Bill Text: FL S0002 | 2015 | 1st Special Session | Comm Sub
NOTE: There are more recent revisions of this legislation. Read Latest Draft
Bill Title: Health Insurance Affordability Exchange
Spectrum: Slight Partisan Bill (? 2-1)
Status: (Engrossed - Dead) 2015-06-05 - CS failed to pass; YEAS 41 NAYS 72 [S0002 Detail]
Download: Florida-2015-S0002-Comm_Sub.html
Bill Title: Health Insurance Affordability Exchange
Spectrum: Slight Partisan Bill (? 2-1)
Status: (Engrossed - Dead) 2015-06-05 - CS failed to pass; YEAS 41 NAYS 72 [S0002 Detail]
Download: Florida-2015-S0002-Comm_Sub.html
Florida Senate - 2015 CS for CS for SB 2-A
By the Committees on Appropriations; and Health Policy; and
Senator Bean
576-00041-15A 20152Ac2
1 A bill to be entitled
2 An act relating to the health insurance affordability
3 exchange; providing a directive to the Division of Law
4 Revision and Information; creating s. 409.72, F.S.;
5 providing a short title; creating s. 409.721, F.S.;
6 creating the Florida Health Insurance Affordability
7 Exchange Program (FHIX) within the Agency for Health
8 Care Administration; providing program authority and
9 principles; creating s. 409.722, F.S.; defining terms;
10 creating s. 409.723, F.S.; providing eligibility and
11 enrollment criteria; providing patient rights and
12 responsibilities; defining the term “disabled”
13 providing premium levels; creating s. 409.724, F.S.;
14 providing for premium credits and choice counseling;
15 establishing an education campaign; providing for
16 customer support and disenrollment; creating s.
17 409.725, F.S.; providing for available products and
18 services; creating s. 409.726, F.S.; requiring the
19 department to develop accountability measures and
20 performance standards governing the administration of
21 the program; creating s. 409.727, F.S.; providing for
22 a readiness review and a two-phase implementation
23 schedule; creating s. 409.728, F.S.; providing program
24 operation and management duties; creating s. 409.729,
25 F.S.; providing for the development of a long-term
26 reorganization plan and the formation of the FHIX
27 Workgroup; creating s. 409.73, F.S.; authorizing the
28 agency to seek federal approval; prohibiting the
29 agency from implementing the FHIX waiver under certain
30 circumstances; creating s. 409.731, F.S.; providing
31 for program expiration; providing for the
32 establishment of a commission; providing purposes and
33 duties of the commission and for the appointment of
34 members; requiring a commission report to be submitted
35 to the Governor and the Legislature; repealing s.
36 408.70, F.S., relating to legislative findings
37 regarding access to affordable health care; amending
38 s. 408.910, F.S.; revising legislative intent;
39 redefining terms; revising the scope of the Florida
40 Health Choices Program and the pricing of services
41 under the program; providing requirements for
42 operation of the marketplace; providing additional
43 duties for the corporation to perform; requiring an
44 annual report to the Governor and the Legislature;
45 amending s. 409.904, F.S.; limiting eligible persons
46 in the Medically Needy program to those under the age
47 of 21 and pregnant women, and specifying an effective
48 date; providing an expiration date for the program;
49 amending s. 624.91, F.S.; revising eligibility
50 requirements for state-funded assistance; revising the
51 duties and powers of the Florida Healthy Kids
52 Corporation; revising provisions for the appointment
53 of members of the board of the Florida Healthy Kids
54 Corporation; requiring transition plans; repealing s.
55 624.915, F.S., relating to the operating fund of the
56 Florida Healthy Kids Corporation; providing a
57 directive to the Division of Law Revision and
58 Information; providing for construction of the act in
59 pari materia with laws enacted during the 2015 Regular
60 Session of the Legislature; providing an effective
61 date.
62
63 Be It Enacted by the Legislature of the State of Florida:
64
65 Section 1. The Division of Law Revision and Information is
66 directed to rename part II of chapter 409, Florida Statutes, as
67 “Insurance Affordability Programs” and to incorporate ss.
68 409.72-409.731, Florida Statutes, under this part.
69 Section 2. Section 409.72, Florida Statutes, is created to
70 read:
71 409.72 Short title.—Sections 409.72-409.731 may be cited as
72 the “Florida Health Insurance Affordability Exchange Program”
73 (“FHIX”).
74 Section 3. Section 409.721, Florida Statutes, is created to
75 read:
76 409.721 Program authority.—The Florida Health Insurance
77 Affordability Exchange Program (FHIX) is created within the
78 Agency for Health Care Administration to assist Floridians in
79 purchasing health benefits coverage and gaining access to health
80 services. The products and services offered by FHIX are based on
81 the following principles:
82 (1) FAIR VALUE.—Financial assistance will be rationally
83 allocated regardless of differences in categorical eligibility.
84 (2) CONSUMER CHOICE.—Participants will be offered
85 meaningful choices in the way the participants can redeem the
86 value of the available assistance.
87 (3) SIMPLICITY.—Obtaining assistance will be consumer
88 friendly, and customer support will be available when needed.
89 (4) PORTABILITY.—Participants can continue to access the
90 FHIX services and products despite changes in their
91 circumstances.
