is medically necessary.
942 (k) Hospice services.—Covered services include reasonable
943 and necessary services for palliation or management of an
944 enrollee’s terminal illness, with the following exceptions:
945 1. Once a family elects to receive hospice care for an
946 enrollee, other services that treat the terminal condition will
947 not be covered; and
948 2. Services required for conditions totally unrelated to
949 the terminal condition are covered to the extent that the
950 services are included in this section.
951 (l) Laboratory and X-ray services.—Covered services include
952 diagnostic testing, including clinical radiologic, laboratory,
953 and other diagnostic tests.
954 (m) Nursing facility services.—Covered services include
955 regular nursing services, rehabilitation services, drugs and
956 biologicals, medical supplies, and the use of appliances and
957 equipment furnished by the facility, with the following
958 limitations:
959 1. All admissions must be authorized by the health benefits
960 coverage provider.
961 2. The length of the patient stay shall be determined based
962 on the medical condition of the enrollee in relation to the
963 necessary and appropriate level of care, but is limited to not
964 more than 100 days per contract year.
965 3. Room and board may be limited to semiprivate
966 accommodations, unless a private room is considered medically
967 necessary or semiprivate accommodations are not available.
968 4. Specialized treatment centers and independent kidney
969 disease treatment centers are excluded.
970 5. Private duty nurses, television, and custodial care are
971 excluded.
972 6. Admissions for rehabilitation and physical therapy are
973 limited to 15 days per contract year.
974 (n) Prescribed drugs.—
975 1. Coverage includes shall include drugs prescribed for the
976 treatment of illness or injury if when prescribed by a licensed
977 health practitioner acting within the scope of his or her
978 practice.
979 2. Prescribed drugs may be limited to generics if available
980 and brand name products if a generic substitution is not
981 available, unless the prescribing licensed health practitioner
982 indicates that a brand name is medically necessary.
983 3. Prescribed drugs covered under this section shall
984 include all prescribed drugs covered under the Florida Medicaid
985 program.
986 (o) Therapy services.—Covered services include
987 rehabilitative services, including occupational, physical,
988 respiratory, and speech therapies, with the following
989 limitations:
990 1. Services must be for short-term rehabilitation where
991 significant improvement in the enrollee’s condition will result;
992 and
993 2. Services are shall be limited to not more than 24
994 treatment sessions within a 60-day period per episode or injury,
995 with the 60-day period beginning with the first treatment.
996 (p) Transportation services.—Covered services include
997 emergency transportation required in response to an emergency
998 situation.
999 (q) Dental services.—Effective October 1, 2009, Dental
1000 services are shall be covered as required under federal law and
1001 may also include those dental benefits provided to children by
1002 the Florida Medicaid program under s. 409.906(6).
1003 (r) Lifetime maximum.—Health benefits coverage obtained
1004 under this part ss. 409.810-409.820 shall pay an enrollee’s
1005 covered expenses at a lifetime maximum of $1 million per covered
1006 child.
1007 (s) Cost sharing.—Cost-sharing provisions must comply with
1008 s. 409.816.
1009 (t) Exclusions.—
1010 1. Experimental or investigational procedures that have not
1011 been clinically proven by reliable evidence are excluded;
1012 2. Services performed for cosmetic purposes only or for the
1013 convenience of the enrollee are excluded; and
1014 3. Abortion may be covered only if necessary to save the
1015 life of the mother or if the pregnancy is the result of an act
1016 of rape or incest.
1017 (u) Enhancements to minimum requirements.—
1018 1. This section sets the minimum benefits that must be
1019 included in any health benefits coverage, other than Medicaid or
1020 Medikids coverage, offered under this part ss. 409.810-409.821.
1021 Health benefits coverage may include additional benefits not
1022 included under this subsection, but may not include benefits
1023 excluded under paragraph (s).
1024 2. Health benefits coverage may extend any limitations
1025 beyond the minimum benefits described in this section.
1026
1027 Except for the Children’s Medical Services Network, the agency
1028 may not increase the premium assistance payment for either
1029 additional benefits provided beyond the minimum benefits
1030 described in this section or the imposition of less restrictive
1031 service limitations.
1032 (v) Applicability of other state laws.—Health insurers,
1033 health maintenance organizations, and their agents are subject
1034 to the provisions of the Florida Insurance Code, except for any
1035 such provisions waived under in this section.
1036 1. Except as expressly provided in this section, a law
1037 requiring coverage for a specific health care service or
1038 benefit, or a law requiring reimbursement, utilization, or
1039 consideration of a specific category of licensed health care
1040 practitioner, does not apply to a health insurance plan policy
1041 or contract offered or delivered under this part ss. 409.810
1042 409.821 unless that law is made expressly applicable to such
1043 policies or contracts.
1044 2. Notwithstanding chapter 641, a health maintenance
1045 organization may issue contracts providing benefits equal to,
1046 exceeding, or actuarially equivalent to the benchmark benefit
1047 plan authorized by this section and may pay providers located in
1048 a rural county negotiated fees or Medicaid reimbursement rates
1049 for services provided to enrollees who are residents of the
1050 rural county.
