Bill Text: FL S7038 | 2013 | Regular Session | Introduced


Bill Title: Health Care

Spectrum: Committee Bill

Status: (N/A - Dead) 2013-03-27 - Submit as committee bill by Appropriations (SB 1816) [S7038 Detail]

Download: Florida-2013-S7038-Introduced.html
       Florida Senate - 2013         (PROPOSED COMMITTEE BILL) SPB 7038
       
       
       
       FOR CONSIDERATION By the Committee on Appropriations
       
       
       
       
       576-02536-13                                          20137038__
    1                        A bill to be entitled                      
    2         An act relating to health care; amending s.
    3         409.811, F.S.; revising and providing definitions;
    4         amending s. 409.813, F.S.; revising the components of
    5         the Florida Kidcare program; prohibiting a cause of
    6         action from arising against the Florida Healthy Kids
    7         Corporation for failure to make health services
    8         available; amending s. 409.8132, F.S.; revising the
    9         eligibility of the Medikids program component;
   10         revising the enrollment requirements of the Medikids
   11         program component; amending s. 409.8134, F.S.;
   12         conforming provisions to changes made by the act;
   13         amending s. 409.814, F.S.; revising eligibility
   14         requirements for the Florida Kidcare program; amending
   15         s. 409.815, F.S.; revising the minimum health benefits
   16         coverage under the Florida Kidcare Act; deleting
   17         obsolete provisions; amending ss. 409.816 and
   18         409.8177, F.S.; conforming provisions to changes made
   19         by the act; repealing s. 409.817, F.S., relating to
   20         the approval of health benefits coverage and financial
   21         assistance; repealing s. 409.8175, F.S., relating to
   22         delivery of services in rural counties; amending s.
   23         409.818, F.S.; revising the duties of the Department
   24         of Children and Families and the Agency for Health
   25         Care Administration with regard to the Florida Kidcare
   26         Act; deleting the duties of the Department of Health
   27         and the Office of Insurance Regulation with regard to
   28         the Florida Kidcare Act; amending s. 409.820, F.S.;
   29         requiring the Department of Health, in consultation
   30         with the agency and the Florida Healthy Kids
   31         Corporation, to develop a minimum set of pediatric and
   32         adolescent quality assurance and access standards for
   33         all program components; amending s. 624.91, F.S.;
   34         revising the legislative intent of the Florida Healthy
   35         Kids Corporation Act to include the Healthy Florida
   36         program; revising the medical loss ratio requirements
   37         for the contracts for the Florida Healthy Kids
   38         Corporation; modifying the membership of the Florida
   39         Healthy Kids Corporation’s board of directors;
   40         creating an executive steering committee; requiring
   41         additional corporate compliance requirements for the
   42         Florida Healthy Kids Corporation; revising
   43         participation guidelines for non-subsidized enrollees
   44         in the Healthy Kids program; repealing s. 624.915,
   45         F.S., relating to the operating fund of the Florida
   46         Healthy Kids Corporation; creating s. 624.917, F.S.;
   47         creating the Healthy Florida program; providing
   48         definitions; providing eligibility and enrollment
   49         requirements; authorizing the Florida Healthy Kids
   50         Corporation to contract with certain insurers;
   51         requiring the corporation to establish a benefits
   52         package and a process for payment of services;
   53         authorizing the corporation to collect premiums and
   54         copayments; requiring the corporation to oversee the
   55         Healthy Florida program and to establish a grievance
   56         process and integrity process; providing applicability
   57         of certain state laws for administration of the
   58         Healthy Florida program; requiring the corporation to
   59         collect certain data and to submit enrollment reports
   60         and interim independent evaluations to the
   61         Legislature; providing for expiration of the program;
   62         providing an implementation and interpretation clause;
   63         providing an effective date.
   64  
   65  Be It Enacted by the Legislature of the State of Florida:
   66  
   67         Section 1. Section 409.811, Florida Statutes, is amended to
   68  read:
   69         409.811 Definitions relating to Florida Kidcare Act.—As
   70  used in ss. 409.810-409.821, the term:
   71         (1) “Actuarially equivalent” means that:
   72         (a) The aggregate value of the benefits included in health
   73  benefits coverage is equal to the value of the benefits in the
   74  benchmark benefit plan; and
   75         (b) The benefits included in health benefits coverage are
   76  substantially similar to the benefits included in the benchmark
   77  benefit plan, except that preventive health services must be the
   78  same as in the benchmark benefit plan.
   79         (2) “Agency” means the Agency for Health Care
   80  Administration.
   81         (3) “Applicant” means a parent or guardian of a child or a
   82  child whose disability of nonage has been removed under chapter
   83  743, who applies for determination of eligibility for health
   84  benefits coverage under ss. 409.810-409.821.
   85         (4) “Child benchmark benefit plan” means the form and level
   86  of health benefits coverage established in s. 409.815.
   87         (5) “Child” means any person under 19 years of age.
   88         (6) “Child with special health care needs” means a child
   89  whose serious or chronic physical or developmental condition
   90  requires extensive preventive and maintenance care beyond that
   91  required by typically healthy children. Health care utilization
   92  by such a child exceeds the statistically expected usage of the
   93  normal child adjusted for chronological age, and such a child
   94  often needs complex care requiring multiple providers,
   95  rehabilitation services, and specialized equipment in a number
   96  of different settings.
   97         (7) “Children’s Medical Services Network” or “network”
   98  means a statewide managed care service system as defined in s.
   99  391.021(1).
  100         (8) “CHIP” means the children’s health insurance program as
  101  authorized under Title XXI of the Social Security Act, and its
  102  regulations, ss. 409.810-820, and as administered in this state
  103  by the agency, the department and the Florida Healthy Kids
  104  Corporation, as appropriate to their responsibilities.
  105         (9) “Combined eligibility notice” means an eligibility
  106  notice that informs an applicant or enrollee or multiple family
  107  members of a household, when feasible, of eligibility for each
  108  of the insurance affordability programs and enrollment into a
  109  program or exchange plan. A combined eligibility form must be
  110  issued by the last agency or department to make an eligibility,
  111  renewal or denial determination. The form must meet all of the
  112  federal and state law and regulatory requirements no later than
  113  January 1, 2014.
  114         (8) “Community rate” means a method used to develop
  115  premiums for a health insurance plan that spreads financial risk
  116  across a large population and allows adjustments only for age,
  117  gender, family composition, and geographic area.
  118         (10)(9) “Department” means the Department of Health.
  119         (11)(10) “Enrollee” means a child who has been determined
  120  eligible for and is receiving coverage under ss. 409.810
  121  409.821.
  122         (11) “Family” means the group or the individuals whose
  123  income is considered in determining eligibility for the Florida
  124  Kidcare program. The family includes a child with a parent or
  125  caretaker relative who resides in the same house or living unit
  126  or, in the case of a child whose disability of nonage has been
  127  removed under chapter 743, the child. The family may also
  128  include other individuals whose income and resources are
  129  considered in whole or in part in determining eligibility of the
  130  child.
  131         (12) “Family income” means cash received at periodic
  132  intervals from any source, such as wages, benefits,
  133  contributions, or rental property. Income also may include any
  134  money that would have been counted as income under the Aid to
  135  Families with Dependent Children (AFDC) state plan in effect
  136  prior to August 22, 1996.
  137         (12)(13) “Florida Kidcare program,” “Kidcare program,” or
  138  “program” means the health benefits program administered through
  139  ss. 409.810-409.821.
  140         (13)(14) “Guarantee issue” means that health benefits
  141  coverage must be offered to an individual regardless of the
  142  individual’s health status, preexisting condition, or claims
  143  history.
  144         (14)(15) “Health benefits coverage” means protection that
  145  provides payment of benefits for covered health care services or
  146  that otherwise provides, either directly or through arrangements
  147  with other persons, covered health care services on a prepaid
  148  per capita basis or on a prepaid aggregate fixed-sum basis.
  149         (15)(16) “Health insurance plan” means health benefits
  150  coverage under the following:
  151         (a) A health plan offered by any certified health
  152  maintenance organization or authorized health insurer, except a
  153  plan that is limited to the following: a limited benefit,
  154  specified disease, or specified accident; hospital indemnity;
  155  accident only; limited benefit convalescent care; Medicare
  156  supplement; credit disability; dental; vision; long-term care;
  157  disability income; coverage issued as a supplement to another
  158  health plan; workers’ compensation liability or other insurance;
  159  or motor vehicle medical payment only; or
  160         (b) An employee welfare benefit plan that includes health
  161  benefits established under the Employee Retirement Income
  162  Security Act of 1974, as amended.
  163         (16) “Household income” means the group or the individual
  164  whose income is considered in determining eligibility for the
  165  Florida Kidcare program. The term “household” has the same
  166  meaning as provided in section 36B(d)(2) of the Internal Revenue
  167  Code of 1986.
  168         (17) “Medicaid” means the medical assistance program
  169  authorized by Title XIX of the Social Security Act, and
  170  regulations thereunder, and ss. 409.901-409.920, as administered
  171  in this state by the agency.