92 (5) EMPLOYMENT.—Assistance will be offered in a way that
93 incentivizes employment.
94 (6) CONSUMER EMPOWERMENT.—Assistance will be offered in a
95 manner that maximizes individual control over available
96 resources.
97 (7) RISK ADJUSTMENT.—The amount of assistance will reflect
98 participants’ medical risk.
99 Section 4. Section 409.722, Florida Statutes, is created to
100 read:
101 409.722 Definitions.—As used in ss. 409.72-409.731, the
102 term:
103 (1) “Agency” means the Agency for Health Care
104 Administration.
105 (2) “Applicant” means an individual who applies for
106 determination of eligibility for health benefits coverage under
107 this part.
108 (3) “Corporation” means Florida Health Choices, Inc., as
109 established under s. 408.910.
110 (4) “Enrollee” means a participant who has been determined
111 eligible for and is receiving health benefits coverage under
112 this part.
113 (5) “Federal exchange” or “exchange” means an insurance
114 platform regulated by the Federal Government which offers tiers
115 of health plans from the least comprehensive plan to the most
116 comprehensive plan.
117 (6) “FHIX marketplace” or “marketplace” means the single,
118 centralized market established under s. 408.910 which
119 facilitates health benefits coverage.
120 (7) “Florida Health Insurance Affordability Exchange
121 Program” or “FHIX” means the program created under ss. 409.72
122 409.731.
123 (8) “Florida Healthy Kids Corporation” means the entity
124 created under s. 624.91.
125 (9) “Florida Kidcare program” or “Kidcare program” means
126 the health benefits coverage administered through ss. 409.810
127 409.821.
128 (10) “Health benefits coverage” means the payment of
129 benefits for covered health care services or the availability,
130 directly or through arrangements with other persons, of covered
131 health care services on a prepaid per capita basis or on a
132 prepaid aggregate fixed-sum basis.
133 (11) “Inactive status” means the enrollment status of a
134 participant previously enrolled in health benefits coverage
135 through FHIX who lost coverage for noncompliance pursuant to s.
136 409.723, but who maintains access to his or her balance in a
137 health savings account or health reimbursement account.
138 (12) “Medicaid” means the medical assistance program
139 authorized by Title XIX of the Social Security Act, and
140 regulations thereunder, and parts III and IV of this chapter, as
141 administered in this state by the agency.
142 (13) “Modified adjusted gross income” means the
143 individual’s or household’s annual adjusted gross income, as
144 defined in s. 36B(d)(2) of the Internal Revenue Code of 1986,
145 which is used to determine eligibility for FHIX.
146 (14) “Patient Protection and Affordable Care Act” or
147 “Affordable Care Act” means Pub. L. No. 111-148, as amended by
148 the Health Care and Education Reconciliation Act of 2010, Pub.
149 L. No. 111-152, and regulations adopted pursuant to those acts.
150 (15) “Premium credit” means the monthly amount paid by the
151 agency per enrollee in the Florida Health Insurance
152 Affordability Exchange Program toward health benefits coverage.
153 (16) “Qualified alien” means an alien as defined in 8
154 U.S.C. s. 1641(b) or (c).
155 (17) “Resident” means a United States citizen or qualified
156 alien who is domiciled in this state.
157 Section 5. Section 409.723, Florida Statutes, is created to
158 read:
159 409.723 Participation.—
160 (1) ELIGIBILITY.—To participate in FHIX, an individual must
161 be a resident and meet the following requirements, as
162 applicable:
163 (a) Qualify as a newly eligible enrollee, and be an
164 individual as described in s. 1902(a)(10)(A)(i)(VIII) of the
165 Social Security Act or s. 2001 of the Affordable Care Act and as
166 may be further defined by federal regulation.
167 (b) Meet and maintain the responsibilities under subsection
168 (4).
169 (c) Qualify for participation in the Florida Healthy Kids
170 program under s. 624.91, subject to the implementation of Phase
171 Two under s. 409.727.
172 (2) ENROLLMENT.—To enroll in FHIX, an applicant must submit
173 an application to the department for an eligibility
174 determination.
175 (a) Applications may be submitted online, or by mail,
176 facsimile, or any other method permitted by law or regulation.
177 (b) The department is responsible for any eligibility
178 correspondence and status updates to the participant and other
179 agencies.
180 (c) The department shall review a participant’s eligibility
181 at least every 12 months.
182 (d) An application or renewal is deemed complete when the
183 participant has met all the requirements under subsection (4),
184 as applicable.
185 (3) PARTICIPANT RIGHTS.—A participant has all of the
186 following rights:
187 (a) Access to the FHIX marketplace or federal exchange to
188 select the scope, amount, and type of health care coverage and
189 other services to be purchased.
190 (b) Continuity and portability of coverage to avoid
191 disruption of coverage and other health care services when the
192 participant’s economic circumstances change.
193 (c) Retention of applicable unspent credits in the
194 participant’s health savings or health reimbursement account
195 following a change in the participant’s eligibility status.
196 Credits are valid for a participant in an inactive status for up
197 to 5 years after the participant’s status first becomes
198 inactive.