1051 (w) Reimbursement of federally qualified health centers and
1052 rural health clinics.—Effective October 1, 2009, Payments for
1053 services provided to enrollees by federally qualified health
1054 centers and rural health clinics under this section shall be
1055 reimbursed using the Medicaid Prospective Payment System as
1056 provided for under s. 2107(e)(1)(D) of the Social Security Act.
1057 If such services are paid for by health insurers or health care
1058 providers under contract with the Florida Healthy Kids
1059 corporation, such entities are responsible for this payment. The
1060 agency may seek any available federal grants to assist with this
1061 transition.
1062 Section 9. Section 409.816, Florida Statutes, is amended to
1063 read:
1064 409.816 Limitations on premiums and cost sharing.—The
1065 following limitations on premiums and cost sharing are
1066 established for the program.
1067 (1) Enrollees who receive coverage under the Medicaid
1068 program may not be required to pay:
1069 (a) Enrollment fees, premiums, or similar charges; or
1070 (b) Copayments, deductibles, coinsurance, or similar
1071 charges.
1072 (2) Enrollees in households that have families with a
1073 modified adjusted gross family income equal to or below 150
1074 percent of the federal poverty level, who are not receiving
1075 coverage under the Medicaid program, are may not be required to
1076 pay:
1077 (a) Enrollment fees, premiums, or similar charges that
1078 exceed the maximum monthly charge permitted under s. 1916(b)(1)
1079 of the Social Security Act; or
1080 (b) Copayments, deductibles, coinsurance, or similar
1081 charges that exceed a nominal amount, as determined consistent
1082 with regulations referred to in s. 1916(a)(3) of the Social
1083 Security Act. However, such charges may not be imposed for
1084 preventive services, including well-baby and well-child care,
1085 age-appropriate immunizations, and routine hearing and vision
1086 screenings.
1087 (3) Enrollees in households that have families with a
1088 modified adjusted gross family income above 150 percent of the
1089 federal poverty level who are not receiving coverage under the
1090 Medicaid program or who are not eligible under s. 409.814(5) s.
1091 409.814(6) may be required to pay enrollment fees, premiums,
1092 copayments, deductibles, coinsurance, or similar charges on a
1093 sliding scale related to income, except that the total annual
1094 aggregate cost sharing with respect to all children in a
1095 household family may not exceed 5 percent of the household’s
1096 modified adjusted family’s income. However, copayments,
1097 deductibles, coinsurance, or similar charges may not be imposed
1098 for preventive services, including well-baby and well-child
1099 care, age-appropriate immunizations, and routine hearing and
1100 vision screenings.
1101 Section 10. Section 409.817, Florida Statutes, is repealed.
1102 Section 11. Section 409.8175, Florida Statutes, is
1103 repealed.
1104 Section 12. Subsection (1) of section 409.8177, Florida
1105 Statutes, is amended to read:
1106 409.8177 Program evaluation.—
1107 (1) The agency, in consultation with the Department of
1108 Health, the Department of Children and Families Family Services,
1109 and the Florida Healthy Kids corporation, shall contract for an
1110 evaluation of the Florida Kidcare program and shall by January 1
1111 of each year submit to the Governor, the President of the
1112 Senate, and the Speaker of the House of Representatives a report
1113 of the program. In addition to the items specified under s. 2108
1114 of Title XXI of the Social Security Act, the report shall
1115 include an assessment of crowd-out and access to health care, as
1116 well as the following:
1117 (a) An assessment of the operation of the program,
1118 including the progress made in reducing the number of uncovered
1119 low-income children.
1120 (b) An assessment of the effectiveness in increasing the
1121 number of children with creditable health coverage, including an
1122 assessment of the impact of outreach.
1123 (c) The characteristics of the children and families
1124 assisted under the program, including ages of the children,
1125 household family income, and access to or coverage by other
1126 health insurance before enrolling in prior to the program and
1127 after disenrollment from the program.
1128 (d) The quality of health coverage provided, including the
1129 types of benefits provided.
1130 (e) The amount and level, including payment of part or all
1131 of any premium, of assistance provided.
1132 (f) The average length of coverage of a child under the
1133 program.
1134 (g) The program’s choice of health benefits coverage and
1135 other methods used for providing child health assistance.
1136 (h) The sources of nonfederal funding used in the program.
1137 (i) An assessment of the effectiveness of the Florida
1138 Kidcare program, including Medicaid, the Florida Healthy Kids
1139 program, Medikids, and the Children’s Medical Services Network,
1140 and other public and private programs in the state in increasing
1141 the availability of affordable quality health insurance and
1142 health care for children.
1143 (j) A review and assessment of state activities to
1144 coordinate the program with other public and private programs.
1145 (k) An analysis of changes and trends in the state that
1146 affect the provision of health insurance and health care to
1147 children.
1148 (l) A description of any plans the state has for improving
1149 the availability of health insurance and health care for
1150 children.
