Bill Amendment: FL S1354 | 2014 | Regular Session
NOTE: For additional amemendments please see the Bill Drafting List
Bill Title: Health Care
Status: 2014-05-02 - Died in Messages, companion bill(s) passed, see CS/HB 323 (Ch. 2014-113) [S1354 Detail]
Download: Florida-2014-S1354-Senate_Floor_Amendment_910258.html
Bill Title: Health Care
Status: 2014-05-02 - Died in Messages, companion bill(s) passed, see CS/HB 323 (Ch. 2014-113) [S1354 Detail]
Download: Florida-2014-S1354-Senate_Floor_Amendment_910258.html
Florida Senate - 2014 SENATOR AMENDMENT
Bill No. CS for CS for SB 1354
Ì9102581Î910258
LEGISLATIVE ACTION
Senate . House
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Floor: 2/WD/2R .
04/28/2014 06:51 PM .
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Senators Soto and Garcia moved the following:
1 Senate Amendment (with title amendment)
2
3 Between lines 364 and 365
4 insert:
5 Section 10. The Division of Law Revision and Information is
6 directed to rename part II of chapter 409, Florida Statutes, as
7 the “Florida Kidcare and Healthy Florida Programs.”
8 Section 11. Section 409.811, Florida Statutes, is reordered
9 and amended to read:
10 409.811 Definitions relating to Florida Kidcare Act.—As
11 used in this part ss. 409.810-409.821, the term:
12 (1) “Actuarially equivalent” means that:
13 (a) The aggregate value of the benefits included in health
14 benefits coverage is equal to the value of the benefits in the
15 benchmark benefit plan; and
16 (b) The benefits included in health benefits coverage are
17 substantially similar to the benefits included in the child
18 benchmark benefit plan, except that preventive health services
19 must be the same as in the benchmark benefit plan.
20 (2) “Agency” means the Agency for Health Care
21 Administration.
22 (3) “Applicant” means:
23 (a) A parent or guardian of a child or a child whose
24 disability of nonage has been removed under chapter 743, who
25 applies for a determination of eligibility for health benefits
26 coverage under Florida Kidcare; or
27 (b) An individual who applies for a determination of
28 eligibility under Healthy Florida ss. 409.810-409.821.
29 (5)(4) “Child benchmark benefit plan” means the form and
30 level of health benefits coverage established under in s.
31 409.815.
32 (4)(5) “Child” means a any person younger than under 19
33 years of age.
34 (6) “Child with special health care needs” means a child
35 whose serious or chronic physical or developmental condition
36 requires extensive preventive and maintenance care beyond that
37 required by typically healthy children. Health care utilization
38 by such a child exceeds the statistically expected usage of the
39 normal child adjusted for chronological age, and such a child
40 often needs complex care requiring multiple providers,
41 rehabilitation services, and specialized equipment in a number
42 of different settings.
43 (7) “Children’s Medical Services Network” or “network” has
44 the same meaning means a statewide managed care service system
45 as defined in s. 391.021(1).
46 (8) “CHIP” means the Children’s Health Insurance Program as
47 authorized under Title XXI of the Social Security Act,
48 regulations adopted thereunder, and this part, and as
49 administered in this state by the agency, the department, and
50 the corporation pursuant to their respective jurisdictions.
51 (8) “Community rate” means a method used to develop
52 premiums for a health insurance plan that spreads financial risk
53 across a large population and allows adjustments only for age,
54 gender, family composition, and geographic area.
55 (9) “Corporation” means the Florida Healthy Kids
56 Corporation established under s. 409.8125.
57 (10)(9) “Department” means the Department of Health.
58 (11)(10) “Enrollee” means a child or adult who has been
59 determined eligible for and is receiving coverage under this
60 part ss. 409.810-409.821.
61 (11) “Family” means the group or the individuals whose
62 income is considered in determining eligibility for the Florida
63 Kidcare program. The family includes a child with a parent or
64 caretaker relative who resides in the same house or living unit
65 or, in the case of a child whose disability of nonage has been
66 removed under chapter 743, the child. The family may also
67 include other individuals whose income and resources are
68 considered in whole or in part in determining eligibility of the
69 child.
70 (12) “Family income” means cash received at periodic
71 intervals from any source, such as wages, benefits,
72 contributions, or rental property. Income also may include any
73 money that would have been counted as income under the Aid to
74 Families with Dependent Children (AFDC) state plan in effect
75 prior to August 22, 1996.
76 (12)(13) “Florida Kidcare Program,” “Kidcare program,” or
77 “program” means the health benefits program described in s.
78 409.813 and administered under this part through ss. 409.810
79 409.821.
80 (13)(14) “Guarantee issue” means that health benefits
81 coverage must be offered to an individual regardless of the
82 individual’s health status, preexisting condition, or claims
83 history.
84 (14)(15) “Health benefits coverage” means protection that
85 provides payment of benefits for covered health care services or
86 that otherwise provides, either directly or through arrangements
87 with other persons, covered health care services on a prepaid
88 per capita basis or on a prepaid aggregate fixed-sum basis.
89 (15)(16) “Health insurance plan” means health benefits
90 coverage under the following:
91 (a) A health plan offered by a any certified health
92 maintenance organization or authorized health insurer, except
93 for a plan that is limited to the following: a limited benefit,
94 specified disease, or specified accident; hospital indemnity;
95 accident only; limited benefit convalescent care; Medicare
96 supplement; credit disability; dental; vision; long-term care;
97 disability income; coverage issued as a supplement to another
98 health plan; workers’ compensation liability or other insurance;
99 or motor vehicle medical payment only; or
100 (b) An employee welfare benefit plan that includes health
101 benefits established under the Employee Retirement Income
102 Security Act of 1974, as amended.
103 (16) “Healthy Florida” means the program established under
104 s. 409.822.
105 (17) “Healthy Kids” means a component of Florida Kidcare
106 created under s. 409.8125 for children who are 5 through 18
107 years of age.
108 (18) “Household income” has the same meaning as in s.
109 36B(d)(2)(A) of the Internal Revenue Code of 1986 and applies to
110 the individual or household whose income is being considered in
111 determining eligibility for Florida Kidcare or Healthy Florida.
112 (19)(17) “Medicaid” means the medical assistance program
113 authorized by Title XIX of the Social Security Act, and
114 regulations thereunder, and ss. 409.901-409.920, as administered
115 in this state by the agency.
116 (20)(18) “Medically necessary” means the use of any medical
117 treatment, service, equipment, or supply necessary to palliate
118 the effects of a terminal condition, or to prevent, diagnose,
119 correct, cure, alleviate, or preclude deterioration of a
120 condition that threatens life, causes pain or suffering, or
121 results in illness or infirmity and which is:
122 (a) Consistent with the symptom, diagnosis, and treatment
123 of the enrollee’s condition;
124 (b) Provided in accordance with generally accepted
125 standards of medical practice;
126 (c) Not primarily intended for the convenience of the
127 enrollee, the enrollee’s family, or the health care provider;
128 (d) The most appropriate level of supply or service for the
129 diagnosis and treatment of the enrollee’s condition; and
130 (e) Approved by the appropriate medical body or health care
131 specialty involved as effective, appropriate, and essential for
132 the care and treatment of the enrollee’s condition.
133 (21)(19) “Medikids” means a component of the Florida
134 Kidcare program of medical assistance authorized by Title XXI of
135 the Social Security Act, and regulations thereunder, and s.
136 409.8132, as administered in the state by the agency.
137 (22) “Modified adjusted gross income” has the same meaning
138 as in s. 36B(d)(2)(B) of the Internal Revenue Code of 1986 and
139 applies to the individual or household whose income is being
140 considered in determining eligibility for Florida Kidcare or
141 Healthy Florida.
142 (23) “Patient Protection and Affordable Care Act” means the
143 federal law enacted as Pub. L. No. 111-148, as amended by the
144 Health Care and Education Reconciliation Act of 2010, Pub. L.
145 No. 111-152, and any regulations or guidance adopted or issued
146 pursuant to those acts.
147 (24)(20) “Preexisting condition exclusion” means, with
148 respect to coverage, a limitation or exclusion of benefits
149 relating to a condition based on the fact that the condition was
150 present before the date of enrollment for such coverage,
151 regardless of whether or not any medical advice, diagnosis,
152 care, or treatment was recommended or received before such date.
153 (25)(21) “Premium” means the entire cost of a health
154 insurance plan, including the administration fee or the risk
155 assumption charge.
156 (26)(22) “Premium assistance payment” means the monthly
157 consideration paid toward health insurance premiums by the
158 agency per enrollee in the Florida Kidcare Program towards
159 health insurance premiums.
160 (27)(23) “Qualified alien” means an alien as defined in 8
161 U.S.C. s. 1641 (b) and (c) s. 431 of the Personal Responsibility
162 and Work Opportunity Reconciliation Act of 1996, as amended,
163 Pub. L. No. 104-193.
164 (28)(24) “Resident” means a United States citizen, or
165 qualified alien, who is domiciled in this state.
166 (29)(25) “Rural county” means a county having a population
167 density of less than 100 persons per square mile, or a county
168 defined by the most recent United States Census as rural, in
169 which there was is no prepaid health plan participating in the
170 Medicaid program as of July 1, 1998.
171 (26) “Substantially similar” means that, with respect to
172 additional services as defined in s. 2103(c)(2) of Title XXI of
173 the Social Security Act, these services must have an actuarial
174 value equal to at least 75 percent of the actuarial value of the
175 coverage for that service in the benchmark benefit plan and,
176 with respect to the basic services as defined in s. 2103(c)(1)
177 of Title XXI of the Social Security Act, these services must be
178 the same as the services in the benchmark benefit plan.
179 Section 12. Section 624.91, Florida Statutes, is
180 transferred and renumbered as section 409.8125, Florida
181 Statutes, and is reordered and amended to read:
182 409.8125 624.91 The Florida Healthy Kids Corporation Act.—
183 (1) SHORT TITLE.—This section may be cited as the “William
184 G. ‘Doc’ Myers Healthy Kids Corporation Act.”
185 (2) LEGISLATIVE INTENT.—
186 (a) The Legislature finds that increased access to health
187 care services could improve children’s health and reduce the
188 incidence and costs of childhood illness and disabilities among
189 children in this state. Many children do not have comprehensive,
190 affordable health care services available. It is the intent of
191 the Legislature that the Florida Healthy Kids Corporation
192 provide comprehensive health insurance coverage to such
193 children. The corporation is encouraged to cooperate with any
194 existing health service programs funded by the public or the
195 private sector.