199 (d) Ability to select more than one product or plan on the
200 FHIX marketplace or federal exchange.
201 (e) Choice of at least two health benefits products that
202 meet the requirements of the Affordable Care Act.
203 (4) PARTICIPANT RESPONSIBILITIES.—A participant must:
204 (a) Complete an initial application for health benefits
205 coverage and the annual renewal process.
206 (b) Provide evidence of participation in one or more of the
207 following activities at the levels required under paragraph (c):
208 1. Paid employment.
209 2. On the job training or job placement activities that are
210 validated through registration with CareerSource Florida.
211 3. Educational pursuits.
212
213 A participant who is a disabled adult or the caregiver of a
214 disabled child or adult may submit a request to the department
215 for an exception to the requirements in this paragraph. Such
216 participant shall annually submit to the department a request to
217 renew the exception. The term “disabled” means any person who
218 has one or more permanent physical or mental impairments that
219 substantially limit his or her ability to perform one or more
220 major life activities of daily living, as defined by the
221 Americans with Disabilities Act, without receiving more than 8
222 hours of assistance per day.
223 (c) Engage in the activities required under paragraph (b)
224 at the following minimum levels:
225 1. For a parent of a child younger than 18 years of age, a
226 minimum of 20 hours weekly.
227 2. For a childless adult, a minimum of 30 hours weekly.
228 (d) Learn and remain informed about the choices available
229 in the FHIX marketplace or the federal exchange and the
230 allowable uses of credits in the individual accounts.
231 (e) Execute a contract with the department which
232 acknowledges that:
233 1. FHIX is not an entitlement and state and federal funding
234 may end at any time;
235 2. Failure to pay required premiums or cost sharing will
236 result in a transition to inactive status; and
237 3. Noncompliance with the participation requirements as
238 established under s. 409.723 will result in a transition to
239 inactive status.
240 (f) Select plans and other products in a timely manner.
241 (g) Comply with program rules and the prohibitions against
242 fraud, as described in s. 414.39.
243 (h) Timely make monthly premium and any other cost-sharing
244 payments.
245 (i) Meet minimum coverage requirements by selecting either
246 a high-deductible health plan combined with a health savings or
247 a reimbursement account or a combination of plans or products
248 with an actuarial value that meets or exceeds benefits available
249 under the federal exchange.
250 (5) COST SHARING.—
251 (a) Enrollees are assessed monthly premiums based on their
252 modified adjusted gross income. The maximum monthly premium
253 payments are set at the following income levels:
254 1. At or below 22 percent of the federal poverty level: $3.
255 2. Greater than 22 percent, but at or below 50 percent, of
256 the federal poverty level: $8.
257 3. Greater than 50 percent, but at or below 75 percent, of
258 the federal poverty level: $15.
259 4. Greater than 75 percent, but at or below 100 percent, of
260 the federal poverty level: $20.
261 5. Greater than 100 percent of the federal poverty level:
262 $25.
263 (b) Depending on the products and services selected by the
264 enrollee, the enrollee may also incur additional cost sharing,
265 such as copayments, deductibles, or other out-of-pocket costs.
266 (c) An enrollee may be subject to charge for an
267 inappropriate emergency room visit of up to $8 for the first
268 visit and up to $25 for any subsequent visit, based on the
269 enrollee’s benefit plan, to discourage inappropriate use of the
270 emergency room.
271 (d) Cumulative annual cost sharing per enrollee may not
272 exceed 5 percent of an enrollee’s annual modified adjusted gross
273 income.
274 (e) If, after a 30-day grace period, a full premium payment
275 has not been received, the enrollee shall be transitioned from
276 coverage to inactive status and may not reenroll for a minimum
277 of 6 months, unless a hardship exception has been granted.
278 Enrollees may seek a hardship exception under the Medicaid Fair
279 Hearing Process.
280 Section 6. Section 409.724, Florida Statutes, is created to
281 read:
282 409.724 Available assistance.—
283 (1) PREMIUM CREDITS.—
284 (a) Standard amount.—The standard monthly premium credit is
285 equivalent to the applicable risk-adjusted capitation rate paid
286 to Medicaid managed care plans under part IV of this chapter.
287 (b) Supplemental funding.—Subject to federal approval,
288 additional resources may be made available to enrollees and
289 incorporated into FHIX.
290 (c) Savings accounts.—In addition to the benefits provided
291 under this section, the corporation must offer each enrollee
292 access to an individual account that qualifies as a health
293 reimbursement account or a health savings account.
294 1. Unexpended Funds.—Eligible unexpended funds from the
295 monthly premium credit must be deposited into each enrollee’s
296 individual account in a timely manner. Funds deposited into
297 these individual accounts may be used to pay cost-sharing
298 obligations or to purchase other health-related items to the
299 extent permitted under federal and state law.
300 2. Healthy Behaviors.—Enrollees may receive credits to
301 their individual accounts for healthy behaviors, adherence to
302 wellness programs, and other activities that demonstrate
303 compliance with prevention or disease management guidelines.
304 3. Enrollee contributions.—The enrollee may make deposits
305 to his or her account at any time to supplement the premium
306 credit, to purchase additional FHIX products, or to offset other
307 cost-sharing obligations.