1151 (m) Recommendations for improving the program.
1152 (n) Other studies as necessary.
1153 Section 13. Section 409.818, Florida Statutes, is amended
1154 to read:
1155 409.818 Administration.—In order to administer this part
1156 implement ss. 409.810-409.821, the following agencies shall have
1157 the following duties:
1158 (1) The Department of Children and Families Family Services
1159 shall:
1160 (a) Maintain Develop a simplified eligibility determination
1161 and renewal process application mail-in form to be used for
1162 determining the eligibility of children for coverage under the
1163 Florida Kidcare program, in consultation with the agency, the
1164 Department of Health, and the Florida Healthy Kids corporation.
1165 The simplified eligibility process application form must include
1166 an item that provides an opportunity for the applicant to
1167 indicate whether coverage is being sought for a child with
1168 special health care needs. Families applying for children’s
1169 Medicaid coverage must also be able to use the simplified
1170 application process form without having to pay a premium.
1171 (b) Establish and maintain the eligibility determination
1172 process under the program except as specified in subsection (3),
1173 which includes the following: (5).
1174 1. The department shall directly, or through the services
1175 of a contracted third-party administrator, establish and
1176 maintain a process to be for determining eligibility of children
1177 for coverage under the program. The eligibility determination
1178 process must be used solely for determining the eligibility of
1179 applicants for health benefits coverage under the program. The
1180 eligibility determination process must include an initial
1181 determination of eligibility for any coverage offered under the
1182 program, as well as a redetermination or reverification of
1183 eligibility each subsequent 6 months. Effective January 1, 1999,
1184 A child who has not attained the age of 5 years of age and who
1185 has been determined eligible for the Medicaid program is
1186 eligible for coverage for 12 months without a redetermination or
1187 reverification of eligibility. In conducting an eligibility
1188 determination, the department shall determine if the child has
1189 special health care needs.
1190 2. The department, in consultation with the agency for
1191 Health Care Administration and the Florida Healthy Kids
1192 corporation, shall develop procedures for redetermining
1193 eligibility which enable applicants and enrollees a family to
1194 easily update any change in circumstances which could affect
1195 eligibility.
1196 3. The department may accept changes in a family’s status
1197 as reported to the department by the Florida Healthy Kids
1198 corporation or the exchange as defined under the Patient
1199 Protection and Affordable Care Act without requiring a new
1200 application from the family. Redetermination of a child’s
1201 eligibility for Medicaid may not be linked to a child’s
1202 eligibility determination for other programs.
1203 4. The department, in consultation with the agency and the
1204 corporation, shall develop a combined eligibility notice to
1205 inform applicants or enrollees of their application or renewal
1206 status, as appropriate. By January 1, 2015, the content of the
1207 notice must be coordinated to meet all federal and state law and
1208 regulatory requirements under the federal Patient Protection and
1209 Affordable Care Act. The notice shall be issued by the last
1210 agency or department to make an eligibility, renewal, or denial
1211 determination.
1212 (c) Inform program applicants about eligibility
1213 determinations and provide information about eligibility of
1214 applicants to the Florida Kidcare program and to insurers and
1215 their agents, through a centralized coordinating office.
1216 (d) Adopt rules necessary for conducting program
1217 eligibility functions.
1218 (2) The Department of Health shall:
1219 (a) Design an eligibility intake process for the program,
1220 in coordination with the Department of Children and Family
1221 Services, the agency, and the Florida Healthy Kids Corporation.
1222 The eligibility intake process may include local intake points
1223 that are determined by the Department of Health in coordination
1224 with the Department of Children and Family Services.
1225 (b) Chair a state-level Florida Kidcare coordinating
1226 council to review and make recommendations concerning the
1227 implementation and operation of the program. The coordinating
1228 council shall include representatives from the department, the
1229 Department of Children and Family Services, the agency, the
1230 Florida Healthy Kids Corporation, the Office of Insurance
1231 Regulation of the Financial Services Commission, local
1232 government, health insurers, health maintenance organizations,
1233 health care providers, families participating in the program,
1234 and organizations representing low-income families.
1235 (c) In consultation with the Florida Healthy Kids
1236 Corporation and the Department of Children and Family Services,
1237 establish a toll-free telephone line to assist families with
1238 questions about the program.
1239 (d) Adopt rules necessary to implement outreach activities.
1240 (2)(3) Pursuant to The agency for Health Care
1241 Administration, under the authority granted in s. 409.914(1),
1242 the agency shall:
1243 (a) Calculate the premium assistance payment necessary to
1244 comply with the premium and cost-sharing limitations specified
1245 in s. 409.816 and the Patient Protection and Affordable Care
1246 Act. The premium assistance payment for each enrollee in a
1247 health insurance plan participating in the Florida Healthy Kids
1248 corporation must shall equal the premium approved by the Florida
1249 Healthy Kids corporation and the Office of Insurance Regulation
1250 of the Financial Services Commission pursuant to ss. 627.410 and
1251 641.31, less any enrollee’s share of the premium established
1252 within the limitations specified in s. 409.816. The premium
1253 assistance payment for each enrollee in an employer-sponsored
1254 health insurance plan approved under ss. 409.810-409.821 shall
1255 equal the premium for the plan adjusted for any benchmark
1256 benefit plan actuarial equivalent benefit rider approved by the
1257 Office of Insurance Regulation pursuant to ss. 627.410 and
1258 641.31, less any enrollee’s share of the premium established
1259 within the limitations specified in s. 409.816. In calculating
1260 the premium assistance payment levels for children with family
1261 coverage, the agency shall set the premium assistance payment
1262 levels for each child proportionately to the total cost of
1263 family coverage.