196 (b) It is also the intent of the Legislature:
197 (a) That the Florida Healthy Kids program, established and
198 administered by the corporation, serve as one of several
199 providers of services to children eligible for medical
200 assistance under the federal Children’s Health Insurance Program
201 (CHIP) Title XXI of the Social Security Act. Although Healthy
202 Kids the corporation may serve other children, the Legislature
203 intends that the primary enrollees recipients of services
204 provided through the corporation be uninsured school-age
205 children eligible for CHIP with a family income below 200
206 percent of the federal poverty level, who do not qualify for
207 Medicaid. It is also the intent of the Legislature that state
208 and local government Florida Healthy Kids funds be used to
209 continue coverage, subject to specific appropriations in the
210 General Appropriations Act, to children not eligible for federal
211 matching funds under CHIP Title XXI.
212 (b) That the corporation administer and manage services for
213 Healthy Florida, a health care program for uninsured adults,
214 using a unique network of providers and contracts. Enrollees in
215 Healthy Florida shall receive comprehensive health care services
216 from private, licensed health insurers that meet standards
217 established by the corporation. It is further the intent of the
218 Legislature that these enrollees participate in their own health
219 care decisionmaking and contribute financially toward their
220 medical costs. The Legislature intends to provide an alternative
221 benefit package that includes a full range of services that meet
222 the needs of the residents of this state. As a new program, the
223 Legislature intends that a comprehensive analysis be conducted
224 to measure the overall impact of the program and evaluate
225 whether the program should be renewed after an initial 3-year
226 term.
227 (6)(3) ELIGIBILITY FOR STATE-FUNDED ASSISTANCE.—Only the
228 following individuals are eligible for state-funded assistance
229 in paying Florida Healthy Kids or Healthy Florida premiums:
230 (a) Residents of this state who are eligible for the
231 Florida Kidcare program pursuant to s. 409.814 or Healthy
232 Florida pursuant to s. 409.822.
233 (b) Notwithstanding s. 409.814, legal aliens who are
234 enrolled in the Florida Healthy Kids program as of January 31,
235 2004, who do not qualify for CHIP Title XXI federal funds
236 because they are not qualified aliens as defined in s. 409.811.
237 (7)(4) NONENTITLEMENT.—Nothing in This section does not
238 provide shall be construed as providing an individual with an
239 entitlement to health care services. No cause of action shall
240 arise against the state, the Florida Healthy Kids corporation,
241 or a unit of local government for failure to make health
242 services available under this section.
243 (3)(5) CORPORATION AUTHORIZATION, DUTIES, POWERS.—
244 (a) There is created The Florida Healthy Kids Corporation
245 is hereby established as, a not-for-profit corporation.
246 (b) The Florida Healthy Kids corporation shall:
247 1. Arrange for the collection of any family, individual, or
248 local contributions, or employer payment or premium, in an
249 amount to be determined by the board of directors, to provide
250 for payment of premiums for comprehensive insurance coverage and
251 for the actual or estimated administrative expenses.
252 2. Arrange for the collection of any voluntary
253 contributions to provide for the payment of premiums for
254 enrollees in Florida Kidcare or Healthy Florida program premiums
255 for children who are not eligible for medical assistance under
256 Title XIX or Title XXI of the Social Security Act.
257 3. Subject to the provisions of s. 409.8134, accept
258 voluntary supplemental local match contributions that comply
259 with CHIP the requirements of Title XXI of the Social Security
260 Act for the purpose of providing additional Florida Kidcare
261 coverage in contributing counties under CHIP Title XXI.
262 4. Establish the administrative and accounting procedures
263 for the operation of the corporation.
264 5. Establish, with consultation from appropriate
265 professional organizations, standards for preventive health
266 services and providers and comprehensive insurance benefits
267 appropriate to children., provided that Such standards for rural
268 areas may shall not require that limit primary care providers be
269 to board-certified pediatricians.
270 6. Determine eligibility for children seeking to
271 participate in CHIP the Title XXI-funded components of the
272 Florida Kidcare program consistent with the requirements
273 specified in s. 409.814, as well as the non-Title-XXI-eligible
274 children not eligible under CHIP as provided in subsection (6)
275 (3).
276 7. Establish procedures under which providers of local
277 match to, applicants to, and participants in Healthy Kids or
278 Healthy Families the program may have grievances reviewed by an
279 impartial body and reported to the board of directors of the
280 corporation.
281 8. Establish participation criteria and, if appropriate,
282 contract with an authorized insurer, health maintenance
283 organization, or third-party administrator to provide
284 administrative services to the corporation.
285 9. Establish enrollment criteria that include penalties or
286 30-day waiting periods of 30 days for reinstatement of coverage
287 upon voluntary cancellation for nonpayment of family and
288 individual premiums under the programs.
289 10. Contract with authorized insurers or providers any
290 provider of health care services who meet the, meeting standards
291 established by the corporation, for the provision of
292 comprehensive insurance coverage to participants. Such standards
293 must shall include criteria under which the corporation may
294 contract with more than one provider of health care services in
295 program sites.
296 a. Health plans shall be selected through a competitive bid
297 process.
298 b. The Florida Healthy Kids corporation shall purchase
299 goods and services in the most cost-effective manner consistent
300 with the delivery of quality medical care. The maximum
301 administrative cost for a Florida Healthy Kids corporation
302 contract is shall be 15 percent. For all health care contracts,
303 the minimum medical loss ratio is for a Florida Healthy Kids
304 Corporation contract shall be 85 percent. The calculations must
305 use uniform financial data collected from all plans in a format
306 established by the corporation and computed for each insurer on
307 a statewide basis. Funds shall be classified in a manner
308 consistent with 45 C.F.R. part 158 For dental contracts, the
309 remaining compensation to be paid to the authorized insurer or
310 provider under a Florida Healthy Kids Corporation contract shall
311 be no less than an amount which is 85 percent of premium; to the
312 extent any contract provision does not provide for this minimum
313 compensation, this section shall prevail.
314 c. The health plan selection criteria, and scoring system,
315 and the scoring results must, shall be available upon request
316 for inspection after the bids have been awarded.
317 11. Establish disenrollment criteria if in the event local
318 matching funds are insufficient to cover enrollments.
319 12. Develop and implement a plan to publicize the Florida
320 Kidcare and Healthy Florida program, the eligibility
321 requirements of the programs program, and the procedures for
322 enrollment in the programs program and to maintain public
323 awareness of the corporation and the programs program.
324 13. Secure staff necessary to properly administer the
325 corporation. Staff costs shall be funded from state and local
326 matching funds and such other private or public funds as become
327 available. The board of directors shall determine the number of
328 staff members necessary to administer the corporation.
329 14. In consultation with the partner agencies, provide an
330 annual a report on the Florida Kidcare program annually to the
331 Governor, the Chief Financial Officer, the Commissioner of
332 Education, the President of the Senate, the Speaker of the House
333 of Representatives, and the Minority Leaders of the Senate and
334 the House of Representatives.
335 15. Provide information on a quarterly basis to the
336 Legislature and the Governor which compares the costs and
337 utilization of the full-pay enrolled population and the CHIP
338 subsidized Title XXI-subsidized enrolled population in the
339 Florida Kidcare program. The information, At a minimum, the
340 information must include:
341 a. The monthly enrollment and expenditure for full-pay
342 enrollees in the Medikids and Florida Healthy Kids programs
343 compared to the CHIP-subsidized Title XXI-subsidized enrolled
344 population; and
345 b. The costs and utilization by service of the full-pay
346 enrollees in the Medikids and Florida Healthy Kids programs and
347 the CHIP-subsidized Title XXI-subsidized enrolled population.
348
349 By February 1, 2010, the Florida Healthy Kids Corporation shall
350 provide a study to the Legislature and the Governor on premium
351 impacts to the subsidized portion of the program from the
352 inclusion of the full-pay program, which shall include
353 recommendations on how to eliminate or mitigate possible impacts
354 to the subsidized premiums.
355 16. Notify all current full-pay enrollees of the
356 availability of the exchange, as defined in the federal Patient
357 Protection and Affordable Care Act, and how to access other
358 affordable insurance options. New applications for full-pay
359 coverage may not be accepted after September 30, 2014.
360 17.16. Establish benefit packages that conform to the
361 provisions of the Florida Kidcare program, as created under this
362 part in ss. 409.810-409.821.
363 (c) Coverage under the corporation’s programs program is
364 secondary to any other available private coverage held by, or
365 applicable to, the participant child or family member. Insurers
366 under contract with the corporation are the payors of last
367 resort and must coordinate benefits with any other third-party
368 payor that may be liable for the participant’s medical care.
369 (d) The Florida Healthy Kids corporation shall be a private
370 corporation not for profit, registered, incorporated, and
371 organized pursuant to chapter 617, and shall have all powers
372 necessary to carry out the purposes of this section act,
373 including, but not limited to, the power to receive and accept
374 grants, loans, or advances of funds from any public or private
375 agency and to receive and accept from any source contributions
376 of money, property, labor, or any other thing of value, to be
377 held, used, and applied for the purposes of this section act.
378 The corporation and any committees it forms shall comply with
379 part III of chapter 112 and chapters 119 and 286.
380 (4)(6) BOARD OF DIRECTORS AND MANAGEMENT SUPERVISION.—
381 (a) The Florida Healthy Kids corporation shall operate
382 subject to the supervision and approval of a board of directors
383 chaired by an appointee designated by the Governor Chief
384 Financial Officer or her or his designee, and composed of 15 12
385 other members. The Senate shall confirm the designated chair and
386 other board appointees selected for 3-year terms of office as
387 follows:
388 1. The Secretary of Health Care Administration, or his or
389 her designee, as an ex-officio member.
390 2. The State Surgeon General, or his or her designee, as an
391 ex-officio member One member appointed by the Commissioner of
392 Education from the Office of School Health Programs of the
393 Florida Department of Education.
394 3. The Secretary of Children and Families, or his or her
395 designee, as an ex-officio member One member appointed by the
396 Chief Financial Officer from among three members nominated by
397 the Florida Pediatric Society.
398 4. Four members One member, appointed by the Governor, who
399 represents the Children’s Medical Services Program.
400 5. Two members One member appointed by the President of the
401 Senate Chief Financial Officer from among three members
402 nominated by the Florida Hospital Association.
403 6. Two members One member, appointed by the Senate Minority
404 Leader Governor, who is an expert on child health policy.
405 7. Two members One member, appointed by the Speaker of the
406 House of Representatives Chief Financial Officer, from among
407 three members nominated by the Florida Academy of Family
408 Physicians.
409 8. Two members One member, appointed by the House Minority
410 Leader Governor, who represents the state Medicaid program.
411 9. One member, appointed by the Chief Financial Officer,
412 from among three members nominated by the Florida Association of
413 Counties.
414 10. The State Health Officer or her or his designee.