308 4. Third parties.—Third parties, including, but not limited
309 to, an employer or relative, may also make deposits on behalf of
310 the enrollee into the enrollee’s FHIX marketplace account. The
311 enrollee may not withdraw any funds as a refund, except those
312 funds the enrollee has deposited into his or her account.
313 (2) CHOICE COUNSELING.—The agency, in consultation with the
314 Florida Healthy Kids Corporation and the corporation, shall
315 develop a choice counseling program for FHIX. The choice
316 counseling program must ensure that participants have
317 information about the FHIX marketplace program, the federal
318 exchange, products, and services and that participants know
319 where and whom to call for questions or to make their plan
320 selections. The choice counseling program must provide
321 culturally sensitive materials and must take into consideration
322 the demographics of the projected population.
323 (3) EDUCATION CAMPAIGN.—The agency, the corporation, and
324 the Florida Healthy Kids Corporation must coordinate in advance
325 of Phase One an ongoing education campaign to inform
326 participants, at a minimum, of the following:
327 (a) How the FHIX marketplace operates and the timeline for
328 enrollment.
329 (b) Plans that are available and how to find information
330 about these plans.
331 (c) Information about other available insurance
332 affordability programs for the participant and his or her
333 family.
334 (d) Information about health benefits coverage, provider
335 networks, and cost sharing for available plans in each region.
336 (e) Information on how to complete the required annual
337 renewal process, including renewal dates and deadlines.
338 (f) Information on how to update eligibility if the
339 participant’s data have changed since his or her last renewal or
340 application date.
341 (4) CUSTOMER SUPPORT.—The Florida Healthy Kids Corporation
342 shall provide customer support for FHIX, including, but not
343 limited to, general program information, financial information,
344 and enrollee payments. Customer support must also provide a
345 toll-free telephone number and maintain a website that is
346 available in multiple languages and that meets the needs of the
347 enrollee population.
348 (5) INACTIVE PARTICIPANTS.—The corporation must inform the
349 inactive participant about other insurance affordability
350 programs and electronically refer the participant to the federal
351 exchange or other insurance affordability programs, as
352 appropriate.
353 Section 7. Section 409.725, Florida Statutes, is created to
354 read:
355 409.725 Available products and services.—The FHIX
356 marketplace shall offer the following products and services:
357 (1) Products and services authorized pursuant to s.
358 408.910.
359 (2) Products authorized by the federal exchange.
360 (3) Products authorized by the Florida Healthy Kids
361 Corporation pursuant to s. 624.91.
362 (4) Premium credits for participation in employer-sponsored
363 plans.
364 Section 8. Section 409.726, Florida Statutes, is created to
365 read:
366 409.726 Program accountability.—
367 (1) All managed care plans that participate in FHIX must
368 collect and maintain encounter level data in accordance with the
369 encounter data requirements under s. 409.967(2)(d) and are
370 subject to the accompanying penalties under s. 409.967(2)(h)2.
371 The agency is responsible for the collection and maintenance of
372 the encounter level data.
373 (2) The corporation, in consultation with the agency, shall
374 establish access and network standards for contracts on the FHIX
375 marketplace, shall ensure that contracted plans have sufficient
376 providers to meet enrollee needs, and shall develop quality of
377 coverage and provider standards specific to the adult
378 population.
379 (3) The department shall develop accountability measures
380 and performance standards to be applied to initial and renewal
381 FHIX applications that are submitted online, by mail, by
382 facsimile, or through referrals from a third party. The minimum
383 performance standards are:
384 (a) Application processing speed.—Ninety percent of all
385 applications, regardless of the method of submission, must be
386 processed within 45 days.
387 (b) Application processing speed from online sources.
388 Ninety-five percent of all applications received from online
389 sources must be processed within 45 days.
390 (c) Renewal application processing speed.—Ninety percent of
391 all renewals, regardless of the method of submission, must be
392 processed within 45 days.
393 (d) Renewal application processing speed from online
394 sources.—Ninety-five percent of all applications received from
395 online sources must be processed within 45 days.
396 (4) The agency, the department, and the Florida Healthy
397 Kids Corporation must meet the following standards for their
398 respective roles in the program:
399 (a) Eighty-five percent of calls must be answered in 20
400 seconds or less.
401 (b) All contacts, including, but not limited to, telephone
402 calls, faxed documents and requests, and e-mails, must be
403 handled within 2 business days.
404 (c) Any self-service tools available to participants, such
405 as interactive voice response systems, must be operational 7
406 days a week, 24 hours a day, at least 98 percent of each month.
407 (5) The agency, the department, and the Florida Healthy
408 Kids Corporation shall conduct an annual satisfaction survey to
409 address all measures that require participant input specific to
410 the FHIX marketplace program. The parties may elect to
411 incorporate these elements into the annual report required under
412 subsection (7).
413 (6) The agency and the corporation shall post online
414 monthly enrollment reports for FHIX.
415 (7) Beginning in 2016, an annual report is due no later
416 than July 1 to the Governor, the President of the Senate, and
417 the Speaker of the House of Representatives. The annual report
418 must be coordinated by the agency and the corporation and must
419 include at least the following:
420 (a) Enrollment and application trends and issues.