  172         (18) “Medically necessary” means the use of any medical
  173  treatment, service, equipment, or supply necessary to palliate
  174  the effects of a terminal condition, or to prevent, diagnose,
  175  correct, cure, alleviate, or preclude deterioration of a
  176  condition that threatens life, causes pain or suffering, or
  177  results in illness or infirmity and which is:
  178         (a) Consistent with the symptom, diagnosis, and treatment
  179  of the enrollee’s condition;
  180         (b) Provided in accordance with generally accepted
  181  standards of medical practice;
  182         (c) Not primarily intended for the convenience of the
  183  enrollee, the enrollee’s family, or the health care provider;
  184         (d) The most appropriate level of supply or service for the
  185  diagnosis and treatment of the enrollee’s condition; and
  186         (e) Approved by the appropriate medical body or health care
  187  specialty involved as effective, appropriate, and essential for
  188  the care and treatment of the enrollee’s condition.
  189         (19) “Medikids” means a component of the Florida Kidcare
  190  program of medical assistance authorized by Title XXI of the
  191  Social Security Act, and regulations thereunder, and s.
  192  409.8132, as administered in the state by the agency.
  193         (20)“Modified Adjusted Gross Income (MAGI)” means the
  194  individual or household’s annual adjusted gross income as
  195  defined in 26 U.S.C. s. 36 of the Internal Revenue Code of 1986
  196  which is used to determine eligibility under the Florida Kidcare
  197  program.
  198         (21) “Patient Protection and Affordable Care Act” or “Act”
  199  means the federal law enacted as Public Law 111-148, as further
  200  amended by the federal Health Care and Education Reconciliation
  201  Act of 2010, Public Law 111-152, and any amendments,
  202  regulations, or guidance thereunder, issued under those acts.
  203         (22)(20) “Preexisting condition exclusion” means, with
  204  respect to coverage, a limitation or exclusion of benefits
  205  relating to a condition based on the fact that the condition was
  206  present before the date of enrollment for such coverage, whether
  207  or not any medical advice, diagnosis, care, or treatment was
  208  recommended or received before such date.
  209         (23)(21) “Premium” means the entire cost of a health
  210  insurance plan, including the administration fee or the risk
  211  assumption charge.
  212         (24)(22) “Premium assistance payment” means the monthly
  213  consideration paid by the agency per enrollee in the Florida
  214  Kidcare program towards health insurance premiums.
  215         (25)(23) “Qualified alien” means an alien as defined in 8
  216  U.S.C. s. 1641 (b) and (c) s. 431 of the Personal Responsibility
  217  and Work Opportunity Reconciliation Act of 1996, as amended,
  218  Pub. L. No. 104-193.
  219         (26)(24) “Resident” means a United States citizen, or
  220  qualified alien, who is domiciled in this state.
  221         (27)(25) “Rural county” means a county having a population
  222  density of less than 100 persons per square mile, or a county
  223  defined by the most recent United States Census as rural, in
  224  which there is no prepaid health plan participating in the
  225  Medicaid program as of July 1, 1998.
  226         (26) “Substantially similar” means that, with respect to
  227  additional services as defined in s. 2103(c)(2) of Title XXI of
  228  the Social Security Act, these services must have an actuarial
  229  value equal to at least 75 percent of the actuarial value of the
  230  coverage for that service in the benchmark benefit plan and,
  231  with respect to the basic services as defined in s. 2103(c)(1)
  232  of Title XXI of the Social Security Act, these services must be
  233  the same as the services in the benchmark benefit plan.
  234         Section 2. Section 409.813, Florida Statutes, is amended to
  235  read:
  236         409.813 Health benefits coverage; program components;
  237  entitlement and nonentitlement.—
  238         (1) The Florida Kidcare program includes health benefits
  239  coverage provided to children through the following program
  240  components, which shall be marketed as the Florida Kidcare
  241  program:
  242         (a) Medicaid;
  243         (b) Medikids as created in s. 409.8132;
  244         (c) The Florida Healthy Kids Corporation as created in s.
  245  624.91; and
  246         (d) Employer-sponsored group health insurance plans
  247  approved under ss. 409.810-409.821; and
  248         (d)(e) The Children’s Medical Services network established
  249  in chapter 391.
  250         (2) Except for Title XIX-funded Florida Kidcare program
  251  coverage under the Medicaid program, coverage under the Florida
  252  Kidcare program is not an entitlement. No cause of action shall
  253  arise against the state, the department, the Department of
  254  Children and Family Services, or the agency, or the Florida
  255  Healthy Kids Corporation for failure to make health services
  256  available to any person under ss. 409.810-409.821.
  257         Section 3. Subsections (6) and (7) of section 409.8132,
  258  Florida Statutes, are amended to read:
  259         409.8132 Medikids program component.—
  260         (6) ELIGIBILITY.—
  261         (a) A child who has attained the age of 1 year but who is
  262  under the age of 5 years is eligible to enroll in the Medikids
  263  program component of the Florida Kidcare program, if the child
  264  is a member of a family that has a family income which exceeds
  265  the Medicaid applicable income level as specified in s. 409.903,
  266  but which is equal to or below 200 percent of the current
  267  federal poverty level. In determining the eligibility of such a
  268  child, an assets test is not required. A child who is eligible
  269  for Medikids may elect to enroll in Florida Healthy Kids
  270  coverage or employer-sponsored group coverage. However, a child
  271  who is eligible for Medikids may participate in the Florida
  272  Healthy Kids program only if the child has a sibling
  273  participating in the Florida Healthy Kids program and the
  274  child’s county of residence permits such enrollment.
  275         (b) The provisions of s. 409.814 apply to the Medikids
  276  program.
  277         (7) ENROLLMENT.—Enrollment in the Medikids program
  278  component may occur at any time throughout the year. A child may
  279  not receive services under the Medikids program until the child
  280  is enrolled in a managed care plan or MediPass. Once determined
  281  eligible, an applicant may receive choice counseling and select
  282  a managed care plan or MediPass. The agency may initiate
  283  mandatory assignment for a Medikids applicant who has not chosen
  284  a managed care plan or MediPass provider after the applicant’s
  285  voluntary choice period ends. An applicant may select MediPass
  286  under the Medikids program component only in counties that have
  287  fewer than two managed care plans available to serve Medicaid
  288  recipients and only if the federal Health Care Financing
  289  Administration determines that MediPass constitutes “health
  290  insurance coverage” as defined in Title XXI of the Social
  291  Security Act.
  292         Section 4. Subsection (2) of section 409.8134, Florida
  293  Statutes, is amended to read:
  294         409.8134 Program expenditure ceiling; enrollment.—
  295         (2) The Florida Kidcare program may conduct enrollment
  296  continuously throughout the year.
  297         (a) Children eligible for coverage under the Title XXI
  298  funded Florida Kidcare program shall be enrolled on a first
  299  come, first-served basis using the date the enrollment
  300  application is received. Enrollment shall immediately cease when
  301  the expenditure ceiling is reached. Year-round enrollment shall
  302  only be held if the Social Services Estimating Conference
  303  determines that sufficient federal and state funds will be
  304  available to finance the increased enrollment.
  305         (b) The application for the Florida Kidcare program is
  306  valid for a period of 120 days after the date it was received.
  307  At the end of the 120-day period, if the applicant has not been
  308  enrolled in the program, the application is invalid and the
  309  applicant shall be notified of the action. The applicant may
  310  reactivate the application after notification of the action
  311  taken by the program.
  312         (c) Except for the Medicaid program, whenever the Social
  313  Services Estimating Conference determines that there are
  314  presently, or will be by the end of the current fiscal year,
  315  insufficient funds to finance the current or projected
  316  enrollment in the Florida Kidcare program, all additional
  317  enrollment must cease and additional enrollment may not resume
  318  until sufficient funds are available to finance such enrollment.
  319         Section 5. Section 409.814, Florida Statutes, is amended to
  320  read:
  321         409.814 Eligibility.—A child who has not reached 19 years
  322  of age whose household family income is equal to or below 200
  323  percent of the federal poverty level is eligible for the Florida
  324  Kidcare program as provided in this section. If an enrolled
  325  individual is determined to be ineligible for coverage, he or
  326  she must be immediately disenrolled from the respective Florida
  327  Kidcare program component and referred to another insurance
  328  affordability program, if appropriate, through a combined
  329  eligibility notice.
  330         (1) A child who is eligible for Medicaid coverage under s.