415 11. The Secretary of Children and Family Services, or his
416 or her designee.
417 12. One member, appointed by the Governor, from among three
418 members nominated by the Florida Dental Association.
419 (b) A member of the board of directors may be removed by
420 the official who made the appointment appointed that member. The
421 board shall appoint an executive director, who is responsible
422 for other staff authorized by the board.
423 (c) Board members are entitled to receive, from funds of
424 the corporation, reimbursement for per diem and travel expenses
425 as provided by s. 112.061.
426 (d) There is shall be no liability on the part of, and no
427 cause of action shall arise against, any member of the board of
428 directors, or its employees or agents, for any action they take
429 in the performance of their powers and duties under this act.
430 (e) Board members who are serving on or before the
431 effective date of this act or similar legislation may remain
432 until July 1, 2015.
433 (f) An executive steering committee is created to provide
434 direction and support to management and to make recommendations
435 to the board on programs. The steering committee consists of the
436 Secretary of Health Care Administration, the Secretary of
437 Children and Families, and the State Surgeon General, who may
438 not delegate their membership or attendance.
439 (5)(7) LICENSING NOT REQUIRED; FISCAL OPERATION.—
440 (a) The corporation is shall not be deemed an insurer. The
441 officers, directors, and employees of the corporation may shall
442 not be deemed to be agents of an insurer. Neither the
443 corporation nor any officer, director, or employee of the
444 corporation is subject to the licensing requirements of the
445 insurance code or the rules of the Department of Financial
446 Services or the Office of Insurance Regulation. However, any
447 marketing representative used utilized and compensated by the
448 corporation must be appointed as a representative of the
449 insurers or health services providers with which the corporation
450 contracts.
451 (b) The board has complete fiscal control over the
452 corporation and is responsible for all corporate operations.
453 (c) The Department of Financial Services shall supervise
454 any liquidation or dissolution of the corporation and shall
455 have, with respect to such liquidation or dissolution, shall
456 have all power granted to it pursuant to the insurance code.
457 Section 13. Section 409.813, Florida Statutes, is amended
458 to read:
459 409.813 Health benefits coverage; program components;
460 entitlement and nonentitlement.—
461 (1) The Florida Kidcare program includes health benefits
462 coverage provided to children through the following program
463 components, which shall be marketed as the Florida Kidcare
464 program:
465 (a) Medicaid;
466 (b) Medikids as created in s. 409.8132;
467 (c) The Florida Healthy Kids Corporation as created in s.
468 409.8125 s. 624.91; and
469 (d) Employer-sponsored group health insurance plans
470 approved under ss. 409.810-409.821; and
471 (d)(e) The Children’s Medical Services network established
472 in chapter 391.
473 (2) Except for CHIP-funded Title XIX-funded Florida Kidcare
474 program coverage under the Medicaid program, coverage under the
475 Florida Kidcare program is not an entitlement. No cause of
476 action shall arise against the state, the department, the
477 Department of Children and Families Family Services, or the
478 agency, or the corporation for failure to make health services
479 available to any person under this part ss. 409.810-409.821.
480 Section 14. Subsections (6) and (7) of section 409.8132,
481 Florida Statutes, are amended to read:
482 409.8132 Medikids program component.—
483 (6) ELIGIBILITY.—
484 (a) A child who has attained the age of 1 year but who is
485 under the age of 5 years is eligible to enroll in the Medikids
486 program component of the Florida Kidcare program, if the child
487 is a member of a family that has a household family income
488 greater than which exceeds the Medicaid applicable income level
489 as specified in s. 409.903, but which is equal to or below 200
490 percent of the current federal poverty level. In determining the
491 eligibility of such a child, an assets test is not required. A
492 child who is eligible for Medikids may elect to enroll in
493 Florida Healthy Kids coverage or employer-sponsored group
494 coverage. However, a child who is eligible for Medikids may
495 participate in the Florida Healthy Kids Program only if the
496 child has a sibling participating in the Florida Healthy Kids
497 Program and the child’s county of residence permits such
498 enrollment.
499 (b) The provisions of s. 409.814 apply to the Medikids
500 program.
501 (7) ENROLLMENT.—Enrollment in the Medikids program
502 component may occur at any time throughout the year. A child may
503 not receive services under the Medikids program until the child
504 is enrolled in a managed care plan or MediPass. Once determined
505 eligible, an applicant may receive choice counseling and select
506 a managed care plan or MediPass. The agency may initiate
507 mandatory assignment for a Medikids applicant who has not chosen
508 a managed care plan or MediPass provider after the applicant’s
509 voluntary choice period ends. An applicant may select MediPass
510 under the Medikids program component only in counties that have
511 fewer than two managed care plans available to serve Medicaid
512 recipients and only if the federal Health Care Financing
513 Administration determines that MediPass constitutes “health
514 insurance coverage” as defined in Title XXI of the Social
515 Security Act.
516 Section 15. Subsection (2) of section 409.8134, Florida
517 Statutes, is amended to read:
518 409.8134 Program expenditure ceiling; enrollment.—
519 (2) The Florida Kidcare program may conduct enrollment
520 continuously throughout the year.
521 (a) Children eligible for coverage under the CHIP-funded
522 Title XXI-funded Florida Kidcare program shall be enrolled on a
523 first-come, first-served basis using the date the enrollment
524 application is received. Enrollment shall immediately cease when
525 the expenditure ceiling is reached. Year-round enrollment shall
526 only be held only if the Social Services Estimating Conference
527 determines that sufficient federal and state funds will be
528 available to finance the increased enrollment.
529 (b) An The application for the Florida Kidcare program is
530 valid for a period of 120 days after the date it was received.
531 At the end of the 120-day period, If the applicant has not been
532 enrolled in the program by the end of the 120-day period, the
533 application is invalid and the applicant shall be notified of
534 the action. The applicant may reactivate the application after
535 notification of the action taken by the program.
536 (c) Except for the Medicaid program, if whenever the Social
537 Services Estimating Conference determines that there are
538 presently, or will be by the end of the current fiscal year will
539 be, insufficient funds to finance the current or projected
540 enrollment in the Florida Kidcare program, all additional
541 enrollment must cease and additional enrollment may not resume
542 until sufficient funds are available to finance such enrollment.
543 Section 16. Section 409.814, Florida Statutes, is amended
544 to read:
545 409.814 Eligibility.—A child who has not reached 19 years
546 of age whose household family income is equal to or below 200
547 percent of the federal poverty level is eligible for the Florida
548 Kidcare program as provided in this section. If an enrolled
549 individual is determined to be ineligible for coverage, he or
550 she must be immediately disenrolled from the respective Florida
551 Kidcare program component and referred to another affordable
552 insurance program.
553 (1) A child who is eligible for Medicaid coverage under s.
554 409.903 or s. 409.904 must be offered an opportunity to enroll
555 enrolled in Medicaid and is not eligible to receive health
556 benefits under any other health benefits coverage authorized
557 under the Florida Kidcare program. A child who is eligible for
558 Medicaid and opts to enroll in CHIP may disenroll from CHIP at
559 any time and transition to Medicaid. Such transition must occur
560 without a break in coverage.
561 (2) A child who is not eligible for Medicaid, but who is
562 eligible for another component of the Florida Kidcare program,
563 may obtain health benefits coverage under any of the other
564 components listed in s. 409.813 if such coverage is approved and
565 available in the county in which the child resides.
566 (3) A CHIP-funded Title XXI-funded child who is eligible
567 for the Florida Kidcare program who is a child with special
568 health care needs, as determined through a medical or behavioral
569 screening instrument, is eligible for health benefits coverage
570 from, and shall be assigned to, and may opt out of the
571 Children’s Medical Services Network.
572 (4) The following children are not eligible to receive
573 CHIP-funded Title XXI-funded premium assistance for health
574 benefits coverage under the Florida Kidcare program, except
575 under Medicaid if the child would have been eligible for
576 Medicaid under s. 409.903 or s. 409.904 as of June 1, 1997:
577 (a) A child who is covered under a family member’s group
578 health benefit plan or under other private or employer health
579 insurance coverage, if the cost of the child’s participation is
580 not greater than 5 percent of the household family’s income. If
581 a child is otherwise eligible for a subsidy under the Florida
582 Kidcare program and the cost of the child’s participation in the
583 family member’s health insurance benefit plan is greater than 5
584 percent of the household family’s income, the child may enroll
585 in the appropriate subsidized Florida Kidcare program component.
586 (b) A child who is seeking premium assistance for the
587 Florida Kidcare program through employer-sponsored group
588 coverage, if the child has been covered by the same employer’s
589 group coverage during the 60 days before the family submitted an
590 application for determination of eligibility under the program.
591 (b)(c) A child who is an alien, but who does not meet the
592 definition of qualified alien, in the United States.
593 (c)(d) A child who is an inmate of a public institution or
594 a patient in an institution for mental diseases.
595 (d)(e) A child who is otherwise eligible for premium
596 assistance for the Florida Kidcare program and has had his or
597 her coverage in an employer-sponsored or private health benefit
598 plan voluntarily canceled in the last 60 days, except those
599 children whose coverage was voluntarily canceled for good cause,
600 including, but not limited to, the following circumstances:
601 1. The cost of participation in an employer-sponsored
602 health benefit plan is greater than 5 percent of the household’s
603 modified adjusted gross family’s income;
604 2. The parent lost a job that provided an employer
605 sponsored health benefit plan for children;
606 3. The parent who had health benefits coverage for the
607 child is deceased;
608 4. The child has a medical condition that, without medical
609 care, would cause serious disability, loss of function, or
610 death;
611 5. The employer of the parent canceled health benefits
612 coverage for children;
613 6. The child’s health benefits coverage ended because the
614 child reached the maximum lifetime coverage amount;
615 7. The child has exhausted coverage under a COBRA
616 continuation provision;
617 8. The health benefits coverage does not cover the child’s
618 health care needs; or
619 9. Domestic violence led to loss of coverage.
620 (5) A child who is otherwise eligible for the Florida
621 Kidcare program and who has a preexisting condition that
622 prevents coverage under another insurance plan as described in
623 paragraph (4)(a) which would have disqualified the child for the
624 Florida Kidcare program if the child were able to enroll in the
625 plan is eligible for Florida Kidcare coverage when enrollment is
626 possible.
627 (5)(6) A child whose household’s modified adjusted gross
628 family income is above 200 percent of the federal poverty level
629 or a child who is excluded under the provisions of subsection
630 (4) may participate in the Florida Kidcare program as provided
631 in s. 409.8132 or, if the child is ineligible for Medikids by
632 reason of age, in the Florida Healthy Kids program, subject to
633 the following:
634 (a) The family is not eligible for premium assistance
635 payments and must pay the full cost of the premium, including
636 any administrative costs.