421 (b) Utilization and cost data.
422 (c) Customer satisfaction.
423 (d) Funding sources in health savings accounts or health
424 reimbursement accounts.
425 (e) Enrollee use of funds in health savings accounts or
426 health reimbursement accounts.
427 (f) Types of products and plans purchased.
428 (g) Movement of enrollees across different insurance
429 affordability programs.
430 (h) Recommendations for program improvement.
431 Section 9. Section 409.727, Florida Statutes, is created to
432 read:
433 409.727 Readiness review and implementation schedule.—The
434 agency, the corporation, the department, and the Florida Healthy
435 Kids Corporation shall begin implementation of FHIX on the
436 effective date of this act, with enrollment for Phase One
437 beginning by January 1, 2016.
438 (1) READINESS REVIEW.—Before implementation of any phase
439 under this part or in any region, the agency shall conduct a
440 readiness review in consultation with the FHIX Workgroup
441 established pursuant to s. 409.729. The agency shall determine,
442 at a minimum, the following readiness milestones:
443 (a) Functional readiness of the service delivery platform.
444 (b) Plan availability and presence of plan choice.
445 (c) Provider network capacity and adequacy of the available
446 plans.
447 (d) Availability of customer support.
448 (e) Other factors critical to the success of FHIX.
449 (2) PHASE ONE.—The agency, the corporation, and the Florida
450 Healthy Kids Corporation shall coordinate implementation
451 activities to ensure that enrollment begins by January 1, 2016,
452 and is available in all regions by July 1, 2016.
453 (a) Beginning no later than January 1, 2016, and contingent
454 upon federal approval, participants may enroll in health
455 benefits coverage under the FHIX marketplace or the federal
456 exchange, if eligible.
457 (b) To be eligible for enrollment during this phase, a
458 participant must meet the requirements under s. 409.723(1)(a)
459 and (b).
460 (c) An enrollee may select any benefit, service, or product
461 available in the region.
462 (d) The corporation shall notify an enrollee of his or her
463 premium credit amount and how to access the FHIX marketplace
464 selection process or the federal exchange.
465 (e) An enrollee must have a choice of at least two managed
466 care plans in each region which meet or exceed the Affordable
467 Care Act’s requirements and which qualify for a premium credit
468 on the FHIX marketplace or federal exchange.
469 (f) Choice counseling and customer service must be provided
470 in accordance with s. 409.724(2) and (4).
471 (3) PHASE TWO.—
472 (a) No later than July 1, 2016, the corporation and the
473 Florida Healthy Kids Corporation shall begin the transition of
474 enrollees under s. 624.91 to the FHIX marketplace.
475 (b) Eligibility during this phase is based on meeting the
476 requirements of s. 409.723(1)(c) and (4).
477 (c) An enrollee may select any available benefit, service,
478 or product available under s. 409.725.
479 (d) A Florida Healthy Kids enrollee who selects a FHIX
480 marketplace plan or federal exchange plan shall be provided a
481 premium credit equivalent to the average capitation rate paid in
482 his or her county of residence under Florida Healthy Kids as of
483 June 30, 2016. The enrollee is responsible for any difference in
484 costs and may use any unexpended funds deposited in his or her
485 savings account under s. 409.724(1)(c) for supplemental benefits
486 on the FHIX marketplace or federal exchange.
487 (e) The corporation shall notify an enrollee of his or her
488 premium credit amount and how to access the FHIX marketplace
489 selection process or federal exchange.
490 (f) Choice counseling and customer service must be provided
491 in accordance with s. 409.724(2) and (4).
492 (g) Enrollees under s. 624.91 must transition to the FHIX
493 marketplace and coverage under s. 409.725 by September 30, 2016.
494 Section 10. Section 409.728, Florida Statutes, is created
495 to read:
496 409.728 Program operation and management.—In order to
497 implement ss. 409.72-409.731:
498 (1) The agency shall do all of the following:
499 (a) Contract with the corporation for the development,
500 implementation, and administration of the Florida Health
501 Insurance Affordability Exchange Program and for the release of
502 any federal, state, or other funds appropriated to the
503 corporation.
504 (b) Provide administrative support to the FHIX Workgroup
505 established pursuant to s. 409.729.
506 (c) Consult with stakeholders that serve low-income
507 individuals and families during implementation, using a public
508 input process.
509 (d) Timely transmit enrollee information to the
510 corporation.
511 (e) Annually determine the risk-adjusted rate to be paid
512 per month based on historical utilization and spending data for
513 the medical and behavioral health of enrollee population,
514 projected forward, and adjusted to reflect the eligibility
515 category, medical and dental trends, geographic areas, and the
516 clinical risk profile of the enrollees.
517 (f) Transfer funds allocated for premium credits by General
518 Appropriations Act to the corporation.
519 (g) Adopt rules in coordination with the corporation and
520 the Florida Healthy Kids Corporation in order to implement FHIX,
521 including modifying existing rules implementing the Children’s
522 Health Insurance Program and adapting adult focused provisions
523 for children to accommodate the seamless transition of Healthy
524 Kids enrollees to FHIX.
525 (2) The department shall, in coordination with the
526 corporation, the agency, and the Florida Healthy Kids
527 Corporation, determine eligibility of applications and
528 application renewals for FHIX in accordance with s. 409.902 and
529 shall transmit eligibility determination information on a timely
530 basis to the agency and corporation.