1264 (b) Make premium assistance payments to health insurance
1265 plans on a periodic basis. The agency may use its Medicaid
1266 fiscal agent or a contracted third-party administrator in making
1267 these payments. The agency may require health insurance plans
1268 that participate in the Medikids program or employer-sponsored
1269 group health insurance to collect premium payments from an
1270 enrollee’s family. Participating health insurance plans shall
1271 report premium payments collected on behalf of enrollees in the
1272 program to the agency in accordance with a schedule established
1273 by the agency.
1274 (c) Monitor compliance with quality assurance and access
1275 standards developed under s. 409.820 and in accordance with s.
1276 2103(f) of the Social Security Act, 42 U.S.C. s. 1397cc(f).
1277 (d) Establish a mechanism for investigating and resolving
1278 complaints and grievances from program applicants, enrollees,
1279 and health benefits coverage providers, and maintain a record of
1280 complaints and confirmed problems. In the case of a child who is
1281 enrolled in a managed care health maintenance organization, the
1282 agency must use the provisions of s. 641.511 to address
1283 grievance reporting and resolution requirements.
1284 (e) Approve health benefits coverage for participation in
1285 the program, following certification by the Office of Insurance
1286 Regulation under subsection (4).
1287 (e)(f) Adopt rules necessary for calculating premium
1288 assistance payment levels, making premium assistance payments,
1289 monitoring access and quality assurance standards and,
1290 investigating and resolving complaints and grievances,
1291 administering the Medikids program, and approving health
1292 benefits coverage.
1293 (f) Contract with the corporation for the administration of
1294 Florida Kidcare and Healthy Florida and to facilitate the
1295 release of any federal and state funds.
1296
1297 The agency is designated the lead state agency for CHIP Title
1298 XXI of the Social Security Act for purposes of receipt of
1299 federal funds, for reporting purposes, and for ensuring
1300 compliance with federal and state regulations and rules.
1301 (4) The Office of Insurance Regulation shall certify that
1302 health benefits coverage plans that seek to provide services
1303 under the Florida Kidcare program, except those offered through
1304 the Florida Healthy Kids Corporation or the Children’s Medical
1305 Services Network, meet, exceed, or are actuarially equivalent to
1306 the benchmark benefit plan and that health insurance plans will
1307 be offered at an approved rate. In determining actuarial
1308 equivalence of benefits coverage, the Office of Insurance
1309 Regulation and health insurance plans must comply with the
1310 requirements of s. 2103 of Title XXI of the Social Security Act.
1311 The department shall adopt rules necessary for certifying health
1312 benefits coverage plans.
1313 (3)(5) The Florida Healthy Kids corporation shall retain
1314 its functions as authorized under s. 409.8125 in s. 624.91,
1315 including eligibility determination for participation in the
1316 Healthy Kids program.
1317 (4)(6) The agency, the Department of Health, the Department
1318 of Children and Families Family Services, and the Florida
1319 Healthy Kids corporation, and the Office of Insurance
1320 Regulation, after consultation with and approval of the Speaker
1321 of the House of Representatives and the President of the Senate,
1322 may are authorized to make program modifications that are
1323 necessary to overcome any objections of the United States
1324 Department of Health and Human Services to obtain approval of
1325 the state’s CHIP child health insurance plan under Title XXI of
1326 the Social Security Act.
1327 Section 14. Section 409.820, Florida Statutes, is amended
1328 to read:
1329 409.820 Quality assurance and access standards.—Except for
1330 Medicaid, the Department of Health, in consultation with the
1331 agency and the Florida Healthy Kids corporation, shall develop a
1332 minimum set of pediatric and adolescent quality assurance and
1333 access standards for all program components. The standards must
1334 include a process for granting exceptions to specific
1335 requirements for quality assurance and access. Compliance with
1336 the standards shall be a condition of program participation by
1337 health benefits coverage providers. These standards must shall
1338 comply with the provisions of this chapter, and chapter 641, and
1339 Title XXI of the Social Security Act.
1340 Section 15. Section 409.822, Florida Statutes, is created
1341 to read:
1342 409.822 Healthy Florida.—
1343 (1) PROGRAM CREATION.—Healthy Florida, a health care
1344 program for lower income, uninsured adults who meet the
1345 eligibility guidelines established under s. 409.8125, is
1346 created. The corporation shall administer the program under its
1347 existing corporate governance and structure.