637 (b) The board of directors of the Florida Healthy Kids
638 Corporation may offer a reduced benefit package to these
639 children in order to limit program costs for such families.
640 (c) The corporation shall notify all current full-pay
641 enrollees of the availability of the exchange and how to access
642 other affordable insurance options.
643 (6)(7) Once a child is enrolled in the Florida Kidcare
644 program, the child is eligible for coverage for 12 months
645 without a redetermination or reverification of eligibility, if
646 the family continues to pay the applicable premium. Eligibility
647 for program components funded through CHIP Title XXI of the
648 Social Security Act terminates when a child attains the age of
649 19. A child who has not attained the age of 5 and who has been
650 determined eligible for the Medicaid program is eligible for
651 coverage for 12 months without a redetermination or
652 reverification of eligibility.
653 (7)(8) When determining or reviewing a child’s eligibility
654 under the Florida Kidcare Program, the applicant shall be
655 provided with reasonable notice of changes in eligibility which
656 may affect enrollment in one or more of the program components.
657 If a transition from one program component to another is
658 authorized, there must shall be cooperation between the program
659 components and the affected family which promotes continuity of
660 health care coverage. Any authorized transfers must be managed
661 within the program’s overall appropriated or authorized levels
662 of funding. Each component of the program shall establish a
663 reserve to ensure that transfers between components are will be
664 accomplished within current year appropriations. These reserves
665 shall be reviewed by each convening of the Social Services
666 Estimating Conference to determine their the adequacy of such
667 reserves to meet actual experience.
668 (8)(9) In determining the eligibility of a child, an assets
669 test is not required. Each applicant shall provide documentation
670 during the application process and the redetermination process,
671 including, but not limited to, the following:
672 (a) Proof of household family income, which must be
673 verified electronically to determine financial eligibility for
674 the Florida Kidcare program. Written documentation, which may
675 include wages and earnings statements or pay stubs, W-2 forms,
676 or a copy of the applicant’s most recent federal income tax
677 return, is required only if the electronic verification is not
678 available or does not substantiate the applicant’s income.
679 (b) A statement from all applicable, employed household
680 family members that:
681 1. Their employers do not sponsor health benefit plans for
682 employees;
683 2. The potential enrollee is not covered by an employer
684 sponsored health benefit plan; or
685 3. The potential enrollee is covered by an employer
686 sponsored health benefit plan and the cost of the employer
687 sponsored health benefit plan is more than 5 percent of the
688 household’s modified adjusted gross family’s income.
689 (c) To enroll in the Children’s Medical Services Network, a
690 completed application, including a clinical screening.
691 (d) Eligibility shall be determined through electronic
692 matching using the federally managed data services hub and other
693 resources. Written documentation from the applicant may be
694 accepted if the electronic verification does not substantiate
695 the applicant’s income or if there has been a change in
696 circumstances.
697 (9)(10) Subject to paragraph (4)(a), the Florida Kidcare
698 program shall withhold benefits from an enrollee if the program
699 obtains evidence that the enrollee is no longer eligible,
700 submitted incorrect or fraudulent information in order to
701 establish eligibility, or failed to provide verification of
702 eligibility. The applicant or enrollee shall be notified that
703 because of such evidence, program benefits will be withheld
704 unless the applicant or enrollee contacts a designated
705 representative of the program by a specified date, which must be
706 within 10 working days after the date of notice, to discuss and
707 resolve the matter. The program shall make every effort to
708 resolve the matter within a timeframe that does will not cause
709 benefits to be withheld from an eligible enrollee.
710 (10)(11) The following individuals may be subject to
711 prosecution in accordance with s. 414.39:
712 (a) An applicant obtaining or attempting to obtain benefits
713 for a potential enrollee under the Florida Kidcare if program
714 when the applicant knows or should have known the potential
715 enrollee does not qualify for the Florida Kidcare program.
716 (b) An individual who assists an applicant in obtaining or
717 attempting to obtain benefits for a potential enrollee under the
718 Florida Kidcare if program when the individual knows or should
719 have known the potential enrollee does not qualify for the
720 Florida Kidcare program.
721 Section 17. Subsection (2) of section 409.815, Florida
722 Statutes, is amended to read:
723 409.815 Health benefits coverage; limitations.—
724 (2) BENCHMARK BENEFITS.—In order for health benefits
725 coverage to qualify for premium assistance payments for an
726 eligible child under this part ss. 409.810-409.821, the health
727 benefits coverage, except for coverage under Medicaid and
728 Medikids, must include the following minimum benefits, as
729 medically necessary.
730 (a) Preventive health services.—Covered services include:
731 1. Well-child care, including services recommended in the
732 Guidelines for Health Supervision of Children and Youth as
733 developed by the American Academy of Pediatrics;
734 2. Immunizations and injections;
735 3. Health education counseling and clinical services;
736 4. Vision screening; and
737 5. Hearing screening.
738 (b) Inpatient hospital services.—All covered services
739 provided for the medical care and treatment of an enrollee who
740 is admitted as an inpatient to a hospital licensed under part I
741 of chapter 395, with the following exceptions:
742 1. All admissions must be authorized by the enrollee’s
743 health benefits coverage provider.
744 2. The length of the patient stay shall be determined based
745 on the medical condition of the enrollee in relation to the
746 necessary and appropriate level of care.
747 3. Room and board may be limited to semiprivate
748 accommodations, unless a private room is considered medically
749 necessary or semiprivate accommodations are not available.
750 4. Admissions for rehabilitation and physical therapy are
751 limited to 15 days per contract year.
752 (c) Emergency services.—Covered services include visits to
753 an emergency room or other licensed facility if needed
754 immediately due to an injury or illness and delay means risk of
755 permanent damage to the enrollee’s health. Health maintenance
756 organizations must shall comply with the provisions of s.
757 641.513.
758 (d) Maternity services.—Covered services include maternity
759 and newborn care, including prenatal and postnatal care, with
760 the following limitations:
761 1. Coverage may be limited to the fee for vaginal
762 deliveries; and
763 2. Initial inpatient care for newborn infants of enrolled
764 adolescents is shall be covered, including normal newborn care,
765 nursery charges, and the initial pediatric or neonatal
766 examination, and the infant may be covered for up to 3 days
767 following birth.
768 (e) Organ transplantation services.—Covered services
769 include pretransplant, transplant, and postdischarge services
770 and treatment of complications after transplantation if for
771 transplants deemed necessary and appropriate within the
772 guidelines set by the Organ Transplant Advisory Council under s.
773 765.53 or the Bone Marrow Transplant Advisory Panel under s.
774 627.4236.
775 (f) Outpatient services.—Covered services include
776 preventive, diagnostic, therapeutic, palliative care, and other
777 services provided to an enrollee in the outpatient portion of a
778 health facility licensed under chapter 395, except for the
779 following limitations:
780 1. Services must be authorized by the enrollee’s health
781 benefits coverage provider; and
782 2. Treatment for temporomandibular joint disease (TMJ) is
783 specifically excluded.
784 (g) Behavioral health services.—
785 1. Mental health benefits include:
786 a. Inpatient services, limited to 30 inpatient days per
787 contract year for psychiatric admissions, or residential
788 services in facilities licensed under s. 394.875(6) or s.
789 395.003 in lieu of inpatient psychiatric admissions; however, a
790 minimum of 10 of the 30 days shall be available only for
791 inpatient psychiatric services if authorized by a physician; and
792 b. Outpatient services, including outpatient visits for
793 psychological or psychiatric evaluation, diagnosis, and
794 treatment by a licensed mental health professional, limited to
795 40 outpatient visits each contract year.
796 2. Substance abuse services include:
797 a. Inpatient services, limited to 7 inpatient days per
798 contract year for medical detoxification only and 30 days of
799 residential services; and
800 b. Outpatient services, including evaluation, diagnosis,
801 and treatment by a licensed practitioner, limited to 40
802 outpatient visits per contract year.
803
804 Effective October 1, 2009, Covered services include inpatient
805 and outpatient services for mental and nervous disorders as
806 defined in the most recent edition of the Diagnostic and
807 Statistical Manual of Mental Disorders published by the American
808 Psychiatric Association. Such benefits include psychological or
809 psychiatric evaluation, diagnosis, and treatment by a licensed
810 mental health professional and inpatient, outpatient, and
811 residential treatment of substance abuse disorders. Any benefit
812 limitations, including duration of services, number of visits,
813 or number of days for hospitalization or residential services,
814 may shall not be any less favorable than those for physical
815 illnesses generally. The program may also implement appropriate
816 financial incentives, peer review, utilization requirements, and
817 other methods used for the management of benefits provided for
818 other medical conditions in order to reduce service costs and
819 utilization without compromising quality of care.
820 (h) Durable medical equipment.—Covered services include
821 equipment and devices that are medically indicated to assist in
822 the treatment of a medical condition and specifically prescribed
823 as medically necessary, with the following limitations:
824 1. Low-vision and telescopic aids aides are not included.
825 2. Corrective lenses and frames may be limited to one pair
826 every 2 years, unless the prescription or head size of the
827 enrollee changes.
828 3. Hearing aids are shall be covered only if when medically
829 indicated to assist in the treatment of a medical condition.
830 4. Covered prosthetic devices include artificial eyes and
831 limbs, braces, and other artificial aids.
832 (i) Health practitioner services.—Covered services include
833 services and procedures rendered to an enrollee if when
834 performed to diagnose and treat diseases, injuries, or other
835 conditions, including care rendered by health practitioners
836 acting within the scope of their practice, with the following
837 exceptions:
838 1. Chiropractic services shall be provided in the same
839 manner as under in the Florida Medicaid program.
840 2. Podiatric services may be limited to one visit per day
841 totaling two visits per month for specific foot disorders.
842 (j) Home health services.—Covered services include
843 prescribed home visits by both registered and licensed practical
844 nurses to provide skilled nursing services on a part-time
845 intermittent basis, subject to the following limitations:
846 1. Coverage may be limited to include skilled nursing
847 services only;
848 2. Meals, housekeeping, and personal comfort items may be
849 excluded; and
850 3. Private duty nursing is limited to circumstances where
851 such care is medically necessary.
852 (k) Hospice services.—Covered services include reasonable
853 and necessary services for palliation or management of an
854 enrollee’s terminal illness, with the following exceptions:
855 1. Once a family elects to receive hospice care for an
856 enrollee, other services that treat the terminal condition will
857 not be covered; and
858 2. Services required for conditions totally unrelated to
859 the terminal condition are covered to the extent that the
860 services are included in this section.