531 (3) The Florida Healthy Kids Corporation shall do all of
532 the following:
533 (a) Retain its duties and responsibilities under s. 624.91
534 during Phase One of the program.
535 (b) In coordination with the agency and the corporation,
536 provide customer service for the FHIX marketplace.
537 (c) Transfer funds and provide financial support to the
538 FHIX marketplace, including the collection of monthly cost
539 sharing payments.
540 (d) Conduct financial reporting related to such activities,
541 in coordination with the corporation and the agency.
542 (e) Coordinate program activities with the agency, the
543 department, and the corporation.
544 (4) Florida Health Choices, Inc., shall do all of the
545 following:
546 (a) Develop and maintain the FHIX marketplace.
547 (b) Implement and administer Phase One and Phase Two of the
548 FHIX marketplace and the ongoing operations of the program.
549 (c) Offer health benefits coverage packages on the FHIX
550 marketplace, including plans compliant with the Affordable Care
551 Act.
552 (d) Offer FHIX enrollees a choice of at least two plans per
553 county at each benefit level which meet the requirements under
554 the Affordable Care Act.
555 (e) Offer the opportunity to participate in the federal
556 exchange.
557 (f) Offer enhanced or customized benefits to FHIX
558 marketplace enrollees.
559 (g) Provide sufficient staff and resources to meet the
560 program needs of enrollees.
561 (h) Provide an opportunity for plans contracted with or
562 previously contracted with the Florida Healthy Kids Corporation
563 under s. 624.91 to participate with FHIX if those plans meet the
564 requirements of the program.
565 (i) Encourage insurance agents licensed under chapter 626
566 to identify and assist enrollees. This act does not prohibit
567 these agents from receiving usual and customary commissions from
568 insurers and health maintenance organizations that offer plans
569 in the FHIX marketplace.
570 Section 11. Section 409.729, Florida Statutes, is created
571 to read:
572 409.729 Long-term reorganization.—The FHIX Workgroup is
573 created to facilitate the implementation of FHIX and to plan for
574 the reorganization of the state’s insurance affordability
575 programs. The FHIX Workgroup consists of two representatives
576 each from the agency, the department, the Florida Healthy Kids
577 Corporation, and the corporation. An additional representative
578 of the agency serves as chair. The FHIX Workgroup must hold its
579 organizational meeting no later than 30 days after the effective
580 date of this act and must meet at least bimonthly. The role of
581 the FHIX Workgroup is to make recommendations to the agency. The
582 responsibilities of the workgroup include, but are not limited
583 to:
584 (1) Developing and presenting a final implementation plan
585 that meets the requirements of this part in a report submitted
586 to the Governor, the President of the Senate, and the Speaker of
587 the House of Representatives no later than November 1, 2015.
588 (2) Reviewing network and access standards for plans and
589 products.
590 (3) Assessing readiness and recommending actions needed to
591 reorganize the state’s insurance affordability programs for each
592 phase or region. If a phase or region receives a nonreadiness
593 recommendation, the agency shall notify the Legislature of that
594 recommendation, the reasons for such a recommendation, and
595 proposed plans for achieving readiness.
596 (4) Recommending any proposed change to the Title XIX
597 funded or Title XXI-funded programs based on the continued
598 availability and reauthorization of the Title XXI program and
599 its federal funding.
600 (5) Identifying duplication of services by the corporation,
601 the agency, and the Florida Healthy Kids Corporation currently
602 and under FHIX’s proposed Phase Two program.
603 (6) Evaluating any fiscal impacts based on the proposed
604 transition plan under Phase Two.
605 (7) Compiling a schedule of impacted contracts, leases, and
606 other assets.
607 (8) Determining staff requirements for Phase Two.
608 Section 12. Section 409.73, Florida Statutes, is created to
609 read:
610 409.73 Legislative Review.—The agency may seek federal
611 approval to implement FHIX as provided in ss. 409.72-409.731.
612 The agency is prohibited from implementing the FHIX waiver
613 without specific legislative approval unless the terms and
614 conditions of the approved waiver are substantially consistent
615 with the statutory requirements for this program.
616 Section 13. Section 409.731, Florida Statutes, is created
617 to read:
618 409.731 Program expiration.—
619 (1) The Florida Health Insurance Affordability Exchange
620 Program expires at the end of the state fiscal year in which any
621 of these conditions occurs:
622 (a) The federal match contribution for the newly eligible
623 under the Affordable Care Act falls below 90 percent.
624 (b) The federal match contribution falls below the
625 increased Federal Medical Assistance Percentage for medical
626 assistance for newly eligible mandatory individuals as specified
627 in the Affordable Care Act.
628 (c) The federal match for the FHIX program and the Medicaid
629 program are blended under federal law or regulation in such a
630 manner that causes the overall federal contribution to diminish
631 when compared to separate, nonblended federal contributions.
632 (2) Provided the conditions specified in subsection (1)
633 have not previously occurred, the Florida Health Insurance
634 Affordability Exchange Program shall expire on July 1, 2018,
635 unless reviewed and reenacted by the Legislature.