1348 (2) ELIGIBILITY.—To be eligible and to remain eligible for
1349 Healthy Florida, an individual must be a resident of this state
1350 and meet the following additional criteria:
1351 (a) Be identified as newly eligible, as defined in s.
1352 1902(a)(10)(A)(i)(VIII) of the Social Security Act or s. 2001 of
1353 the federal Patient Protection and Affordable Care Act, and as
1354 may be further defined by federal regulation.
1355 (b) Maintain eligibility with the corporation and meet all
1356 renewal requirements as established by the corporation.
1357 (c) Renew eligibility on at least an annual basis.
1358 (3) ENROLLMENT.—The corporation may begin the enrollment of
1359 applicants in Healthy Florida on October 1, 2014. Enrollment may
1360 occur directly, through the services of a third-party
1361 administrator, referrals from the Department of Children and
1362 Families, and the exchange as defined by the federal Patient
1363 Protection and Affordable Care Act. When an enrollee disenrolls,
1364 the corporation must provide him or her with information about
1365 other affordable insurance programs and electronically refer the
1366 enrollee to the exchange or other programs, as appropriate. The
1367 earliest coverage effective date under the program shall be
1368 January 1, 2015.
1369 (4) DELIVERY OF SERVICES.—The corporation shall contract
1370 with authorized insurers licensed under chapter 627; managed
1371 care organizations authorized under chapter 641; and provider
1372 service networks authorized under ss. 409.912(4)(d) and
1373 409.962(13) which are prepaid plans. These insurers, managed
1374 care organizations, and provider service networks must meet
1375 standards established by the corporation to provide
1376 comprehensive health care services to enrollees who qualify for
1377 services under this section. The corporation may contract for
1378 such services on a statewide or regional basis. To encourage
1379 continuity of care among enrollees who transition across
1380 multiple affordable insurance programs, the corporation is
1381 encouraged to contract with those insurers and managed care
1382 organizations that participate in more than one such program.
1383 (a) The corporation shall establish access and network
1384 standards for such contracts and ensure that contracted
1385 providers have sufficient providers to meet enrollee needs.
1386 Quality standards shall be developed by the corporation,
1387 specific to the adult population, which take into consideration
1388 recommendations from the National Committee on Quality
1389 Assurance, stakeholders, and other existing performance
1390 indicators from both public and commercial populations. The
1391 corporation and its contracted health plans shall develop
1392 policies that minimize the disruption of enrollee medical homes
1393 when enrollees transition between affordable insurance plans.
1394 (b) The corporation shall provide an enrollee a choice of
1395 plans. The corporation may select a plan if no selection has
1396 been received before the coverage start date. Once enrolled, an
1397 enrollee has an initial 90-day, free-look period before a lock
1398 in period of up to 12 months is applied. Exceptions to the lock
1399 in period must be offered to an enrollee for reasons based on
1400 good cause or qualifying events.
1401 (c) The corporation may consider contracts that provide
1402 family plans that would allow members from multiple state and
1403 federally funded programs to remain together under the same
1404 plan.
1405 (d) All contracts must meet the medical loss ratio
1406 requirements under this part.
1407 (5) BENEFITS.—The corporation shall establish a benefits
1408 package that is actuarially equivalent to the benchmark benefit
1409 plan offered under s. 409.815(2), excluding dental, and meets
1410 the alternative benefits package requirements under s. 1937 of
1411 the Social Security Act. Benefits must be offered as an
1412 integrated, single package.
1413 (a) In addition to benchmark benefits, health reimbursement
1414 accounts or a comparable health savings account for each
1415 enrollee must be established through the corporation or the
1416 contracts managed by the corporation. Enrollees must be rewarded
1417 for healthy behaviors, wellness program adherence, and other
1418 activities established by the corporation which demonstrate
1419 compliance with preventive care or disease management
1420 guidelines. Funds deposited into these accounts may be used to
1421 pay cost-sharing obligations or to purchase over-the-counter
1422 health items to the extent allowed under federal law or
1423 regulation.
1424 (b) Enhanced services may be offered if the cost of such
1425 additional services provides savings to the overall plan.
1426 (c) The corporation shall establish a process for the
1427 payment of wrap-around services not covered by the benchmark
1428 benefit plan through a separate subcapitation process to its
1429 contracted providers if it is determined that such services are
1430 required by federal law. Such services would be covered if
1431 deemed medically necessary on an individual basis. The
1432 subcapitation pool is subject to a separate reconciliation
1433 process under the medical loss ratio provisions in this part.
1434 (d) A prior authorization process and other utilization
1435 controls may be established by the plan for any benefit if
1436 approved by the corporation.
1437 (6) COST SHARING.—The corporation may collect premiums and
1438 copayments from enrollees in accordance with federal law.
1439 Amounts to be collected for Healthy Florida must be established
1440 annually in the General Appropriations Act.
1441 (a) Payment of a monthly premium may be required before the
1442 establishment of an enrollee’s coverage start date and to retain
1443 monthly coverage.