861 (l) Laboratory and X-ray services.—Covered services include
862 diagnostic testing, including clinical radiologic, laboratory,
863 and other diagnostic tests.
864 (m) Nursing facility services.—Covered services include
865 regular nursing services, rehabilitation services, drugs and
866 biologicals, medical supplies, and the use of appliances and
867 equipment furnished by the facility, with the following
868 limitations:
869 1. All admissions must be authorized by the health benefits
870 coverage provider.
871 2. The length of the patient stay shall be determined based
872 on the medical condition of the enrollee in relation to the
873 necessary and appropriate level of care, but is limited to not
874 more than 100 days per contract year.
875 3. Room and board may be limited to semiprivate
876 accommodations, unless a private room is considered medically
877 necessary or semiprivate accommodations are not available.
878 4. Specialized treatment centers and independent kidney
879 disease treatment centers are excluded.
880 5. Private duty nurses, television, and custodial care are
881 excluded.
882 6. Admissions for rehabilitation and physical therapy are
883 limited to 15 days per contract year.
884 (n) Prescribed drugs.—
885 1. Coverage includes shall include drugs prescribed for the
886 treatment of illness or injury if when prescribed by a licensed
887 health practitioner acting within the scope of his or her
888 practice.
889 2. Prescribed drugs may be limited to generics if available
890 and brand name products if a generic substitution is not
891 available, unless the prescribing licensed health practitioner
892 indicates that a brand name is medically necessary.
893 3. Prescribed drugs covered under this section shall
894 include all prescribed drugs covered under the Florida Medicaid
895 program.
896 (o) Therapy services.—Covered services include
897 rehabilitative services, including occupational, physical,
898 respiratory, and speech therapies, with the following
899 limitations:
900 1. Services must be for short-term rehabilitation where
901 significant improvement in the enrollee’s condition will result;
902 and
903 2. Services are shall be limited to not more than 24
904 treatment sessions within a 60-day period per episode or injury,
905 with the 60-day period beginning with the first treatment.
906 (p) Transportation services.—Covered services include
907 emergency transportation required in response to an emergency
908 situation.
909 (q) Dental services.—Effective October 1, 2009, Dental
910 services are shall be covered as required under federal law and
911 may also include those dental benefits provided to children by
912 the Florida Medicaid program under s. 409.906(6).
913 (r) Lifetime maximum.—Health benefits coverage obtained
914 under this part ss. 409.810-409.820 shall pay an enrollee’s
915 covered expenses at a lifetime maximum of $1 million per covered
916 child.
917 (s) Cost sharing.—Cost-sharing provisions must comply with
918 s. 409.816.
919 (t) Exclusions.—
920 1. Experimental or investigational procedures that have not
921 been clinically proven by reliable evidence are excluded;
922 2. Services performed for cosmetic purposes only or for the
923 convenience of the enrollee are excluded; and
924 3. Abortion may be covered only if necessary to save the
925 life of the mother or if the pregnancy is the result of an act
926 of rape or incest.
927 (u) Enhancements to minimum requirements.—
928 1. This section sets the minimum benefits that must be
929 included in any health benefits coverage, other than Medicaid or
930 Medikids coverage, offered under this part ss. 409.810-409.821.
931 Health benefits coverage may include additional benefits not
932 included under this subsection, but may not include benefits
933 excluded under paragraph (s).
934 2. Health benefits coverage may extend any limitations
935 beyond the minimum benefits described in this section.
936
937 Except for the Children’s Medical Services Network, the agency
938 may not increase the premium assistance payment for either
939 additional benefits provided beyond the minimum benefits
940 described in this section or the imposition of less restrictive
941 service limitations.
942 (v) Applicability of other state laws.—Health insurers,
943 health maintenance organizations, and their agents are subject
944 to the provisions of the Florida Insurance Code, except for any
945 such provisions waived under in this section.
946 1. Except as expressly provided in this section, a law
947 requiring coverage for a specific health care service or
948 benefit, or a law requiring reimbursement, utilization, or
949 consideration of a specific category of licensed health care
950 practitioner, does not apply to a health insurance plan policy
951 or contract offered or delivered under this part ss. 409.810
952 409.821 unless that law is made expressly applicable to such
953 policies or contracts.
954 2. Notwithstanding chapter 641, a health maintenance
955 organization may issue contracts providing benefits equal to,
956 exceeding, or actuarially equivalent to the benchmark benefit
957 plan authorized by this section and may pay providers located in
958 a rural county negotiated fees or Medicaid reimbursement rates
959 for services provided to enrollees who are residents of the
960 rural county.
961 (w) Reimbursement of federally qualified health centers and
962 rural health clinics.—Effective October 1, 2009, Payments for
963 services provided to enrollees by federally qualified health
964 centers and rural health clinics under this section shall be
965 reimbursed using the Medicaid Prospective Payment System as
966 provided for under s. 2107(e)(1)(D) of the Social Security Act.
967 If such services are paid for by health insurers or health care
968 providers under contract with the Florida Healthy Kids
969 corporation, such entities are responsible for this payment. The
970 agency may seek any available federal grants to assist with this
971 transition.
972 Section 18. Section 409.816, Florida Statutes, is amended
973 to read:
974 409.816 Limitations on premiums and cost sharing.—The
975 following limitations on premiums and cost sharing are
976 established for the program.
977 (1) Enrollees who receive coverage under the Medicaid
978 program may not be required to pay:
979 (a) Enrollment fees, premiums, or similar charges; or
980 (b) Copayments, deductibles, coinsurance, or similar
981 charges.
982 (2) Enrollees in households that have families with a
983 modified adjusted gross family income equal to or below 150
984 percent of the federal poverty level, who are not receiving
985 coverage under the Medicaid program, are may not be required to
986 pay:
987 (a) Enrollment fees, premiums, or similar charges that
988 exceed the maximum monthly charge permitted under s. 1916(b)(1)
989 of the Social Security Act; or
990 (b) Copayments, deductibles, coinsurance, or similar
991 charges that exceed a nominal amount, as determined consistent
992 with regulations referred to in s. 1916(a)(3) of the Social
993 Security Act. However, such charges may not be imposed for
994 preventive services, including well-baby and well-child care,
995 age-appropriate immunizations, and routine hearing and vision
996 screenings.
997 (3) Enrollees in households that have families with a
998 modified adjusted gross family income above 150 percent of the
999 federal poverty level who are not receiving coverage under the
1000 Medicaid program or who are not eligible under s. 409.814(5) s.
1001 409.814(6) may be required to pay enrollment fees, premiums,
1002 copayments, deductibles, coinsurance, or similar charges on a
1003 sliding scale related to income, except that the total annual
1004 aggregate cost sharing with respect to all children in a
1005 household family may not exceed 5 percent of the household’s
1006 modified adjusted family’s income. However, copayments,
1007 deductibles, coinsurance, or similar charges may not be imposed
1008 for preventive services, including well-baby and well-child
1009 care, age-appropriate immunizations, and routine hearing and
1010 vision screenings.
1011 Section 19. Section 409.817, Florida Statutes, is repealed.
1012 Section 20. Section 409.8175, Florida Statutes, is
1013 repealed.
1014 Section 21. Subsection (1) of section 409.8177, Florida
1015 Statutes, is amended to read:
1016 409.8177 Program evaluation.—
1017 (1) The agency, in consultation with the Department of
1018 Health, the Department of Children and Families Family Services,
1019 and the Florida Healthy Kids corporation, shall contract for an
1020 evaluation of the Florida Kidcare program and shall by January 1
1021 of each year submit to the Governor, the President of the
1022 Senate, and the Speaker of the House of Representatives a report
1023 of the program. In addition to the items specified under s. 2108
1024 of Title XXI of the Social Security Act, the report shall
1025 include an assessment of crowd-out and access to health care, as
1026 well as the following:
1027 (a) An assessment of the operation of the program,
1028 including the progress made in reducing the number of uncovered
1029 low-income children.
1030 (b) An assessment of the effectiveness in increasing the
1031 number of children with creditable health coverage, including an
1032 assessment of the impact of outreach.
1033 (c) The characteristics of the children and families
1034 assisted under the program, including ages of the children,
1035 household family income, and access to or coverage by other
1036 health insurance before enrolling in prior to the program and
1037 after disenrollment from the program.
1038 (d) The quality of health coverage provided, including the
1039 types of benefits provided.
1040 (e) The amount and level, including payment of part or all
1041 of any premium, of assistance provided.
1042 (f) The average length of coverage of a child under the
1043 program.
1044 (g) The program’s choice of health benefits coverage and
1045 other methods used for providing child health assistance.
1046 (h) The sources of nonfederal funding used in the program.
1047 (i) An assessment of the effectiveness of the Florida
1048 Kidcare program, including Medicaid, the Florida Healthy Kids
1049 program, Medikids, and the Children’s Medical Services Network,
1050 and other public and private programs in the state in increasing
1051 the availability of affordable quality health insurance and
1052 health care for children.
1053 (j) A review and assessment of state activities to
1054 coordinate the program with other public and private programs.
1055 (k) An analysis of changes and trends in the state that
1056 affect the provision of health insurance and health care to
1057 children.
1058 (l) A description of any plans the state has for improving
1059 the availability of health insurance and health care for
1060 children.
1061 (m) Recommendations for improving the program.
1062 (n) Other studies as necessary.
1063 Section 22. Section 409.818, Florida Statutes, is amended
1064 to read:
1065 409.818 Administration.—In order to administer this part
1066 implement ss. 409.810-409.821, the following agencies shall have
1067 the following duties:
1068 (1) The Department of Children and Families Family Services
1069 shall:
1070 (a) Maintain Develop a simplified eligibility determination
1071 and renewal process application mail-in form to be used for
1072 determining the eligibility of children for coverage under the
1073 Florida Kidcare program, in consultation with the agency, the
1074 Department of Health, and the Florida Healthy Kids corporation.
1075 The simplified eligibility process application form must include
1076 an item that provides an opportunity for the applicant to
1077 indicate whether coverage is being sought for a child with
1078 special health care needs. Families applying for children’s
1079 Medicaid coverage must also be able to use the simplified
1080 application process form without having to pay a premium.
1081 (b) Establish and maintain the eligibility determination
1082 process under the program except as specified in subsection (3),
1083 which includes the following: (5).
1084 1. The department shall directly, or through the services
1085 of a contracted third-party administrator, establish and
1086 maintain a process to be for determining eligibility of children
1087 for coverage under the program. The eligibility determination
1088 process must be used solely for determining the eligibility of
1089 applicants for health benefits coverage under the program. The
1090 eligibility determination process must include an initial
1091 determination of eligibility for any coverage offered under the
1092 program, as well as a redetermination or reverification of
1093 eligibility each subsequent 6 months. Effective January 1, 1999,
1094 A child who has not attained the age of 5 years of age and who
1095 has been determined eligible for the Medicaid program is
1096 eligible for coverage for 12 months without a redetermination or
1097 reverification of eligibility. In conducting an eligibility
1098 determination, the department shall determine if the child has
1099 special health care needs.