  331  409.903 or s. 409.904 must be offered the opportunity to enroll
  332  enrolled in Medicaid and is not eligible to receive health
  333  benefits under any other health benefits coverage authorized
  334  under the Florida Kidcare program. A child who is eligible for
  335  Medicaid and opts to enroll in CHIP may disenroll from CHIP at
  336  any time and transition to Medicaid. This transition must occur
  337  without any break in coverage.
  338         (2) A child who is not eligible for Medicaid, but who is
  339  eligible for the Florida Kidcare program, may obtain health
  340  benefits coverage under any of the other components listed in s.
  341  409.813 if such coverage is approved and available in the county
  342  in which the child resides.
  343         (3) A Title XXI-funded child who is eligible for the
  344  Florida Kidcare program who is a child with special health care
  345  needs, as determined through a medical or behavioral screening
  346  instrument, is eligible for health benefits coverage from and
  347  shall be assigned to and may opt out of the Children’s Medical
  348  Services Network.
  349         (4) The following children are not eligible to receive
  350  Title XXI-funded premium assistance for health benefits coverage
  351  under the Florida Kidcare program, except under Medicaid if the
  352  child would have been eligible for Medicaid under s. 409.903 or
  353  s. 409.904 as of June 1, 1997:
  354         (a) A child who is covered under a family member’s group
  355  health benefit plan or under other private or employer health
  356  insurance coverage, if the cost of the child’s participation is
  357  not greater than 5 percent of the household’s family’s income.
  358  If a child is otherwise eligible for a subsidy under the Florida
  359  Kidcare program and the cost of the child’s participation in the
  360  family member’s health insurance benefit plan is greater than 5
  361  percent of the household’s family’s income, the child may enroll
  362  in the appropriate subsidized Kidcare program.
  363         (b) A child who is seeking premium assistance for the
  364  Florida Kidcare program through employer-sponsored group
  365  coverage, if the child has been covered by the same employer’s
  366  group coverage during the 60 days before the family submitted an
  367  application for determination of eligibility under the program.
  368         (b)(c) A child who is an alien, but who does not meet the
  369  definition of qualified alien, in the United States.
  370         (c)(d) A child who is an inmate of a public institution or
  371  a patient in an institution for mental diseases.
  372         (d)(e) A child who is otherwise eligible for premium
  373  assistance for the Florida Kidcare program and has had his or
  374  her coverage in an employer-sponsored or private health benefit
  375  plan voluntarily canceled in the last 60 days, except those
  376  children whose coverage was voluntarily canceled for good cause,
  377  including, but not limited to, the following circumstances:
  378         1. The cost of participation in an employer-sponsored
  379  health benefit plan is greater than 5 percent of the household’s
  380  modified adjusted gross family’s income;
  381         2. The parent lost a job that provided an employer
  382  sponsored health benefit plan for children;
  383         3. The parent who had health benefits coverage for the
  384  child is deceased;
  385         4. The child has a medical condition that, without medical
  386  care, would cause serious disability, loss of function, or
  387  death;
  388         5. The employer of the parent canceled health benefits
  389  coverage for children;
  390         6. The child’s health benefits coverage ended because the
  391  child reached the maximum lifetime coverage amount;
  392         7. The child has exhausted coverage under a COBRA
  393  continuation provision;
  394         8. The health benefits coverage does not cover the child’s
  395  health care needs; or
  396         9. Domestic violence led to loss of coverage.
  397         (5) A child who is otherwise eligible for the Florida
  398  Kidcare program and who has a preexisting condition that
  399  prevents coverage under another insurance plan as described in
  400  paragraph (4)(a) which would have disqualified the child for the
  401  Florida Kidcare program if the child were able to enroll in the
  402  plan is eligible for Florida Kidcare coverage when enrollment is
  403  possible.
  404         (5)(6) A child whose household’s modified adjusted gross
  405  family income is above 200 percent of the federal poverty level
  406  or a child who is excluded under the provisions of subsection
  407  (4) may participate in the Florida Kidcare program as provided
  408  in s. 409.8132 or, if the child is ineligible for Medikids by
  409  reason of age, in the Florida Healthy Kids program, subject to
  410  the following:
  411         (a) The family is not eligible for premium assistance
  412  payments and must pay the full cost of the premium, including
  413  any administrative costs.
  414         (b) The board of directors of the Florida Healthy Kids
  415  Corporation may offer a reduced benefit package to these
  416  children in order to limit program costs for such families.
  417         (c) By August 15, 2013, the Florida Healthy Kids
  418  Corporation shall notify all current full-pay enrollees of the
  419  availability of the exchange and how to access other insurance
  420  affordability options. New applications for full-pay coverage
  421  may not be accepted after September 30, 2013.
  422         (6)(7) Once a child is enrolled in the Florida Kidcare
  423  program, the child is eligible for coverage for 12 months
  424  without a redetermination or reverification of eligibility, if
  425  the family continues to pay the applicable premium. Eligibility
  426  for program components funded through Title XXI of the Social
  427  Security Act terminates when a child attains the age of 19. A
  428  child who has not attained the age of 5 and who has been
  429  determined eligible for the Medicaid program is eligible for
  430  coverage for 12 months without a redetermination or
  431  reverification of eligibility.
  432         (7)(8) When determining or reviewing a child’s eligibility
  433  under the Florida Kidcare program, the applicant shall be
  434  provided with reasonable notice of changes in eligibility which
  435  may affect enrollment in one or more of the program components.
  436  If a transition from one program component to another is
  437  authorized, there shall be cooperation between the program
  438  components and the affected family which promotes continuity of
  439  health care coverage. Any authorized transfers must be managed
  440  within the program’s overall appropriated or authorized levels
  441  of funding. Each component of the program shall establish a
  442  reserve to ensure that transfers between components will be
  443  accomplished within current year appropriations. These reserves
  444  shall be reviewed by each convening of the Social Services
  445  Estimating Conference to determine the adequacy of such reserves
  446  to meet actual experience.
  447         (8)(9) In determining the eligibility of a child, an assets
  448  test is not required. Each applicant shall provide documentation
  449  during the application process and the redetermination process,
  450  including, but not limited to, the following:
  451         (a) Proof of household family income, which must be
  452  verified electronically to determine financial eligibility for
  453  the Florida Kidcare program. Written documentation, which may
  454  include wages and earnings statements or pay stubs, W-2 forms,
  455  or a copy of the applicant’s most recent federal income tax
  456  return, is required only if the electronic verification is not
  457  available or does not substantiate the applicant’s income. This
  458  paragraph expires December 31, 2013.
  459         (b)  A statement from all applicable, employed household
  460  family members that:
  461         1. Their employers do not sponsor health benefit plans for
  462  employees;
  463         2. The potential enrollee is not covered by an employer
  464  sponsored health benefit plan; or
  465         3. The potential enrollee is covered by an employer
  466  sponsored health benefit plan and the cost of the employer
  467  sponsored health benefit plan is more than 5 percent of the
  468  household’s modified adjusted gross family’s income.
  469         (c) To enroll in the Children’s Medical Services Network, a
  470  completed application, including a clinical screening.
  471         (d) Effective January 1, 2014, eligibility will be
  472  determined through electronic matching using the federal hub and
  473  other resources. Written documentation from the applicant may be
  474  accepted if the electronic verification does not substantiate
  475  the applicant’s income or if there has been a change in
  476  circumstances.
  477         (9)(10) Subject to paragraph (4)(a), the Florida Kidcare
  478  program shall withhold benefits from an enrollee if the program
  479  obtains evidence that the enrollee is no longer eligible,
  480  submitted incorrect or fraudulent information in order to
  481  establish eligibility, or failed to provide verification of
  482  eligibility. The applicant or enrollee shall be notified that
  483  because of such evidence program benefits will be withheld
  484  unless the applicant or enrollee contacts a designated
  485  representative of the program by a specified date, which must be
  486  within 10 working days after the date of notice, to discuss and
  487  resolve the matter. The program shall make every effort to
  488  resolve the matter within a timeframe that will not cause
  489  benefits to be withheld from an eligible enrollee.
  490         (10)(11) The following individuals may be subject to
  491  prosecution in accordance with s. 414.39:
  492         (a) An applicant obtaining or attempting to obtain benefits
  493  for a potential enrollee under the Florida Kidcare program when
  494  the applicant knows or should have known the potential enrollee
  495  does not qualify for the Florida Kidcare program.
  496         (b) An individual who assists an applicant in obtaining or
  497  attempting to obtain benefits for a potential enrollee under the
  498  Florida Kidcare program when the individual knows or should have
  499  known the potential enrollee does not qualify for the Florida
  500  Kidcare program.
  501         Section 6. Paragraphs (g), (k), (q), and (w) of subsection
  502  (2) of section 409.815, Florida Statutes, are amended to read:
  503         409.815 Health benefits coverage; limitations.—
  504         (2) BENCHMARK BENEFITS.—In order for health benefits
  505  coverage to qualify for premium assistance payments for an
  506  eligible child under ss. 409.810-409.821, the health benefits
  507  coverage, except for coverage under Medicaid and Medikids, must
  508  include the following minimum benefits, as medically necessary.