636 (3) The Health Outcomes Review Commission is established to
637 assess the following indicators:
638 (a) Patient outcomes.—Selected measures from the National
639 Healthcare Quality Report or similarly credible sources will be
640 applied to FHIX enrollees and compared to outcomes for Managed
641 Medical Assistance enrollees and uninsured patients.
642 (b) Fiscal impact.—Actual annual state general revenue
643 expenditures for the FHIX program will be compared to predicted
644 expenditures.
645 (c) Access to care.—Potentially preventable hospitalization
646 rates for acute and chronic conditions and potentially
647 preventable emergency department visits among FHIX enrollees
648 will be compared to Managed Medical Assistance enrollees and
649 uninsured patients.
650 (4) The Health Outcomes Review Commission shall consist of
651 nine members appointed by the Governor, the President of the
652 Senate, and the Speaker of the House. The Governor and each
653 presiding officer shall appoint one healthcare professional, one
654 private business representative, and one elected official.
655 (5) The commission shall be appointed no later than January
656 1, 2017, and shall meet regularly to select specific indicators,
657 review preliminary data, and develop a framework for a final
658 report. Staff support shall be provided to the commission by the
659 Agency for Health Care Administration.
660 (6) The commission’s final report shall be submitted to the
661 Governor, the President of the Senate, and the Speaker of the
662 House by January 1, 2018.
663 Section 14. Section 408.70, Florida Statutes, is repealed.
664 Section 15. Section 408.910, Florida Statutes, is amended
665 to read:
666 408.910 Florida Health Choices Program.—
667 (1) LEGISLATIVE INTENT.—The Legislature finds that a
668 significant number of the residents of this state do not have
669 adequate access to affordable, quality health care. The
670 Legislature further finds that increasing access to affordable,
671 quality health care can be best accomplished by establishing a
672 competitive market for purchasing health insurance and health
673 services. It is therefore the intent of the Legislature to
674 create and expand the Florida Health Choices Program to:
675 (a) Expand opportunities for Floridians to purchase
676 affordable health insurance and health services.
677 (b) Preserve the benefits of employment-sponsored insurance
678 while easing the administrative burden for employers who offer
679 these benefits.
680 (c) Enable individual choice in both the manner and amount
681 of health care purchased.
682 (d) Provide for the purchase of individual, portable health
683 care coverage.
684 (e) Disseminate information to consumers on the price and
685 quality of health services.
686 (f) Sponsor a competitive market that stimulates product
687 innovation, quality improvement, and efficiency in the
688 production and delivery of health services.
689 (2) DEFINITIONS.—As used in this section, the term:
690 (a) “Corporation” means the Florida Health Choices, Inc.,
691 established under this section.
692 (b) “Corporation’s marketplace” means the single,
693 centralized market established by the program that facilitates
694 the purchase of products made available in the marketplace.
695 (c) “Florida Health Insurance Affordability Exchange
696 Program” or “FHIX” is the program created under ss. 409.72
697 409.731 for low-income, uninsured residents of this state.
698 (d)(c) “Health insurance agent” means an agent licensed
699 under part IV of chapter 626.
700 (e)(d) “Insurer” means an entity licensed under chapter 624
701 which offers an individual health insurance policy or a group
702 health insurance policy, a preferred provider organization as
703 defined in s. 627.6471, an exclusive provider organization as
704 defined in s. 627.6472, or a health maintenance organization
705 licensed under part I of chapter 641, or a prepaid limited
706 health service organization or discount medical plan
707 organization licensed under chapter 636.
708 (f) “Patient Protection and Affordable Care Act” or
709 “Affordable Care Act” means Pub. L. No. 111-148, as further
710 amended by the Health Care and Education Reconciliation Act of
711 2010, Pub. L. No. 111-152, and regulations adopted pursuant to
712 those acts.
713 (g)(e) “Program” means the Florida Health Choices Program
714 established by this section.
715 (3) PROGRAM PURPOSE AND COMPONENTS.—The Florida Health
716 Choices Program is created as a single, centralized market for
717 the sale and purchase of various products that enable
718 individuals to pay for health care. These products include, but
719 are not limited to, health insurance plans, health maintenance
720 organization plans, prepaid services, service contracts, and
721 flexible spending accounts. The components of the program
722 include:
723 (a) Enrollment of employers.
724 (b) Administrative services for participating employers,
725 including:
726 1. Assistance in seeking federal approval of cafeteria
727 plans.
728 2. Collection of premiums and other payments.
729 3. Management of individual benefit accounts.
730 4. Distribution of premiums to insurers and payments to
731 other eligible vendors.
732 5. Assistance for participants in complying with reporting
733 requirements.
734 (c) Services to individual participants, including:
735 1. Information about available products and participating
736 vendors.
737 2. Assistance with assessing the benefits and limits of
738 each product, including information necessary to distinguish
739 between policies offering creditable coverage and other products
740 available through the program.
741 3. Account information to assist individual participants
742 with managing available resources.
743 4. Services that promote healthy behaviors.
744 5. Health benefits coverage information about health
745 insurance plans compliant with the Affordable Care Act.