1444 (b) An enrollee who has a family income above the federal
1445 poverty level may be required to make nominal copayments, in
1446 accordance with federal rule, as a condition of receiving a
1447 health care service.
1448 (c) A provider is responsible for the collection of point
1449 of-service cost-sharing obligations. The enrollee’s cost-sharing
1450 contribution is considered part of the provider’s total
1451 reimbursement. Failure to collect an enrollee’s cost sharing
1452 reduces the provider’s share of the reimbursement.
1453 (7) PROGRAM MANAGEMENT.—The corporation is responsible for
1454 the oversight of Healthy Florida. The agency shall seek a state
1455 plan amendment or other appropriate federal approval to
1456 implement Healthy Florida. The agency shall consult with the
1457 corporation in the amendment’s development and, by June 14,
1458 2014, submit the state plan amendment to the federal Department
1459 of Health and Human Services. The agency shall contract with the
1460 corporation for the administration of Healthy Florida and for
1461 the timely release of federal and state funds. The agency
1462 retains its authority as provided in ss. 409.902 and 409.963.
1463 (a) The corporation shall establish a grievance resolution
1464 process in which Healthy Florida enrollees are informed of their
1465 rights under the Medicaid fair hearing process, as appropriate,
1466 or any alternative resolution process adopted by the
1467 corporation.
1468 (b) The corporation shall establish a program integrity
1469 process to ensure compliance with program guidelines. At a
1470 minimum, the corporation shall withhold benefits from an
1471 applicant or enrollee if the corporation obtains evidence that
1472 the applicant or enrollee is no longer eligible, submitted
1473 incorrect or fraudulent information in order to establish
1474 eligibility, or failed to provide verification of eligibility.
1475 The corporation shall notify the applicant or enrollee that,
1476 because of such evidence, program benefits must be withheld
1477 unless the applicant or enrollee contacts a designated
1478 representative of the corporation by a specified date, which
1479 must be within 10 working days after the date of notice, to
1480 discuss and resolve the matter. The corporation shall make every
1481 effort to resolve the matter within a timeframe that does not
1482 cause benefits to be withheld from an eligible enrollee. The
1483 following individuals may be subject to specific prosecution in
1484 accordance with s. 414.39:
1485 1. An applicant who obtains or attempts to obtain benefits
1486 for a potential enrollee under Healthy Florida when the
1487 applicant knows or should have known that the potential enrollee
1488 does not qualify for Healthy Florida.
1489 2. An individual who assists an applicant in obtaining or
1490 attempting to obtain benefits for a potential enrollee under
1491 Healthy Florida when the individual knows or should have known
1492 that the potential enrollee does not qualify for Healthy
1493 Florida.
1494 (8) APPLICABILITY OF LAWS RELATING TO MEDICAID.—Sections
1495 409.902, 409.9128, and 409.920 apply to the administration of
1496 Healthy Florida.
1497 (9) PROGRAM EVALUATION.—The corporation shall collect both
1498 eligibility and enrollment data from program applicants and
1499 enrollees as well as encounter and utilization data from all
1500 contracted entities during the program term. The corporation
1501 shall submit monthly enrollment reports to the President of the
1502 Senate, the Speaker of the House of Representatives, and the
1503 Minority Leaders of the Senate and the House of Representatives.
1504 The corporation shall submit an interim independent evaluation
1505 of Healthy Florida to the presiding officers by July 1, 2016,
1506 with annual evaluations due July 1 thereafter. The evaluations
1507 must address, at a minimum, application and enrollment trends
1508 and issues, utilization and cost data, and customer
1509 satisfaction.
1510 (10) PROGRAM EXPIRATION.—The Healthy Florida program
1511 expires at the end of the state fiscal year in which any of
1512 these conditions occur:
1513 (a) The federal match contribution falls below 90 percent.
1514 (b) The federal match contribution falls below the
1515 increased federal medical assistance percentages for medical
1516 assistance for newly eligible mandatory individuals as specified
1517 in the Patient Protection and Affordable Care Act.
1518 (c) The federal match for the Healthy Florida program and
1519 the Medicaid program are blended under federal law or regulation
1520 in a way that causes the overall federal contribution to
1521 diminish when compared to separate, nonblended federal
1522 contributions.
1523 Section 16. The Florida Healthy Kids Corporation may make
1524 such changes as are necessary to comply with the objections of
1525 the federal Department of Health and Human Services in order to
1526 gain approval of the Healthy Florida program in compliance with
1527 the federal Patient Protection and Affordable Care Act, Pub. L.
1528 No. 111-148, as amended by the federal Health Care and Education
1529 Reconciliation Act of 2010, Pub. L. No. 111-152, upon giving
1530 notice to the Senate and the House of Representatives of the
1531 proposed changes. If there is a conflict between this section
1532 and the federal Patient Protection and Affordable Care Act, the
1533 provision must be interpreted and applied so as to comply with
1534 federal law.