1100 2. The department, in consultation with the agency for
1101 Health Care Administration and the Florida Healthy Kids
1102 corporation, shall develop procedures for redetermining
1103 eligibility which enable applicants and enrollees a family to
1104 easily update any change in circumstances which could affect
1105 eligibility.
1106 3. The department may accept changes in a family’s status
1107 as reported to the department by the Florida Healthy Kids
1108 corporation or the exchange as defined under the Patient
1109 Protection and Affordable Care Act without requiring a new
1110 application from the family. Redetermination of a child’s
1111 eligibility for Medicaid may not be linked to a child’s
1112 eligibility determination for other programs.
1113 4. The department, in consultation with the agency and the
1114 corporation, shall develop a combined eligibility notice to
1115 inform applicants or enrollees of their application or renewal
1116 status, as appropriate. By January 1, 2015, the content of the
1117 notice must be coordinated to meet all federal and state law and
1118 regulatory requirements under the federal Patient Protection and
1119 Affordable Care Act. The notice shall be issued by the last
1120 agency or department to make an eligibility, renewal, or denial
1121 determination.
1122 (c) Inform program applicants about eligibility
1123 determinations and provide information about eligibility of
1124 applicants to the Florida Kidcare program and to insurers and
1125 their agents, through a centralized coordinating office.
1126 (d) Adopt rules necessary for conducting program
1127 eligibility functions.
1128 (2) The Department of Health shall:
1129 (a) Design an eligibility intake process for the program,
1130 in coordination with the Department of Children and Family
1131 Services, the agency, and the Florida Healthy Kids Corporation.
1132 The eligibility intake process may include local intake points
1133 that are determined by the Department of Health in coordination
1134 with the Department of Children and Family Services.
1135 (b) Chair a state-level Florida Kidcare coordinating
1136 council to review and make recommendations concerning the
1137 implementation and operation of the program. The coordinating
1138 council shall include representatives from the department, the
1139 Department of Children and Family Services, the agency, the
1140 Florida Healthy Kids Corporation, the Office of Insurance
1141 Regulation of the Financial Services Commission, local
1142 government, health insurers, health maintenance organizations,
1143 health care providers, families participating in the program,
1144 and organizations representing low-income families.
1145 (c) In consultation with the Florida Healthy Kids
1146 Corporation and the Department of Children and Family Services,
1147 establish a toll-free telephone line to assist families with
1148 questions about the program.
1149 (d) Adopt rules necessary to implement outreach activities.
1150 (2)(3) Pursuant to The agency for Health Care
1151 Administration, under the authority granted in s. 409.914(1),
1152 the agency shall:
1153 (a) Calculate the premium assistance payment necessary to
1154 comply with the premium and cost-sharing limitations specified
1155 in s. 409.816 and the Patient Protection and Affordable Care
1156 Act. The premium assistance payment for each enrollee in a
1157 health insurance plan participating in the Florida Healthy Kids
1158 corporation must shall equal the premium approved by the Florida
1159 Healthy Kids corporation and the Office of Insurance Regulation
1160 of the Financial Services Commission pursuant to ss. 627.410 and
1161 641.31, less any enrollee’s share of the premium established
1162 within the limitations specified in s. 409.816. The premium
1163 assistance payment for each enrollee in an employer-sponsored
1164 health insurance plan approved under ss. 409.810-409.821 shall
1165 equal the premium for the plan adjusted for any benchmark
1166 benefit plan actuarial equivalent benefit rider approved by the
1167 Office of Insurance Regulation pursuant to ss. 627.410 and
1168 641.31, less any enrollee’s share of the premium established
1169 within the limitations specified in s. 409.816. In calculating
1170 the premium assistance payment levels for children with family
1171 coverage, the agency shall set the premium assistance payment
1172 levels for each child proportionately to the total cost of
1173 family coverage.
1174 (b) Make premium assistance payments to health insurance
1175 plans on a periodic basis. The agency may use its Medicaid
1176 fiscal agent or a contracted third-party administrator in making
1177 these payments. The agency may require health insurance plans
1178 that participate in the Medikids program or employer-sponsored
1179 group health insurance to collect premium payments from an
1180 enrollee’s family. Participating health insurance plans shall
1181 report premium payments collected on behalf of enrollees in the
1182 program to the agency in accordance with a schedule established
1183 by the agency.
1184 (c) Monitor compliance with quality assurance and access
1185 standards developed under s. 409.820 and in accordance with s.
1186 2103(f) of the Social Security Act, 42 U.S.C. s. 1397cc(f).
1187 (d) Establish a mechanism for investigating and resolving
1188 complaints and grievances from program applicants, enrollees,
1189 and health benefits coverage providers, and maintain a record of
1190 complaints and confirmed problems. In the case of a child who is
1191 enrolled in a managed care health maintenance organization, the
1192 agency must use the provisions of s. 641.511 to address
1193 grievance reporting and resolution requirements.
1194 (e) Approve health benefits coverage for participation in
1195 the program, following certification by the Office of Insurance
1196 Regulation under subsection (4).
1197 (e)(f) Adopt rules necessary for calculating premium
1198 assistance payment levels, making premium assistance payments,
1199 monitoring access and quality assurance standards and,
1200 investigating and resolving complaints and grievances,
1201 administering the Medikids program, and approving health
1202 benefits coverage.
1203 (f) Contract with the corporation for the administration of
1204 Florida Kidcare and Healthy Florida and to facilitate the
1205 release of any federal and state funds.
1206
1207 The agency is designated the lead state agency for CHIP Title
1208 XXI of the Social Security Act for purposes of receipt of
1209 federal funds, for reporting purposes, and for ensuring
1210 compliance with federal and state regulations and rules.
1211 (4) The Office of Insurance Regulation shall certify that
1212 health benefits coverage plans that seek to provide services
1213 under the Florida Kidcare program, except those offered through
1214 the Florida Healthy Kids Corporation or the Children’s Medical
1215 Services Network, meet, exceed, or are actuarially equivalent to
1216 the benchmark benefit plan and that health insurance plans will
1217 be offered at an approved rate. In determining actuarial
1218 equivalence of benefits coverage, the Office of Insurance
1219 Regulation and health insurance plans must comply with the
1220 requirements of s. 2103 of Title XXI of the Social Security Act.
1221 The department shall adopt rules necessary for certifying health
1222 benefits coverage plans.
1223 (3)(5) The Florida Healthy Kids corporation shall retain
1224 its functions as authorized under s. 409.8125 in s. 624.91,
1225 including eligibility determination for participation in the
1226 Healthy Kids program.
1227 (4)(6) The agency, the Department of Health, the Department
1228 of Children and Families Family Services, and the Florida
1229 Healthy Kids corporation, and the Office of Insurance
1230 Regulation, after consultation with and approval of the Speaker
1231 of the House of Representatives and the President of the Senate,
1232 may are authorized to make program modifications that are
1233 necessary to overcome any objections of the United States
1234 Department of Health and Human Services to obtain approval of
1235 the state’s CHIP child health insurance plan under Title XXI of
1236 the Social Security Act.
1237 Section 23. Section 409.820, Florida Statutes, is amended
1238 to read:
1239 409.820 Quality assurance and access standards.—Except for
1240 Medicaid, the Department of Health, in consultation with the
1241 agency and the Florida Healthy Kids corporation, shall develop a
1242 minimum set of pediatric and adolescent quality assurance and
1243 access standards for all program components. The standards must
1244 include a process for granting exceptions to specific
1245 requirements for quality assurance and access. Compliance with
1246 the standards shall be a condition of program participation by
1247 health benefits coverage providers. These standards must shall
1248 comply with the provisions of this chapter, and chapter 641, and
1249 Title XXI of the Social Security Act.
1250 Section 24. Section 409.822, Florida Statutes, is created
1251 to read:
1252 409.822 Healthy Florida.—
1253 (1) PROGRAM CREATION.—Healthy Florida, a health care
1254 program for lower income, uninsured adults who meet the
1255 eligibility guidelines established under s. 409.8125, is
1256 created. The corporation shall administer the program under its
1257 existing corporate governance and structure.
1258 (2) ELIGIBILITY.—To be eligible and to remain eligible for
1259 Healthy Florida, an individual must be a resident of this state
1260 and meet the following additional criteria:
1261 (a) Be identified as newly eligible, as defined in s.
1262 1902(a)(10)(A)(i)(VIII) of the Social Security Act or s. 2001 of
1263 the federal Patient Protection and Affordable Care Act, and as
1264 may be further defined by federal regulation.
1265 (b) Maintain eligibility with the corporation and meet all
1266 renewal requirements as established by the corporation.
1267 (c) Renew eligibility on at least an annual basis.
1268 (3) ENROLLMENT.—The corporation may begin the enrollment of
1269 applicants in Healthy Florida on October 1, 2014. Enrollment may
1270 occur directly, through the services of a third-party
1271 administrator, referrals from the Department of Children and
1272 Families, and the exchange as defined by the federal Patient
1273 Protection and Affordable Care Act. When an enrollee disenrolls,
1274 the corporation must provide him or her with information about
1275 other affordable insurance programs and electronically refer the
1276 enrollee to the exchange or other programs, as appropriate. The
1277 earliest coverage effective date under the program shall be
1278 January 1, 2015.
1279 (4) DELIVERY OF SERVICES.—The corporation shall contract
1280 with authorized insurers licensed under chapter 627; managed
1281 care organizations authorized under chapter 641; and provider
1282 service networks authorized under ss. 409.912(4)(d) and
1283 409.962(13) which are prepaid plans. These insurers, managed
1284 care organizations, and provider service networks must meet
1285 standards established by the corporation to provide
1286 comprehensive health care services to enrollees who qualify for
1287 services under this section. The corporation may contract for
1288 such services on a statewide or regional basis. To encourage
1289 continuity of care among enrollees who transition across
1290 multiple affordable insurance programs, the corporation is
1291 encouraged to contract with those insurers and managed care
1292 organizations that participate in more than one such program.
1293 (a) The corporation shall establish access and network
1294 standards for such contracts and ensure that contracted
1295 providers have sufficient providers to meet enrollee needs.
1296 Quality standards shall be developed by the corporation,
1297 specific to the adult population, which take into consideration
1298 recommendations from the National Committee on Quality
1299 Assurance, stakeholders, and other existing performance
1300 indicators from both public and commercial populations. The
1301 corporation and its contracted health plans shall develop
1302 policies that minimize the disruption of enrollee medical homes
1303 when enrollees transition between affordable insurance plans.