  509         (g) Behavioral health services.—
  510         1. Mental health benefits include:
  511         a. Inpatient services, limited to 30 inpatient days per
  512  contract year for psychiatric admissions, or residential
  513  services in facilities licensed under s. 394.875(6) or s.
  514  395.003 in lieu of inpatient psychiatric admissions; however, a
  515  minimum of 10 of the 30 days shall be available only for
  516  inpatient psychiatric services if authorized by a physician; and
  517         b. Outpatient services, including outpatient visits for
  518  psychological or psychiatric evaluation, diagnosis, and
  519  treatment by a licensed mental health professional, limited to
  520  40 outpatient visits each contract year.
  521         2. Substance abuse services include:
  522         a. Inpatient services, limited to 7 inpatient days per
  523  contract year for medical detoxification only and 30 days of
  524  residential services; and
  525         b. Outpatient services, including evaluation, diagnosis,
  526  and treatment by a licensed practitioner, limited to 40
  527  outpatient visits per contract year.
  528  
  529  Effective October 1, 2009, Covered services include inpatient
  530  and outpatient services for mental and nervous disorders as
  531  defined in the most recent edition of the Diagnostic and
  532  Statistical Manual of Mental Disorders published by the American
  533  Psychiatric Association. Such benefits include psychological or
  534  psychiatric evaluation, diagnosis, and treatment by a licensed
  535  mental health professional and inpatient, outpatient, and
  536  residential treatment of substance abuse disorders. Any benefit
  537  limitations, including duration of services, number of visits,
  538  or number of days for hospitalization or residential services,
  539  shall not be any less favorable than those for physical
  540  illnesses generally. The program may also implement appropriate
  541  financial incentives, peer review, utilization requirements, and
  542  other methods used for the management of benefits provided for
  543  other medical conditions in order to reduce service costs and
  544  utilization without compromising quality of care.
  545         (k) Hospice services.—Covered services include reasonable
  546  and necessary services for palliation or management of an
  547  enrollee’s terminal illness, with the following exceptions:
  548         1. Once a family elects to receive hospice care for an
  549  enrollee, other services that treat the terminal condition will
  550  not be covered; and
  551         2. Services required for conditions totally unrelated to
  552  the terminal condition are covered to the extent that the
  553  services are included in this section.
  554         (q) Dental services.Effective October 1, 2009, Dental
  555  services shall be covered as required under federal law and may
  556  also include those dental benefits provided to children by the
  557  Florida Medicaid program under s. 409.906(6).
  558         (w) Reimbursement of federally qualified health centers and
  559  rural health clinics.Effective October 1, 2009, Payments for
  560  services provided to enrollees by federally qualified health
  561  centers and rural health clinics under this section shall be
  562  reimbursed using the Medicaid Prospective Payment System as
  563  provided for under s. 2107(e)(1)(D) of the Social Security Act.
  564  If such services are paid for by health insurers or health care
  565  providers under contract with the Florida Healthy Kids
  566  Corporation, such entities are responsible for this payment. The
  567  agency may seek any available federal grants to assist with this
  568  transition.
  569         Section 7. Section 409.816, Florida Statutes, is amended to
  570  read:
  571         409.816 Limitations on premiums and cost-sharing.—The
  572  following limitations on premiums and cost-sharing are
  573  established for the program.
  574         (1) Enrollees who receive coverage under the Medicaid
  575  program may not be required to pay:
  576         (a) Enrollment fees, premiums, or similar charges; or
  577         (b) Copayments, deductibles, coinsurance, or similar
  578  charges.
  579         (2) Enrollees in households that have families with a
  580  modified adjusted gross family income equal to or below 150
  581  percent of the federal poverty level, who are not receiving
  582  coverage under the Medicaid program, may not be required to pay:
  583         (a) Enrollment fees, premiums, or similar charges that
  584  exceed the maximum monthly charge permitted under s. 1916(b)(1)
  585  of the Social Security Act; or
  586         (b) Copayments, deductibles, coinsurance, or similar
  587  charges that exceed a nominal amount, as determined consistent
  588  with regulations referred to in s. 1916(a)(3) of the Social
  589  Security Act. However, such charges may not be imposed for
  590  preventive services, including well-baby and well-child care,
  591  age-appropriate immunizations, and routine hearing and vision
  592  screenings.
  593         (3) Enrollees in households that have families with a
  594  modified adjusted gross family income above 150 percent of the
  595  federal poverty level who are not receiving coverage under the
  596  Medicaid program or who are not eligible under s. 409.814(5) s.
  597  409.814(6) may be required to pay enrollment fees, premiums,
  598  copayments, deductibles, coinsurance, or similar charges on a
  599  sliding scale related to income, except that the total annual
  600  aggregate cost-sharing with respect to all children in a
  601  household family may not exceed 5 percent of the household’s
  602  modified adjusted family’s income. However, copayments,
  603  deductibles, coinsurance, or similar charges may not be imposed
  604  for preventive services, including well-baby and well-child
  605  care, age-appropriate immunizations, and routine hearing and
  606  vision screenings.
  607         Section 8. Section 409.817, Florida Statutes, is repealed.
  608         Section 9. Section 409.8175, Florida Statutes, is repealed.
  609         Section 10. Paragraph (c) of subsection (1) of section
  610  409.8177, Florida Statutes, is amended to read:
  611         409.8177 Program evaluation.—
  612         (1) The agency, in consultation with the Department of
  613  Health, the Department of Children and Family Services, and the
  614  Florida Healthy Kids Corporation, shall contract for an
  615  evaluation of the Florida Kidcare program and shall by January 1
  616  of each year submit to the Governor, the President of the
  617  Senate, and the Speaker of the House of Representatives a report
  618  of the program. In addition to the items specified under s. 2108
  619  of Title XXI of the Social Security Act, the report shall
  620  include an assessment of crowd-out and access to health care, as
  621  well as the following:
  622         (c) The characteristics of the children and families
  623  assisted under the program, including ages of the children,
  624  household family income, and access to or coverage by other
  625  health insurance prior to the program and after disenrollment
  626  from the program.
  627         Section 11. Section 409.818, Florida Statutes, is amended
  628  to read:
  629         409.818 Administration.—In order to implement ss. 409.810
  630  409.821, the following agencies shall have the following duties:
  631         (1) The Department of Children and Family Services shall:
  632         (a) Maintain Develop a simplified eligibility determination
  633  and renewal process application mail-in form to be used for
  634  determining the eligibility of children for coverage under the
  635  Florida Kidcare program, in consultation with the agency, the
  636  Department of Health, and the Florida Healthy Kids Corporation.
  637  The simplified eligibility process application form must include
  638  an item that provides an opportunity for the applicant to
  639  indicate whether coverage is being sought for a child with
  640  special health care needs. Families applying for children’s
  641  Medicaid coverage must also be able to use the simplified
  642  application process form without having to pay a premium.
  643         (b) Establish and maintain the eligibility determination
  644  process under the program except as specified in subsection (3),
  645  which includes the following: (5).
  646         1. The department shall directly, or through the services
  647  of a contracted third-party administrator, establish and
  648  maintain a process for determining eligibility of children for
  649  coverage under the program. The eligibility determination
  650  process must be used solely for determining eligibility of
  651  applicants for health benefits coverage under the program. The
  652  eligibility determination process must include an initial
  653  determination of eligibility for any coverage offered under the
  654  program, as well as a redetermination or reverification of
  655  eligibility each subsequent 6 months. Effective January 1, 1999,
  656  A child who has not attained the age of 5 and who has been
  657  determined eligible for the Medicaid program is eligible for
  658  coverage for 12 months without a redetermination or
  659  reverification of eligibility. In conducting an eligibility
  660  determination, the department shall determine if the child has
  661  special health care needs.
  662         2. The department, in consultation with the Agency for
  663  Health Care Administration and the Florida Healthy Kids
  664  Corporation, shall develop procedures for redetermining
  665  eligibility which enable applicants and enrollees a family to
  666  easily update any change in circumstances which could affect
  667  eligibility.
  668         3. The department may accept changes in a family’s status
  669  as reported to the department by the Florida Healthy Kids
  670  Corporation or the exchange without requiring a new application
  671  from the family. Redetermination of a child’s eligibility for
  672  Medicaid may not be linked to a child’s eligibility
  673  determination for other programs.
  674         4. The department, in consultation with the agency and the
  675  Florida Healthy Kids Corporation, shall develop a combined
  676  eligibility notice to inform applicants and enrollees of their
  677  application or renewal status, as appropriate. The content must
  678  be coordinated to meet all federal and state requirements under
  679  the Act.