1535 Section 17. Paragraph (e) of subsection (2) of section
1536 154.503, Florida Statutes, is amended to read:
1537 154.503 Primary Care for Children and Families Challenge
1538 Grant Program; creation; administration.—
1539 (2) The department shall:
1540 (e) Coordinate with the primary care program developed
1541 pursuant to s. 154.011, the Florida Healthy Kids Corporation
1542 program created in s. 409.8125 s. 624.91, the school health
1543 services program created in ss. 381.0056 and 381.0057, and the
1544 volunteer health care provider program developed pursuant to s.
1545 766.1115.
1546 Section 18. Paragraph (d) of subsection (14) of section
1547 408.910, Florida Statutes, is amended to read:
1548 408.910 Florida Health Choices Program.—
1549 (14) EXEMPTION FROM PUBLIC RECORDS REQUIREMENTS.—
1550 (d) Authorized release.—
1551 1. Upon request, information made confidential and exempt
1552 pursuant to this subsection shall be disclosed to:
1553 a. Another governmental entity in the performance of its
1554 official duties and responsibilities.
1555 b. Any person who has the written consent of the program
1556 applicant.
1557 c. The Florida Kidcare program for the purpose of
1558 administering the program authorized under part II of chapter
1559 409 in ss. 409.810-409.821.
1560 2. Paragraph (b) does not prohibit a participant’s legal
1561 guardian from obtaining confirmation of coverage, dates of
1562 coverage, the name of the participant’s health plan, and the
1563 amount of premium being paid.
1564 Section 19. Paragraph (c) of subsection (4) of section
1565 408.915, Florida Statutes, is amended to read:
1566 408.915 Eligibility pilot project.—The Agency for Health
1567 Care Administration, in consultation with the steering committee
1568 established in s. 408.916, shall develop and implement a pilot
1569 project to integrate the determination of eligibility for health
1570 care services with information and referral services.
1571 (4) The pilot project shall include eligibility
1572 determinations for the following programs:
1573 (c) Florida Healthy Kids as described in s. 409.8125 s.
1574 624.91 and within eligibility guidelines provided in s. 409.814.
1575 Section 20. Section 624.915, Florida Statutes, is repealed.
1576 Section 21. Section 627.6474, Florida Statutes, is amended
1577 to read:
1578 627.6474 Provider contracts.—
1579 (1) A health insurer may shall not require a contracted
1580 health care practitioner as defined in s. 456.001(4) to accept
1581 the terms of other health care practitioner contracts with the
1582 insurer or any other insurer, or health maintenance
1583 organization, under common management and control with the
1584 insurer, including Medicare and Medicaid practitioner contracts
1585 and those authorized by s. 627.6471, s. 627.6472, s. 636.035, or
1586 s. 641.315, except for a practitioner in a group practice as
1587 defined in s. 456.053 who must accept the terms of a contract
1588 negotiated for the practitioner by the group, as a condition of
1589 continuation or renewal of the contract. A Any contract
1590 provision that violates this section is void. A violation of
1591 this subsection section is not subject to the criminal penalty
1592 specified in s. 624.15.
1593 (2) A contract between a health insurer and a dentist
1594 licensed under chapter 466 for the provision of services to an
1595 insured may not:
1596 (a) Contain a provision that requires the dentist to
1597 provide services to the insured under such contract at a fee set
1598 by the health insurer unless such services are covered services
1599 under the applicable contract. Covered services are those
1600 services that are listed as a benefit that the insured is
1601 entitled to receive under the contract. An insurer may not
1602 provide merely de minimis reimbursement or coverage in order to
1603 avoid the requirements of this subsection. Fees for covered
1604 services shall be set in good faith and may not be nominal.
1605 (b) Require as a condition of the contract that the dentist
1606 participate in a discount medical plan under part II of chapter
1607 636.
1608 Section 22. Subsection (13) is added to section 636.035,
1609 Florida Statutes, to read:
1610 636.035 Provider arrangements.—
1611 (13) A contract between a prepaid limited health service
1612 organization and a dentist licensed under chapter 466 for the
1613 provision of services to a subscriber of the prepaid limited
1614 health service organization may not:
1615 (a) Contain a provision that requires the dentist to
1616 provide services to the subscriber of the prepaid limited health
1617 service organization at a fee set by the prepaid limited health
1618 service organization unless such services are covered services
1619 under the applicable contract. Covered services are those
1620 services that are listed as a benefit that the subscriber is
1621 entitled to receive under the contract. A prepaid limited health
1622 service organization may not provide merely de minimis
1623 reimbursement or coverage in order to avoid the requirements of
1624 this subsection. Fees for covered services shall be set in good
1625 faith and may not be nominal.
1626 (b) Require as a condition of the contract that the dentist
1627 participate in a discount medical plan under part II of this
1628 chapter.