1304 (b) The corporation shall provide an enrollee a choice of
1305 plans. The corporation may select a plan if no selection has
1306 been received before the coverage start date. Once enrolled, an
1307 enrollee has an initial 90-day, free-look period before a lock
1308 in period of up to 12 months is applied. Exceptions to the lock
1309 in period must be offered to an enrollee for reasons based on
1310 good cause or qualifying events.
1311 (c) The corporation may consider contracts that provide
1312 family plans that would allow members from multiple state and
1313 federally funded programs to remain together under the same
1314 plan.
1315 (d) All contracts must meet the medical loss ratio
1316 requirements under this part.
1317 (5) BENEFITS.—The corporation shall establish a benefits
1318 package that is actuarially equivalent to the benchmark benefit
1319 plan offered under s. 409.815(2), excluding dental, and meets
1320 the alternative benefits package requirements under s. 1937 of
1321 the Social Security Act. Benefits must be offered as an
1322 integrated, single package.
1323 (a) In addition to benchmark benefits, health reimbursement
1324 accounts or a comparable health savings account for each
1325 enrollee must be established through the corporation or the
1326 contracts managed by the corporation. Enrollees must be rewarded
1327 for healthy behaviors, wellness program adherence, and other
1328 activities established by the corporation which demonstrate
1329 compliance with preventive care or disease management
1330 guidelines. Funds deposited into these accounts may be used to
1331 pay cost-sharing obligations or to purchase over-the-counter
1332 health items to the extent allowed under federal law or
1333 regulation.
1334 (b) Enhanced services may be offered if the cost of such
1335 additional services provides savings to the overall plan.
1336 (c) The corporation shall establish a process for the
1337 payment of wrap-around services not covered by the benchmark
1338 benefit plan through a separate subcapitation process to its
1339 contracted providers if it is determined that such services are
1340 required by federal law. Such services would be covered if
1341 deemed medically necessary on an individual basis. The
1342 subcapitation pool is subject to a separate reconciliation
1343 process under the medical loss ratio provisions in this part.
1344 (d) A prior authorization process and other utilization
1345 controls may be established by the plan for any benefit if
1346 approved by the corporation.
1347 (6) COST SHARING.—The corporation may collect premiums and
1348 copayments from enrollees in accordance with federal law.
1349 Amounts to be collected for Healthy Florida must be established
1350 annually in the General Appropriations Act.
1351 (a) Payment of a monthly premium may be required before the
1352 establishment of an enrollee’s coverage start date and to retain
1353 monthly coverage.
1354 (b) An enrollee who has a family income above the federal
1355 poverty level may be required to make nominal copayments, in
1356 accordance with federal rule, as a condition of receiving a
1357 health care service.
1358 (c) A provider is responsible for the collection of point
1359 of-service cost-sharing obligations. The enrollee’s cost-sharing
1360 contribution is considered part of the provider’s total
1361 reimbursement. Failure to collect an enrollee’s cost sharing
1362 reduces the provider’s share of the reimbursement.
1363 (7) PROGRAM MANAGEMENT.—The corporation is responsible for
1364 the oversight of Healthy Florida. The agency shall seek a state
1365 plan amendment or other appropriate federal approval to
1366 implement Healthy Florida. The agency shall consult with the
1367 corporation in the amendment’s development and, by June 14,
1368 2014, submit the state plan amendment to the federal Department
1369 of Health and Human Services. The agency shall contract with the
1370 corporation for the administration of Healthy Florida and for
1371 the timely release of federal and state funds. The agency
1372 retains its authority as provided in ss. 409.902 and 409.963.
1373 (a) The corporation shall establish a grievance resolution
1374 process in which Healthy Florida enrollees are informed of their
1375 rights under the Medicaid fair hearing process, as appropriate,
1376 or any alternative resolution process adopted by the
1377 corporation.
1378 (b) The corporation shall establish a program integrity
1379 process to ensure compliance with program guidelines. At a
1380 minimum, the corporation shall withhold benefits from an
1381 applicant or enrollee if the corporation obtains evidence that
1382 the applicant or enrollee is no longer eligible, submitted
1383 incorrect or fraudulent information in order to establish
1384 eligibility, or failed to provide verification of eligibility.
1385 The corporation shall notify the applicant or enrollee that,
1386 because of such evidence, program benefits must be withheld
1387 unless the applicant or enrollee contacts a designated
1388 representative of the corporation by a specified date, which
1389 must be within 10 working days after the date of notice, to
1390 discuss and resolve the matter. The corporation shall make every
1391 effort to resolve the matter within a timeframe that does not
1392 cause benefits to be withheld from an eligible enrollee. The
1393 following individuals may be subject to specific prosecution in
1394 accordance with s. 414.39:
1395 1. An applicant who obtains or attempts to obtain benefits
1396 for a potential enrollee under Healthy Florida when the
1397 applicant knows or should have known that the potential enrollee
1398 does not qualify for Healthy Florida.
1399 2. An individual who assists an applicant in obtaining or
1400 attempting to obtain benefits for a potential enrollee under
1401 Healthy Florida when the individual knows or should have known
1402 that the potential enrollee does not qualify for Healthy
1403 Florida.
1404 (8) APPLICABILITY OF LAWS RELATING TO MEDICAID.—Sections
1405 409.902, 409.9128, and 409.920 apply to the administration of
1406 Healthy Florida.
1407 (9) PROGRAM EVALUATION.—The corporation shall collect both
1408 eligibility and enrollment data from program applicants and
1409 enrollees as well as encounter and utilization data from all
1410 contracted entities during the program term. The corporation
1411 shall submit monthly enrollment reports to the President of the
1412 Senate, the Speaker of the House of Representatives, and the
1413 Minority Leaders of the Senate and the House of Representatives.
1414 The corporation shall submit an interim independent evaluation
1415 of Healthy Florida to the presiding officers by July 1, 2016,
1416 with annual evaluations due July 1 thereafter. The evaluations
1417 must address, at a minimum, application and enrollment trends
1418 and issues, utilization and cost data, and customer
1419 satisfaction.
1420 (10) PROGRAM EXPIRATION.—The Healthy Florida program
1421 expires at the end of the state fiscal year in which any of
1422 these conditions occur:
1423 (a) The federal match contribution falls below 90 percent.
1424 (b) The federal match contribution falls below the
1425 increased federal medical assistance percentages for medical
1426 assistance for newly eligible mandatory individuals as specified
1427 in the Patient Protection and Affordable Care Act.
1428 (c) The federal match for the Healthy Florida program and
1429 the Medicaid program are blended under federal law or regulation
1430 in a way that causes the overall federal contribution to
1431 diminish when compared to separate, nonblended federal
1432 contributions.
1433 Section 25. The Florida Healthy Kids Corporation may make
1434 such changes as are necessary to comply with the objections of
1435 the federal Department of Health and Human Services in order to
1436 gain approval of the Healthy Florida program in compliance with
1437 the federal Patient Protection and Affordable Care Act, Pub. L.
1438 No. 111-148, as amended by the federal Health Care and Education
1439 Reconciliation Act of 2010, Pub. L. No. 111-152, upon giving
1440 notice to the Senate and the House of Representatives of the
1441 proposed changes. If there is a conflict between this section
1442 and the federal Patient Protection and Affordable Care Act, the
1443 provision must be interpreted and applied so as to comply with
1444 federal law.
1445 Section 26. Paragraph (e) of subsection (2) of section
1446 154.503, Florida Statutes, is amended to read:
1447 154.503 Primary Care for Children and Families Challenge
1448 Grant Program; creation; administration.—
1449 (2) The department shall:
1450 (e) Coordinate with the primary care program developed
1451 pursuant to s. 154.011, the Florida Healthy Kids Corporation
1452 program created in s. 409.8125 s. 624.91, the school health
1453 services program created in ss. 381.0056 and 381.0057, and the
1454 volunteer health care provider program developed pursuant to s.
1455 766.1115.
1456 Section 27. Paragraph (d) of subsection (14) of section
1457 408.910, Florida Statutes, is amended to read:
1458 408.910 Florida Health Choices Program.—
1459 (14) EXEMPTION FROM PUBLIC RECORDS REQUIREMENTS.—
1460 (d) Authorized release.—
1461 1. Upon request, information made confidential and exempt
1462 pursuant to this subsection shall be disclosed to:
1463 a. Another governmental entity in the performance of its
1464 official duties and responsibilities.
1465 b. Any person who has the written consent of the program
1466 applicant.
1467 c. The Florida Kidcare program for the purpose of
1468 administering the program authorized under part II of chapter
1469 409 in ss. 409.810-409.821.
1470 2. Paragraph (b) does not prohibit a participant’s legal
1471 guardian from obtaining confirmation of coverage, dates of
1472 coverage, the name of the participant’s health plan, and the
1473 amount of premium being paid.
1474 Section 28. Paragraph (c) of subsection (4) of section
1475 408.915, Florida Statutes, is amended to read:
1476 408.915 Eligibility pilot project.—The Agency for Health
1477 Care Administration, in consultation with the steering committee
1478 established in s. 408.916, shall develop and implement a pilot
1479 project to integrate the determination of eligibility for health
1480 care services with information and referral services.
1481 (4) The pilot project shall include eligibility
1482 determinations for the following programs:
1483 (c) Florida Healthy Kids as described in s. 409.8125 s.
1484 624.91 and within eligibility guidelines provided in s. 409.814.
1485 Section 29. Section 624.915, Florida Statutes, is repealed.
1486 Section 30. Section 627.6474, Florida Statutes, is amended
1487 to read:
1488 627.6474 Provider contracts.—
1489 (1) A health insurer may shall not require a contracted
1490 health care practitioner as defined in s. 456.001(4) to accept
1491 the terms of other health care practitioner contracts with the
1492 insurer or any other insurer, or health maintenance
1493 organization, under common management and control with the
1494 insurer, including Medicare and Medicaid practitioner contracts
1495 and those authorized by s. 627.6471, s. 627.6472, s. 636.035, or
1496 s. 641.315, except for a practitioner in a group practice as
1497 defined in s. 456.053 who must accept the terms of a contract
1498 negotiated for the practitioner by the group, as a condition of
1499 continuation or renewal of the contract. A Any contract
1500 provision that violates this section is void. A violation of
1501 this subsection section is not subject to the criminal penalty
1502 specified in s. 624.15.