  680         (c) Inform program applicants about eligibility
  681  determinations and provide information about eligibility of
  682  applicants to the Florida Kidcare program and to insurers and
  683  their agents, through a centralized coordinating office.
  684         (d) Adopt rules necessary for conducting program
  685  eligibility functions.
  686         (2) The Department of Health shall:
  687         (a) Design an eligibility intake process for the program,
  688  in coordination with the Department of Children and Family
  689  Services, the agency, and the Florida Healthy Kids Corporation.
  690  The eligibility intake process may include local intake points
  691  that are determined by the Department of Health in coordination
  692  with the Department of Children and Family Services.
  693         (b) Chair a state-level Florida Kidcare coordinating
  694  council to review and make recommendations concerning the
  695  implementation and operation of the program. The coordinating
  696  council shall include representatives from the department, the
  697  Department of Children and Family Services, the agency, the
  698  Florida Healthy Kids Corporation, the Office of Insurance
  699  Regulation of the Financial Services Commission, local
  700  government, health insurers, health maintenance organizations,
  701  health care providers, families participating in the program,
  702  and organizations representing low-income families.
  703         (c) In consultation with the Florida Healthy Kids
  704  Corporation and the Department of Children and Family Services,
  705  establish a toll-free telephone line to assist families with
  706  questions about the program.
  707         (d) Adopt rules necessary to implement outreach activities.
  708         (2)(3) The Agency for Health Care Administration, under the
  709  authority granted in s. 409.914(1), shall:
  710         (a) Calculate the premium assistance payment necessary to
  711  comply with the premium and cost-sharing limitations specified
  712  in s. 409.816 and the Act. The premium assistance payment for
  713  each enrollee in a health insurance plan participating in the
  714  Florida Healthy Kids Corporation shall equal the premium
  715  approved by the Florida Healthy Kids Corporation and the Office
  716  of Insurance Regulation of the Financial Services Commission
  717  pursuant to ss. 627.410 and 641.31, less any enrollee’s share of
  718  the premium established within the limitations specified in s.
  719  409.816. The premium assistance payment for each enrollee in an
  720  employer-sponsored health insurance plan approved under ss.
  721  409.810-409.821 shall equal the premium for the plan adjusted
  722  for any benchmark benefit plan actuarial equivalent benefit
  723  rider approved by the Office of Insurance Regulation pursuant to
  724  ss. 627.410 and 641.31, less any enrollee’s share of the premium
  725  established within the limitations specified in s. 409.816. In
  726  calculating the premium assistance payment levels for children
  727  with family coverage, the agency shall set the premium
  728  assistance payment levels for each child proportionately to the
  729  total cost of family coverage.
  730         (b) Make premium assistance payments to health insurance
  731  plans on a periodic basis. The agency may use its Medicaid
  732  fiscal agent or a contracted third-party administrator in making
  733  these payments. The agency may require health insurance plans
  734  that participate in the Medikids program or employer-sponsored
  735  group health insurance to collect premium payments from an
  736  enrollee’s family. Participating health insurance plans shall
  737  report premium payments collected on behalf of enrollees in the
  738  program to the agency in accordance with a schedule established
  739  by the agency.
  740         (c) Monitor compliance with quality assurance and access
  741  standards developed under s. 409.820 and in accordance with s.
  742  2103(f) of the Social Security Act, 42 U.S.C. s. 1397cc(f).
  743         (d) Establish a mechanism for investigating and resolving
  744  complaints and grievances from program applicants, enrollees,
  745  and health benefits coverage providers, and maintain a record of
  746  complaints and confirmed problems. In the case of a child who is
  747  enrolled in a managed care organization health maintenance
  748  organization, the agency must use the provisions of s. 641.511
  749  to address grievance reporting and resolution requirements.
  750         (e) Approve health benefits coverage for participation in
  751  the program, following certification by the Office of Insurance
  752  Regulation under subsection (4).
  753         (e)(f) Adopt rules necessary for calculating premium
  754  assistance payment levels, making premium assistance payments,
  755  monitoring access and quality assurance standards and,
  756  investigating and resolving complaints and grievances,
  757  administering the Medikids program, and approving health
  758  benefits coverage.
  759         (f) Contract with the Florida Healthy Kids Corporation for
  760  the administration of the Florida Kidcare Program and the
  761  Healthy Florida Program and to facilitate the release of any
  762  federal and state funds.
  763  
  764  The agency is designated the lead state agency for Title XXI of
  765  the Social Security Act for purposes of receipt of federal
  766  funds, for reporting purposes, and for ensuring compliance with
  767  federal and state regulations and rules.
  768         (4) The Office of Insurance Regulation shall certify that
  769  health benefits coverage plans that seek to provide services
  770  under the Florida Kidcare program, except those offered through
  771  the Florida Healthy Kids Corporation or the Children’s Medical
  772  Services Network, meet, exceed, or are actuarially equivalent to
  773  the benchmark benefit plan and that health insurance plans will
  774  be offered at an approved rate. In determining actuarial
  775  equivalence of benefits coverage, the Office of Insurance
  776  Regulation and health insurance plans must comply with the
  777  requirements of s. 2103 of Title XXI of the Social Security Act.
  778  The department shall adopt rules necessary for certifying health
  779  benefits coverage plans.
  780         (3)(5) The Florida Healthy Kids Corporation shall retain
  781  its functions as authorized in s. 624.91, including eligibility
  782  determination for participation in the Healthy Kids program.
  783         (4)(6) The agency, the Department of Health, the Department
  784  of Children and Family Services, and the Florida Healthy Kids
  785  Corporation, and the Office of Insurance Regulation, after
  786  consultation with and approval of the Speaker of the House of
  787  Representatives and the President of the Senate, are authorized
  788  to make program modifications that are necessary to overcome any
  789  objections of the United States Department of Health and Human
  790  Services to obtain approval of the state’s child health
  791  insurance plan under Title XXI of the Social Security Act.
  792         Section 12. Section 409.820, Florida Statutes, is amended
  793  to read:
  794         409.820 Quality assurance and access standards.—Except for
  795  Medicaid, the Department of Health, in consultation with the
  796  agency and the Florida Healthy Kids Corporation, shall develop a
  797  minimum set of pediatric and adolescent quality assurance and
  798  access standards for all program components. The standards must
  799  include a process for granting exceptions to specific
  800  requirements for quality assurance and access. Compliance with
  801  the standards shall be a condition of program participation by
  802  health benefits coverage providers. These standards shall comply
  803  with the provisions of this chapter and chapter 641 and Title
  804  XXI of the Social Security Act.
  805         Section 13. Section 624.91, Florida Statutes, is amended to
  806  read:
  807         624.91 The Florida Healthy Kids Corporation Act.—
  808         (1) SHORT TITLE.—This section may be cited as the “William
  809  G. ‘Doc’ Myers Healthy Kids Corporation Act.”
  810         (2) LEGISLATIVE INTENT.—
  811         (a) The Legislature finds that increased access to health
  812  care services could improve children’s health and reduce the
  813  incidence and costs of childhood illness and disabilities among
  814  children in this state. Many children do not have comprehensive,
  815  affordable health care services available. It is the intent of
  816  the Legislature that the Florida Healthy Kids Corporation
  817  provide comprehensive health insurance coverage to such
  818  children. The corporation is encouraged to cooperate with any
  819  existing health service programs funded by the public or the
  820  private sector.
  821         (b) It is the intent of the Legislature that the Florida
  822  Healthy Kids Corporation serve as one of several providers of
  823  services to children eligible for medical assistance under Title
  824  XXI of the Social Security Act. Although the corporation may
  825  serve other children, the Legislature intends the primary
  826  recipients of services provided through the corporation be
  827  school-age children with a family income below 200 percent of
  828  the federal poverty level, who do not qualify for Medicaid. It
  829  is also the intent of the Legislature that state and local
  830  government Florida Healthy Kids funds be used to continue
  831  coverage, subject to specific appropriations in the General
  832  Appropriations Act, to children not eligible for federal
  833  matching funds under Title XXI.
  834         (c) It is further the intent of the Legislature that the
  835  Florida Healthy Kids Corporation administer and manage services
  836  for Healthy Florida, a health care program for uninsured adults
  837  using a unique network of providers and contracts. Enrollees in
  838  Healthy Florida will receive comprehensive health care services
  839  from private, licensed health insurers who meet standards
  840  established by the corporation. It is further the intent of the
  841  Legislature that these enrollees participate in their own health
  842  care decisionmaking and contribute financially toward their
  843  medical costs. The Legislature intends to provide an alternative
  844  benefit package that includes a full range of services which
  845  meet the needs of residents of this state. As a new program, the
  846  Legislature will also ensure that a comprehensive evaluation is
  847  conducted to measure the overall impact of the program and
  848  identify whether to renew the program after an initial 3-year
  849  term.