1629 Section 23. Subsection (11) is added to section 641.315,
1630 Florida Statutes, to read:
1631 641.315 Provider contracts.—
1632 (11) A contract between a health maintenance organization
1633 and a dentist licensed under chapter 466 for the provision of
1634 services to a subscriber of the health maintenance organization
1635 may not:
1636 (a) Contain a provision that requires the dentist to
1637 provide services to the subscriber of the health maintenance
1638 organization at a fee set by the health maintenance organization
1639 unless such services are covered services under the applicable
1640 contract. Covered services are those services that are listed as
1641 a benefit that the subscriber is entitled to receive under the
1642 contract. A health maintenance organization may not provide
1643 merely de minimis reimbursement or coverage in order to avoid
1644 the requirements of this subsection. Fees for covered services
1645 shall be set in good faith and may not be nominal.
1646 (b) Require as a condition of the contract that the dentist
1647 participate in a discount medical plan under part II of chapter
1648 636.
1649 Section 24. Paragraph (a) of subsection (3) of section
1650 766.1115, Florida Statutes, is amended, and paragraph (h) is
1651 added to subsection (4) of that section, to read:
1652 766.1115 Health care providers; creation of agency
1653 relationship with governmental contractors.—
1654 (3) DEFINITIONS.—As used in this section, the term:
1655 (a) “Contract” means an agreement executed in compliance
1656 with this section between a health care provider and a
1657 governmental contractor which allows. This contract shall allow
1658 the health care provider to deliver health care services to low
1659 income recipients as an agent of the governmental contractor.
1660 The contract must be for volunteer, uncompensated services. For
1661 services to qualify as volunteer, uncompensated services under
1662 this section, the health care provider may not must receive no
1663 compensation from the governmental contractor for any services
1664 provided under the contract and may must not bill or accept
1665 compensation from the recipient, or a any public or private
1666 third-party payor, for the specific services provided to the
1667 low-income recipients covered by the contract.
1668 (4) CONTRACT REQUIREMENTS.—A health care provider that
1669 executes a contract with a governmental contractor to deliver
1670 health care services on or after April 17, 1992, as an agent of
1671 the governmental contractor is an agent for purposes of s.
1672 768.28(9), while acting within the scope of duties under the
1673 contract, if the contract complies with the requirements of this
1674 section and regardless of whether the individual treated is
1675 later found to be ineligible. A health care provider under
1676 contract with the state may not be named as a defendant in any
1677 action arising out of medical care or treatment provided on or
1678 after April 17, 1992, under contracts entered into under this
1679 section. The contract must provide that:
1680 (h) As an agent of the governmental contractor for purposes
1681 of s. 768.28(9), while acting within the scope of duties under
1682 the contract, a health care provider licensed under chapter 466
1683 may allow a patient or a parent or guardian of the patient to
1684 voluntarily contribute a fee to cover costs of dental laboratory
1685 work related to the services provided to the patient. This
1686 contribution may not exceed the actual cost of the dental
1687 laboratory charges and is deemed in compliance with this
1688 section.
1689
1690 A governmental contractor that is also a health care provider is
1691 not required to enter into a contract under this section with
1692 respect to the health care services delivered by its employees.
1693 Section 25. The amendments to ss. 627.6474, 636.035, and
1694 641.315, Florida Statutes, apply to contracts entered into or
1695 renewed on or after July 1, 2014.
1696 Section 26. (1) The sum of $1,258,054,808 from the Medical
1697 Care Trust Fund is appropriated to the Agency for Health Care
1698 Administration beginning in the 2014-2015 fiscal year to provide
1699 coverage for individuals who enroll in the Healthy Florida
1700 program.
1701 (2) The sum of $254,151 from the General Revenue Fund and
1702 $18,235,833 from the Medical Care Trust Fund is appropriated to
1703 the Agency for Health Care Administration beginning in the 2014
1704 2015 fiscal year to comply with federal regulations to
1705 compensate insurers and managed care organizations that contract
1706 with the Healthy Florida program for the imposition of the
1707 annual fee on health insurance providers under s. 9010 of the
1708 federal Patient Protection and Affordable Care Act, Pub. L. No.
1709 111-148, as amended by the federal Health Care and Education
1710 Reconciliation Act of 2010, Pub. L. No. 111-152.
1711 (3) The sum of $10,676,377 from the General Revenue Fund
1712 and $10,676,377 from the Medical Care Trust Fund is appropriated
1713 beginning in the 2014-2015 fiscal year to the Agency for Health
1714 Care Administration to contract with the Florida Healthy Kids
1715 Corporation under s. 409.818(2)(f), Florida Statutes, to fund
1716 the administrative costs of implementing and operating the
1717 Healthy Florida program.
1718 (4) The Agency for Health Care Administration may submit
1719 budget amendments to the Legislative Budget Commission pursuant
1720 to chapter 216, Florida Statutes, during the 2014-2015 fiscal
1721 year to fund the Healthy Florida program for the coverage of
1722 children who transfer from the Florida Kidcare program to the
1723 Healthy Florida program, or to provide additional spending
1724 authority from the Medical Care Trust Fund under subsection (1)
1725 for the coverage of individuals who enroll in the Healthy
1726 Florida program.
1727 Section 27. This act shall take effect upon becoming a law.