1503 (2) A contract between a health insurer and a dentist
1504 licensed under chapter 466 for the provision of services to an
1505 insured may not:
1506 (a) Contain a provision that requires the dentist to
1507 provide services to the insured under such contract at a fee set
1508 by the health insurer unless such services are covered services
1509 under the applicable contract. Covered services are those
1510 services that are listed as a benefit that the insured is
1511 entitled to receive under the contract. An insurer may not
1512 provide merely de minimis reimbursement or coverage in order to
1513 avoid the requirements of this subsection. Fees for covered
1514 services shall be set in good faith and may not be nominal.
1515 (b) Require as a condition of the contract that the dentist
1516 participate in a discount medical plan under part II of chapter
1517 636.
1518 Section 31. Subsection (13) is added to section 636.035,
1519 Florida Statutes, to read:
1520 636.035 Provider arrangements.—
1521 (13) A contract between a prepaid limited health service
1522 organization and a dentist licensed under chapter 466 for the
1523 provision of services to a subscriber of the prepaid limited
1524 health service organization may not:
1525 (a) Contain a provision that requires the dentist to
1526 provide services to the subscriber of the prepaid limited health
1527 service organization at a fee set by the prepaid limited health
1528 service organization unless such services are covered services
1529 under the applicable contract. Covered services are those
1530 services that are listed as a benefit that the subscriber is
1531 entitled to receive under the contract. A prepaid limited health
1532 service organization may not provide merely de minimis
1533 reimbursement or coverage in order to avoid the requirements of
1534 this subsection. Fees for covered services shall be set in good
1535 faith and may not be nominal.
1536 (b) Require as a condition of the contract that the dentist
1537 participate in a discount medical plan under part II of this
1538 chapter.
1539 Section 32. Subsection (11) is added to section 641.315,
1540 Florida Statutes, to read:
1541 641.315 Provider contracts.—
1542 (11) A contract between a health maintenance organization
1543 and a dentist licensed under chapter 466 for the provision of
1544 services to a subscriber of the health maintenance organization
1545 may not:
1546 (a) Contain a provision that requires the dentist to
1547 provide services to the subscriber of the health maintenance
1548 organization at a fee set by the health maintenance organization
1549 unless such services are covered services under the applicable
1550 contract. Covered services are those services that are listed as
1551 a benefit that the subscriber is entitled to receive under the
1552 contract. A health maintenance organization may not provide
1553 merely de minimis reimbursement or coverage in order to avoid
1554 the requirements of this subsection. Fees for covered services
1555 shall be set in good faith and may not be nominal.
1556 (b) Require as a condition of the contract that the dentist
1557 participate in a discount medical plan under part II of chapter
1558 636.
1559 Section 33. Paragraph (a) of subsection (3) of section
1560 766.1115, Florida Statutes, is amended, and paragraph (h) is
1561 added to subsection (4) of that section, to read:
1562 766.1115 Health care providers; creation of agency
1563 relationship with governmental contractors.—
1564 (3) DEFINITIONS.—As used in this section, the term:
1565 (a) “Contract” means an agreement executed in compliance
1566 with this section between a health care provider and a
1567 governmental contractor which allows. This contract shall allow
1568 the health care provider to deliver health care services to low
1569 income recipients as an agent of the governmental contractor.
1570 The contract must be for volunteer, uncompensated services. For
1571 services to qualify as volunteer, uncompensated services under
1572 this section, the health care provider may not must receive no
1573 compensation from the governmental contractor for any services
1574 provided under the contract and may must not bill or accept
1575 compensation from the recipient, or a any public or private
1576 third-party payor, for the specific services provided to the
1577 low-income recipients covered by the contract.
1578 (4) CONTRACT REQUIREMENTS.—A health care provider that
1579 executes a contract with a governmental contractor to deliver
1580 health care services on or after April 17, 1992, as an agent of
1581 the governmental contractor is an agent for purposes of s.
1582 768.28(9), while acting within the scope of duties under the
1583 contract, if the contract complies with the requirements of this
1584 section and regardless of whether the individual treated is
1585 later found to be ineligible. A health care provider under
1586 contract with the state may not be named as a defendant in any
1587 action arising out of medical care or treatment provided on or
1588 after April 17, 1992, under contracts entered into under this
1589 section. The contract must provide that:
1590 (h) As an agent of the governmental contractor for purposes
1591 of s. 768.28(9), while acting within the scope of duties under
1592 the contract, a health care provider licensed under chapter 466
1593 may allow a patient or a parent or guardian of the patient to
1594 voluntarily contribute a fee to cover costs of dental laboratory
1595 work related to the services provided to the patient. This
1596 contribution may not exceed the actual cost of the dental
1597 laboratory charges and is deemed in compliance with this
1598 section.
1599
1600 A governmental contractor that is also a health care provider is
1601 not required to enter into a contract under this section with
1602 respect to the health care services delivered by its employees.
1603 Section 34. The amendments to ss. 627.6474, 636.035, and
1604 641.315, Florida Statutes, apply to contracts entered into or
1605 renewed on or after July 1, 2014.
1606 Section 35. (1) Funding for Healthy Florida shall be
1607 provided from the Medical Care Trust Fund, and matching funds
1608 shall be provided by local governmental entities through
1609 intergovernmental transfers in accordance with federal statutes
1610 and regulations. The Agency for Health Care Administration may
1611 accept voluntary transfers of local taxes and other qualified
1612 revenue from counties, municipalities, and special taxing
1613 districts. Such transfers must be contributed to advance the
1614 general goals of the Healthy Florida program without restriction
1615 and must be executed pursuant to a contract between the agency
1616 and the local funding source.
1617 (2) The Agency for Health Care Administration shall submit
1618 budget amendments to the Legislative Budget Commission pursuant
1619 to chapter 216, Florida Statutes, to the extent necessary to
1620 implement Healthy Florida on a statewide basis during the 2014
1621 2015 fiscal year. The nature of such amendments shall be to fund
1622 Healthy Florida for the coverage of children who transfer from
1623 the Florida Kidcare program to the Healthy Florida program, to
1624 fund Healthy Florida for the coverage of adults who were
1625 previously eligible for the Medicaid program as medically needy
1626 under s. 409.904(2), Florida Statutes, and who transfer to the
1627 Healthy Florida program, or to provide additional spending
1628 authority from the Medical Care Trust Fund under subsection (1)
1629 for the coverage of individuals who enroll in the Healthy
1630 Florida program.
1631
1632 ================= T I T L E A M E N D M E N T ================
1633 And the title is amended as follows:
1634 Between lines 47 and 48
1635 insert:
1636 providing a directive to the Division of Law Revision
1637 and Information; amending s. 409.811, F.S.; revising
1638 and providing definitions; transferring, renumbering,
1639 and amending s. 624.91, F.S.; revising the Florida
1640 Healthy Kids Corporation Act to include the Healthy
1641 Florida program; revising participation guidelines for
1642 nonsubsidized enrollees in the Healthy Kids program;
1643 revising the medical loss ratio requirements for
1644 contracts for the Florida Healthy Kids Corporation;
1645 modifying the membership of the corporation’s board of
1646 directors; creating an executive steering committee;
1647 requiring additional corporate compliance
1648 requirements; amending s. 409.813, F.S.; revising the
1649 components of Florida Kidcare; prohibiting a cause of
1650 action from arising against the Florida Healthy Kids
1651 Corporation for failure to make health services
1652 available; amending s. 409.8132, F.S.; revising the
1653 eligibility of the Medikids program component;
1654 revising the enrollment requirements for Medikids;
1655 amending s. 409.8134, F.S., relating to Florida
1656 Kidcare; conforming provisions to changes made by the
1657 act; amending s. 409.814, F.S.; revising eligibility
1658 requirements for Florida Kidcare; amending s. 409.815,
1659 F.S.; revising certain minimum health benefits
1660 coverage under Florida Kidcare; deleting obsolete
1661 provisions; amending s. 409.816, F.S.; conforming
1662 provisions to changes made by the act; repealing s.
1663 409.817, F.S., relating to the approval of health
1664 benefits coverage and financial assistance under the
1665 Kidcare program; repealing s. 409.8175, F.S., relating
1666 to the delivery of services in rural counties;
1667 amending s. 409.8177, F.S.; conforming provisions to
1668 changes made by the act; amending s. 409.818, F.S.;
1669 revising the duties of the Department of Children and
1670 Families and the Agency for Health Care Administration
1671 with regard to the Kidcare program; deleting the
1672 duties of the Department of Health and the Office of
1673 Insurance Regulation with regard to the Kidcare
1674 program; amending s. 409.820, F.S.; requiring the
1675 Department of Health, in consultation with the agency
1676 and the Florida Healthy Kids Corporation, to develop a
1677 minimum set of pediatric and adolescent quality
1678 assurance and access standards for all program
1679 components; creating s. 409.822, F.S.; creating the
1680 Healthy Florida program; providing eligibility and
1681 enrollment requirements; authorizing the corporation
1682 to contract with certain insurers, managed care
1683 organizations, and provider service networks;
1684 encouraging the corporation to contract with insurers
1685 and managed care organizations that participate in
1686 more than one affordable insurance program under
1687 certain circumstances; requiring the corporation to
1688 establish a benefits package and a process for payment
1689 of services; authorizing the corporation to collect
1690 premiums and copayments; requiring the corporation to
1691 oversee the Healthy Florida program and to establish a
1692 grievance process and integrity process; providing for
1693 the applicability of certain state laws for
1694 administering the program; requiring the corporation
1695 to collect certain data and to submit enrollment
1696 reports and interim independent evaluations to the
1697 Legislature; providing for expiration of the program;
1698 authorizing the corporation to comply with federal
1699 requirements upon giving notice to the Legislature;
1700 amending ss. 154.503, 408.910, and 408.915, F.S.;
1701 conforming cross-references; repealing s. 624.915,
1702 F.S., relating to the operating fund of the Florida
1703 Healthy Kids Corporation; amending ss. 627.6474,
1704 636.035, and 641.315, F.S.; prohibiting a contract
1705 between a health insurer, a prepaid health service
1706 organization, or a health maintenance organization and
1707 a dentist from requiring the dentist to provide
1708 services at a set fee under certain circumstances or
1709 to participate in a discount medical plan; amending s.
1710 766.1115, F.S.; revising a definition; requiring a
1711 contract with a governmental contractor for health
1712 care services to include a provision that a health
1713 care provider licensed under ch. 466, F.S., as an
1714 agent of the governmental contractor, may allow a
1715 patient or a parent or guardian of the patient to
1716 voluntarily contribute a fee to cover costs of dental
1717 laboratory work related to the services provided to
1718 the patient without forfeiting the provider’s
1719 sovereign immunity; prohibiting the contribution from
1720 exceeding the actual amount of the dental laboratory
1721 charges; providing that the contribution complies with
1722 the requirements of s. 766.1115, F.S.; providing
1723 applicability; providing for funding;