  850         (3) ELIGIBILITY FOR STATE-FUNDED ASSISTANCE.—Only the
  851  following individuals are eligible for state-funded assistance
  852  in paying premiums for Healthy Florida or Florida Healthy Kids
  853  premiums:
  854         (a) Residents of this state who are eligible for the
  855  Florida Kidcare program pursuant to s. 409.814 or the Healthy
  856  Florida pursuant to s. 624.917.
  857         (b) Notwithstanding s. 409.814, legal aliens who are
  858  enrolled in the Florida Healthy Kids program as of January 31,
  859  2004, who do not qualify for Title XXI federal funds because
  860  they are not qualified aliens as defined in s. 409.811.
  861         (4) NONENTITLEMENT.—Nothing in this section shall be
  862  construed as providing an individual with an entitlement to
  863  health care services. No cause of action shall arise against the
  864  state, the Florida Healthy Kids Corporation, or a unit of local
  865  government for failure to make health services available under
  866  this section.
  867         (5) CORPORATION AUTHORIZATION, DUTIES, POWERS.—
  868         (a) There is created the Florida Healthy Kids Corporation,
  869  a not-for-profit corporation.
  870         (b) The Florida Healthy Kids Corporation shall:
  871         1. Arrange for the collection of any family, individual, or
  872  local contributions, or employer payment or premium, in an
  873  amount to be determined by the board of directors, to provide
  874  for payment of premiums for comprehensive insurance coverage and
  875  for the actual or estimated administrative expenses.
  876         2. Arrange for the collection of any voluntary
  877  contributions to provide for payment of Florida Kidcare or
  878  Healthy Florida program premiums for enrollees children who are
  879  not eligible for medical assistance under Title XIX or Title XXI
  880  of the Social Security Act.
  881         3. Subject to the provisions of s. 409.8134, accept
  882  voluntary supplemental local match contributions that comply
  883  with the requirements of Title XXI of the Social Security Act
  884  for the purpose of providing additional Florida Kidcare coverage
  885  in contributing counties under Title XXI.
  886         4. Establish the administrative and accounting procedures
  887  for the operation of the corporation.
  888         5. Establish, with consultation from appropriate
  889  professional organizations, standards for preventive health
  890  services and providers and comprehensive insurance benefits
  891  appropriate to children, provided that such standards for rural
  892  areas shall not limit primary care providers to board-certified
  893  pediatricians.
  894         6. Determine eligibility for children seeking to
  895  participate in the Title XXI-funded components of the Florida
  896  Kidcare program consistent with the requirements specified in s.
  897  409.814, as well as the non-Title-XXI-eligible children as
  898  provided in subsection (3).
  899         7. Establish procedures under which providers of local
  900  match to, applicants to and participants in the program may have
  901  grievances reviewed by an impartial body and reported to the
  902  board of directors of the corporation.
  903         8. Establish participation criteria and, if appropriate,
  904  contract with an authorized insurer, health maintenance
  905  organization, or third-party administrator to provide
  906  administrative services to the corporation.
  907         9. Establish enrollment criteria that include penalties or
  908  waiting periods of 30 days for reinstatement of coverage upon
  909  voluntary cancellation for nonpayment of family and individual
  910  premiums under the programs.
  911         10.a. Contract with authorized insurers or any provider of
  912  health care services, meeting standards established by the
  913  corporation, for the provision of comprehensive insurance
  914  coverage to participants. Such standards shall include criteria
  915  under which the corporation may contract with more than one
  916  provider of health care services in program sites.
  917         b. Health plans shall be selected through a competitive bid
  918  process.
  919         c. The Florida Healthy Kids Corporation shall purchase
  920  goods and services in the most cost-effective manner consistent
  921  with the delivery of quality medical care. The maximum
  922  administrative cost for a Florida Healthy Kids Corporation
  923  contract shall be 15 percent. For all health care contracts, the
  924  minimum medical loss ratio is for a Florida Healthy Kids
  925  Corporation contract shall be 85 percent. The calculations must
  926  use uniform financial data collected from all plans in a format
  927  established by the corporation and shall be computed for each
  928  insurer on a statewide basis. Funds shall be classified in a
  929  manner consistent with 45 C.F.R. part 158 For dental contracts,
  930  the remaining compensation to be paid to the authorized insurer
  931  or provider under a Florida Healthy Kids Corporation contract
  932  shall be no less than an amount which is 85 percent of premium;
  933  to the extent any contract provision does not provide for this
  934  minimum compensation, this section shall prevail.
  935         d. The health plan selection criteria and scoring system,
  936  and the scoring results, shall be available upon request for
  937  inspection after the bids have been awarded.
  938         11. Establish disenrollment criteria in the event local
  939  matching funds are insufficient to cover enrollments.
  940         12. Develop and implement a plan to publicize the Florida
  941  Kidcare program and Healthy Florida, the eligibility
  942  requirements of the programs program, and the procedures for
  943  enrollment in the program and to maintain public awareness of
  944  the corporation and the programs program.
  945         13. Secure staff necessary to properly administer the
  946  corporation. Staff costs shall be funded from state and local
  947  matching funds and such other private or public funds as become
  948  available. The board of directors shall determine the number of
  949  staff members necessary to administer the corporation.
  950         14. In consultation with the partner agencies, provide a
  951  report on the Florida Kidcare program annually to the Governor,
  952  the Chief Financial Officer, the Commissioner of Education, the
  953  President of the Senate, the Speaker of the House of
  954  Representatives, and the Minority Leaders of the Senate and the
  955  House of Representatives.
  956         15. Provide information on a quarterly basis to the
  957  Legislature and the Governor which compares the costs and
  958  utilization of the full-pay enrolled population and the Title
  959  XXI-subsidized enrolled population in the Florida Kidcare
  960  program. The information, at a minimum, must include:
  961         a. The monthly enrollment and expenditure for full-pay
  962  enrollees in the Medikids and Florida Healthy Kids programs
  963  compared to the Title XXI-subsidized enrolled population; and
  964         b. The costs and utilization by service of the full-pay
  965  enrollees in the Medikids and Florida Healthy Kids programs and
  966  the Title XXI-subsidized enrolled population. This subparagraph
  967  is repealed effective December 31, 2013.
  968  
  969  By February 1, 2010, the Florida Healthy Kids Corporation shall
  970  provide a study to the Legislature and the Governor on premium
  971  impacts to the subsidized portion of the program from the
  972  inclusion of the full-pay program, which shall include
  973  recommendations on how to eliminate or mitigate possible impacts
  974  to the subsidized premiums.
  975         16. By August 15, 2013, the corporation shall notify all
  976  current full-pay enrollees of the availability of the exchange,
  977  as defined in the federal Patient Protection and Affordable Care
  978  Act, and how to access other insurance affordability options.
  979  New applications for full-pay coverage may not be accepted after
  980  September 30, 2013.
  981         17.16. Establish benefit packages that conform to the
  982  provisions of the Florida Kidcare program, as created in ss.
  983  409.810-409.821.
  984         (c) Coverage under the corporation’s program is secondary
  985  to any other available private coverage held by, or applicable
  986  to, the participant child or family member. Insurers under
  987  contract with the corporation are the payors of last resort and
  988  must coordinate benefits with any other third-party payor that
  989  may be liable for the participant’s medical care.
  990         (d) The Florida Healthy Kids Corporation shall be a private
  991  corporation not for profit, registered, incorporated, and
  992  organized pursuant to chapter 617, and shall have all powers
  993  necessary to carry out the purposes of this act, including, but
  994  not limited to, the power to receive and accept grants, loans,
  995  or advances of funds from any public or private agency and to
  996  receive and accept from any source contributions of money,
  997  property, labor, or any other thing of value, to be held, used,
  998  and applied for the purposes of this act. The corporation and
  999  any committees it forms shall act in compliance with part III of
 1000  chapter 112, and chapters 119 and 286.
 1001         (6) BOARD OF DIRECTORS AND MANAGEMENT SUPERVISION.—
 1002         (a) The Florida Healthy Kids Corporation shall operate
 1003  subject to the supervision and approval of a board of directors
 1004  chaired by an appointee designated by the Governor Chief
 1005  Financial Officer or her or his designee, and composed of 12
 1006  other members. The Senate shall confirm the designated chair and
 1007  other board appointees selected for 3-year terms of office as
 1008  follows:
 1009         1. The Secretary of Health Care Administration, or his or
 1010  her designee.
 1011         2. One member appointed by the Commissioner of Education
 1012  from the Office of School Health Programs of the Florida
 1013  Department of Education.
 1014         3. One member appointed by the Chief Financial Officer from
 1015  among three members nominated by the Florida Pediatric Society.
 1016         4. One member, appointed by the Governor, who represents
 1017  the Children’s Medical Services Program.
 1018         5. One member appointed by the Chief Financial Officer from
 1019  among three members nominated by the Florida Hospital
 1020  Association.
 1021         6. One member, appointed by the Governor, who is an expert
 1022  on child health policy.
 1023         7. One member, appointed by the Chief Financial Officer,
 1024  from among three members nominated by the Florida Academy of
 1025  Family Physicians.
 1026         8. One member, appointed by the Governor, who represents
 1027  the state Medicaid program.
 1028         9. One member, appointed by the Chief Financial Officer,
 1029  from among three members nominated by the Florida Association of
 1030  Counties.
 1031         10. The State Health Officer or her or his designee.
 1032         11. The Secretary of Children and Family Services, or his
 1033  or her designee.
 1034         12. One member, appointed by the Governor, from among three
 1035  members nominated by the Florida Dental Association.
 1036         (b) A member of the board of directors serves at the
 1037  pleasure of the Governor may be removed by the official who
 1038  appointed that member. The board shall appoint an executive
 1039  director, who is responsible for other staff authorized by the
 1040  board.
 1041         (c) Board members are entitled to receive, from funds of
 1042  the corporation, reimbursement for per diem and travel expenses
 1043  as provided by s. 112.061.
 1044         (d) There shall be no liability on the part of, and no
 1045  cause of action shall arise against, any member of the board of
 1046  directors, or its employees or agents, for any action they take
 1047  in the performance of their powers and duties under this act.
 1048         (e) Board members who are serving on or before the date of
 1049  enactment of this act or similar legislation may remain until
 1050  July 1, 2013.
 1051         (f) An executive steering committee is created to provide
 1052  management direction and support and to make recommendations to
 1053  the board on the programs. The steering committee is composed of
 1054  the Secretary of Health Care Administration, the Secretary of
 1055  Children and Families, and the State Surgeon General. Committee
 1056  members may not delegate their membership or attendance.
 1057         (7) LICENSING NOT REQUIRED; FISCAL OPERATION.—
 1058         (a) The corporation shall not be deemed an insurer. The
 1059  officers, directors, and employees of the corporation shall not
 1060  be deemed to be agents of an insurer. Neither the corporation
 1061  nor any officer, director, or employee of the corporation is
 1062  subject to the licensing requirements of the insurance code or
 1063  the rules of the Department of Financial Services or Office of
 1064  Insurance Regulation. However, any marketing representative
 1065  utilized and compensated by the corporation must be appointed as
 1066  a representative of the insurers or health services providers
 1067  with which the corporation contracts.
 1068         (b) The board has complete fiscal control over the
 1069  corporation and is responsible for all corporate operations.
 1070         (c) The Department of Financial Services shall supervise
 1071  any liquidation or dissolution of the corporation and shall
 1072  have, with respect to such liquidation or dissolution, all power
 1073  granted to it pursuant to the insurance code.
 1074         Section 14. Section 624.915, Florida Statutes, is repealed.
 1075         Section 15. Section 624.917, Florida Statutes, is created
 1076  to read:
 1077         624.917Healthy Florida program.—
 1078         (1) PROGRAM CREATION.—There is created Healthy Florida, a
 1079  health care program for lower income, uninsured adults who meet
 1080  the eligibility guidelines established under s. 624.91. The
 1081  Florida Healthy Kids Corporation shall administer the program
 1082  under its existing corporate governance and structure.
 1083         (2) DEFINITIONS.—As used in this section, the term:
 1084         (a) “Actuarially equivalent” means:
 1085         1. The aggregate value of the benefits included in health
 1086  benefits coverage is equal to the value of the benefits in the
 1087  child benchmark benefit plan as defined in s. 409.811; and
 1088         2. The benefits included in health benefits coverage are
 1089  substantially similar to the benefits included in the child
 1090  benchmark benefit plan, except that preventive health services
 1091  do not include dental services.
 1092         (b) “Agency” means the Agency for Health Care
 1093  Administration.
 1094         (c) “Applicant” means the individual who applies for
 1095  determination of eligibility for health benefits coverage under
 1096  s. 624.91(8).
 1097         (d) “Child benchmark benefit plan” means the form and level
 1098  of health benefits coverage established in s. 409.815.
 1099         (e) “Child” means any person under 19 years of age.
 1100         (f) “Corporation” means Florida Healthy Kids Corporation.
 1101         (g) “Enrollee” means an individual who has been determined
 1102  eligible for and is receiving coverage under s. 624.91(8).
 1103         (h) “Florida Kidcare program” or “Kidcare program,” means
 1104  the health benefits program administered through ss. 409.810
 1105  409.821.
 1106         (i)“Health benefits coverage” means protection that
 1107  provides payment of benefits for covered health care services or
 1108  that otherwise provides, either directly or through arrangements
 1109  with other persons, covered health care services on a prepaid
 1110  per capita basis or on a prepaid aggregate fixed-sum basis.
 1111         (j) “Healthy Florida” means the program created by this
 1112  section which is administered by the Florida Healthy Kids
 1113  Corporation.
 1114         (k) “Healthy Kids” means the Florida Kidcare program
 1115  component created under s. 624.91 for children ages 5 through
 1116  18.
 1117         (l) “Household income” means the group or the individual
 1118  whose income is considered in determining eligibility for the
 1119  Healthy Florida program. The household has the same meaning as
 1120  it is defined under section 36B(d)(2) of the Internal Revenue
 1121  Code of 1986.
 1122         (m) “Medicaid” means the medical assistance program
 1123  authorized by Title XIX of the Social Security Act, and
 1124  regulations thereunder, and ss. 409.901-409.920, as administered
 1125  in this state by the agency.
 1126         (n) “Medically necessary” means the use of any medical
 1127  treatment, service, equipment, or supply necessary to palliate
 1128  the effects of a terminal condition, or to prevent, diagnose,
 1129  correct, cure, alleviate, or preclude deterioration of a
 1130  condition that threatens life, causes pain or suffering, or
 1131  results in illness or infirmity and which is:
 1132         1. Consistent with the symptom, diagnosis, and treatment of
 1133  the enrollee’s condition;
 1134         2. Provided in accordance with generally accepted standards
 1135  of medical practice;
 1136         3. Not primarily intended for the convenience of the
 1137  enrollee, the enrollee’s family, or the health care provider;
 1138         4. The most appropriate level of supply or service for the
 1139  diagnosis and treatment of the enrollee’s condition; and
 1140         5. Approved by the appropriate medical body or health care
 1141  specialty involved as effective, appropriate, and essential for
 1142  the care and treatment of the enrollee’s condition.
 1143         (o)“Modified Adjusted Gross Income (MAGI)” means the
 1144  individual or household’s annual adjusted gross income as
 1145  defined in 26 U.S.C. s. 36 of the Internal Revenue Code of 1986
 1146  which is used to determine eligibility under the Florida Kidcare
 1147  program.
 1148         (p) “Patient Protection and Affordable Care Act” or “Act”
 1149  means the federal law enacted as Pub. L. No. 111-148, as further
 1150  amended by the federal Health Care and Education Reconciliation
 1151  Act of 2010, Public Law 111-152, and any amendments, regulations
 1152  or guidance thereunder, issued under those acts.
 1153         (q) “Premium” means the entire cost of a health insurance
 1154  plan, including the administration fee or the risk assumption
 1155  charge.
 1156         (r) “Premium assistance payment” means the monthly
 1157  consideration paid by the agency per enrollee in the Florida
 1158  Kidcare program towards health insurance premiums.
 1159         (s) “Qualified alien” means an alien as defined in 8 U.S.C.
 1160  s. 1641(b) and (c).
 1161         (t) “Resident” means a United States citizen or qualified
 1162  alien who is domiciled in this state.
 1163         (3) ELIGIBILITY.—To be eligible and remain eligible for the
 1164  Healthy Florida program, an individual must be a resident of
 1165  this state and meet the following additional criteria:
 1166         (a) Be identified as “newly eligible” as defined in
 1167  subclause (VIII) of section 1902(a)(10)(A)(i) of the Social
 1168  Security Act (section 2001 of the Patient Protection and
 1169  Affordable Care Act) and as may be further defined by federal
 1170  regulation.
 1171         (b) Maintain eligibility with the corporation and meet all
 1172  renewal requirements as established by the corporation.
 1173         (c) Renew eligibility on at least an annual basis.
 1174         (4) ENROLLMENT.—The corporation may begin the enrollment of
 1175  applicants in the Healthy Florida program on October 1, 2013.
 1176  Enrollment may occur directly, through the services of a third
 1177  party administrator, referrals from the Department of Children
 1178  and Families and the exchange as defined by the federal Patient
 1179  Protection and Affordable Care Act. As an enrollee disenrolls,
 1180  the corporation must also provide the enrollee with information
 1181  about other insurance affordability programs and electronically
 1182  refer the enrollee to the exchange or other programs, as
 1183  appropriate. The earliest coverage effective date under the
 1184  program shall be January 1, 2014.
 1185         (5) DELIVERY OF SERVICES.—The corporation shall contract
 1186  with authorized insurers licensed under chapter 627 and managed
 1187  care organizations under chapter 624 which meet standards
 1188  established by the corporation to provide comprehensive health
 1189  care services to enrollees who qualify for services under this
 1190  section. The corporation may contract for such services on a
 1191  statewide or regional basis.
 1192         (a) The corporation must establish access and network
 1193  standards for such contracts and ensure that contracted
 1194  providers have sufficient providers to meet enrollee needs.
 1195  Quality standards must be developed by the corporation, specific
 1196  to the adult population, which take into consideration
 1197  recommendations from the National Committee on Quality
 1198  Assurance, stakeholders, and other existing performance
 1199  indicators from both public and commercial populations.
 1200         (b) Enrollees must be provided a choice. The corporation
 1201  has the authority to select a plan if no selection has been
 1202  received before the coverage start date. Once enrolled,
 1203  enrollees have an initial 90-day free look period before a lock
 1204  in period of not more than 12 months is applied. Exceptions to
 1205  the lock-in period must be offered to enrollees for good cause
 1206  reasons and qualifying events.
 1207         (c) The corporation may consider contracts that provide
 1208  family plans that would allow members from multiple state and
 1209  federal funded programs to remain together under the same plan.
 1210         (d) All contracts must meet the medical loss ratio
 1211  requirements under s. 624.91.
 1212         (6) BENEFITS.—The corporation shall establish a benefits
 1213  package that is actuarially equivalent to the benchmark benefit
 1214  plan offered under s. 409.815(2), excluding dental, and meets
 1215  the alternative benefits package requirements under section 1937
 1216  of the Social Security Act. Benefits must be offered as an
 1217  integrated, single package.
 1218         (a) In addition to benchmark benefits, health reimbursement
 1219  accounts (HRAs) or a comparable health savings account for each
 1220  enrollee must be established through the corporation or the
 1221  contracts managed by the corporation. Enrollees must be rewarded
 1222  for healthy behaviors, wellness program adherence, and other
 1223  activities established by the corporation which demonstrate
 1224  compliance with preventive care or disease management
 1225  guidelines. Funds deposited into these accounts may be used to
 1226  pay cost-sharing obligations or to purchase over the counter
 1227  health related items, to the extent allowed under federal law or
 1228  regulation.
 1229         (b) Enhanced services may be offered if the cost of such
 1230  additional services provides savings to the overall plan.
 1231         (c) The corporation shall establish a process for the
 1232  payment of wrap-around services not covered by the benchmark
 1233  plan through a separate subcapitation process to its contracted
 1234  providers if it is determined that such services are required by
 1235  federal law. Such services would be covered when deemed
 1236  medically necessary on an individual basis. The subcapitation
 1237  pool is subject to a separate reconciliation process under the
 1238  medical loss ratio provisions in s. 624.91.
 1239         (d) A prior authorization process and other utilization
 1240  controls may be established by the plan for any benefit if
 1241  approved by the corporation.
 1242         (7) COST SHARING.—The corporation may collect premiums and
 1243  copayments from enrollees in accordance with federal law.
 1244  Amounts to be collected for the Healthy Florida program must be
 1245  established annually in the General Appropriations Act.
 1246         (a) Payment of a monthly premium may be required before the
 1247  establishment of an enrollee’s coverage start date and to retain
 1248  monthly coverage.
 1249         (b) Enrollees may be required to make copayments as a
 1250  condition of receiving a health care service.
 1251         (c) Providers are responsible for the collection of point
 1252  of service cost sharing obligations. The enrollee’s cost sharing
 1253  contribution will be considered part of the provider’s total
 1254  reimbursement. Failure to collect any enrollee cost sharing will
 1255  reduce the provider’s share of the reimbursement.
 1256         (8) PROGRAM MANAGEMENT.—The corporation is responsible for
 1257  the oversight of the Healthy Florida program. The agency shall
 1258  seek a state plan amendment or other appropriate federal
 1259  approval to implement the Healthy Florida program. The agency
 1260  shall consult with the corporation in the amendment’s
 1261  development with a submission deadline to the federal Department
 1262  of Health and Human Services of June 14, 2013. The Agency will
 1263  contract with the corporation for the administration of the
 1264  program and for the timely release of federal and state funds.
 1265  The Agency retains its authorities as provided under ss. 409.902
 1266  and 409.963.
 1267         (a) The corporation shall establish a process by which
 1268  grievances can be resolved and Healthy Florida recipients can be
 1269  informed of their rights under the Medicaid Fair Hearing
 1270  Process, as appropriate, or any alternative resolution process
 1271  adopted by the corporation.
 1272         (b) The corporation shall establish a program integrity
 1273  process to ensure compliance with program guidelines. At a
 1274  minimum, the corporation shall withhold benefits from an
 1275  applicant or enrollee if the corporation obtains evidence that
 1276  the applicant or enrollee is no longer eligible, submitted
 1277  incorrect or fraudulent information in order to establish
 1278  eligibility, or failed to provide verification of eligibility.
 1279  The applicant or enrollee shall be notified that because of such
 1280  evidence program benefits will be withheld unless the applicant
 1281  or enrollee contacts a designated representative of the
 1282  corporation by a specified date, which must be within 10 working
 1283  days after the date of notice, to discuss and resolve the
 1284  matter. The corporation shall make every effort to resolve the
 1285  matter within a timeframe that will not cause benefits to be
 1286  withheld from an eligible enrollee. The following individuals
 1287  may be subject to specific prosecution in accordance with s.
 1288  414.39:
 1289         1. An applicant obtaining or attempting to obtain benefits
 1290  for a potential enrollee under the Healthy Florida program when
 1291  the applicant knows or should have known the potential enrollee
 1292  does not qualify for the Healthy Florida program.
 1293         2. An individual who assists an applicant in obtaining or
 1294  attempting to obtain benefits for a potential enrollee under the
 1295  Healthy Florida program when the individual knows or should have
 1296  known the potential enrollee does not qualify for the Healthy
 1297  Florida program.
 1298         (9) APPLICABILITY OF LAWS RELATING TO MEDICAID.—The
 1299  provisions of ss. 409.902, 409.9128, and 409.920 apply to the
 1300  administration of the program.
 1301         (10) PROGRAM EVALUATION.—The corporation must collect both
 1302  eligibility and enrollment data from program applicants and
 1303  enrollees as well as encounter and utilization data from all
 1304  contracted entities during the program term. Monthly enrollment
 1305  reports must be submitted to the Senate President, the Speaker
 1306  of the House of Representative and the Minority Leaders of the
 1307  Florida Senate and House of Representatives. An interim
 1308  independent evaluation of the program shall be submitted to the
 1309  presiding officers no later than July 1, 2015, with annual
 1310  evaluations due thereafter every July 1. The evaluations should
 1311  address at a minimum application and enrollment trends and
 1312  issues, utilization and cost data, and customer satisfaction.
 1313         (11) PROGRAM EXPIRATION.—The Healthy Florida program shall
 1314  expire at the end of the state fiscal year in which any of these
 1315  conditions occur, whichever occurs first:
 1316         (a) The federal match contribution falls below 90 percent.
 1317         (b) The federal match contribution falls below the
 1318  “Increased FMAP for Medical Assistance for Newly Eligible
 1319  Mandatory Individuals” as specified in the federal Patient
 1320  Protection and Affordable Care Act (Public Law 111-148), as
 1321  amended by the federal Health Care and Education Reconciliation
 1322  Act of 2010 (Public Law 111-152).
 1323         (c) The federal match for the Healthy Florida program and
 1324  the Medicaid program are blended under federal law or regulation
 1325  in such a way that causes the overall federal contribution to
 1326  diminish when compared to separate, non-blended federal
 1327  contributions.
 1328         Section 16.The corporation may make changes to comply with
 1329  the objections of the federal Department of Health and Human
 1330  Services to gain approval of the Healthy Florida program in
 1331  compliance with the federal Patient Protection and Affordable
 1332  Care Act upon giving notice to the Senate and the House of
 1333  Representatives of the proposed changes. If there is a conflict
 1334  between a provision in this section and the federal Patient
 1335  Protection and Affordable Care Act (Public Law 111-148), as
 1336  amended by the federal Health Care and Education Reconciliation
 1337  Act of 2010 (Public Law 111-152), the provision must be
 1338  interpreted and applied so as to comply with the requirement of
 1339  the federal law.
 1340         Section 17. This act shall take effect upon becoming a law.

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