746 6. Consumer assistance with web-based information services
747 for the Florida Health Insurance Affordability Exchange Program,
748 or (”FHIX”).
749 (d) Recruitment of vendors, including insurers, health
750 maintenance organizations, prepaid clinic service providers,
751 provider service networks, and other providers.
752 (e) Certification of vendors to ensure capability,
753 reliability, and validity of offerings.
754 (f) Collection of data, monitoring, assessment, and
755 reporting of vendor performance.
756 (g) Information services for individuals and employers.
757 (h) Program evaluation.
758 (4) ELIGIBILITY AND PARTICIPATION.—Participation in the
759 program is voluntary and shall be available to employers,
760 individuals, vendors, and health insurance agents as specified
761 in this subsection.
762 (a) Employers eligible to enroll in the program include
763 those employers that meet criteria established by the
764 corporation and elect to make their employees eligible through
765 the program.
766 (b) Individuals eligible to participate in the program
767 include:
768 1. Individual employees of enrolled employers.
769 2. Other individuals that meet criteria established by the
770 corporation.
771 (c) Employers who choose to participate in the program may
772 enroll by complying with the procedures established by the
773 corporation. The procedures must include, but are not limited
774 to:
775 1. Submission of required information.
776 2. Compliance with federal tax requirements for the
777 establishment of a cafeteria plan, pursuant to s. 125 of the
778 Internal Revenue Code, including designation of the employer’s
779 plan as a premium payment plan, a salary reduction plan that has
780 flexible spending arrangements, or a salary reduction plan that
781 has a premium payment and flexible spending arrangements.
782 3. Determination of the employer’s contribution, if any,
783 per employee, provided that such contribution is equal for each
784 eligible employee.
785 4. Establishment of payroll deduction procedures, subject
786 to the agreement of each individual employee who voluntarily
787 participates in the program.
788 5. Designation of the corporation as the third-party
789 administrator for the employer’s health benefit plan.
790 6. Identification of eligible employees.
791 7. Arrangement for periodic payments.
792 8. Employer notification to employees of the intent to
793 transfer from an existing employee health plan to the program at
794 least 90 days before the transition.
795 (d) All eligible vendors who choose to participate and the
796 products and services that the vendors are permitted to sell are
797 as follows:
798 1. Insurers licensed under chapter 624 may sell health
799 insurance policies, limited benefit policies, other risk-bearing
800 coverage, and other products or services.
801 2. Health maintenance organizations licensed under part I
802 of chapter 641 may sell health maintenance contracts, limited
803 benefit policies, other risk-bearing products, and other
804 products or services.
805 3. Prepaid limited health service organizations may sell
806 products and services as authorized under part I of chapter 636,
807 and discount medical plan organizations may sell products and
808 services as authorized under part II of chapter 636.
809 4. Prepaid health clinic service providers licensed under
810 part II of chapter 641 may sell prepaid service contracts and
811 other arrangements for a specified amount and type of health
812 services or treatments.
813 5. Health care providers, including hospitals and other
814 licensed health facilities, health care clinics, licensed health
815 professionals, pharmacies, and other licensed health care
816 providers, may sell service contracts and arrangements for a
817 specified amount and type of health services or treatments.
818 6. Provider organizations, including service networks,
819 group practices, professional associations, and other
820 incorporated organizations of providers, may sell service
821 contracts and arrangements for a specified amount and type of
822 health services or treatments.
823 7. Corporate entities providing specific health services in
824 accordance with applicable state law may sell service contracts
825 and arrangements for a specified amount and type of health
826 services or treatments.
827
828 A vendor described in subparagraphs 3.-7. may not sell products
829 that provide risk-bearing coverage unless that vendor is
830 authorized under a certificate of authority issued by the Office
831 of Insurance Regulation and is authorized to provide coverage in
832 the relevant geographic area. Otherwise eligible vendors may be
833 excluded from participating in the program for deceptive or
834 predatory practices, financial insolvency, or failure to comply
835 with the terms of the participation agreement or other standards
836 set by the corporation.
837 (e) Eligible individuals may participate in the program
838 voluntarily. Individuals who join the program may participate by
839 complying with the procedures established by the corporation.
840 These procedures must include, but are not limited to:
841 1. Submission of required information.
842 2. Authorization for payroll deduction, if applicable.
843 3. Compliance with federal tax requirements.
844 4. Arrangements for payment.
845 5. Selection of products and services.
846 (f) Vendors who choose to participate in the program may
847 enroll by complying with the procedures established by the
848 corporation. These procedures may include, but are not limited
849 to:
850 1. Submission of required information, including a complete
851 description of the coverage, services, provider network, payment
852 restrictions, and other requirements of each product offered
853 through the program.
854 2. Execution of an agreement to comply with requirements
855 established by the corporation.
856 3. Execution of an agreement that prohibits refusal to sell
857 any offered product or service to a participant who elects to
858 buy it.
859 4. Establishment of product prices based on applicable
860 criteria.
861 5. Arrangements for receiving payment for enrolled
862 participants.
863 6. Participation in ongoing reporting processes established
864 by the corporation.
865 7. Compliance with grievance procedures established by the
866 corporation.
867 (g) Health insurance agents licensed under part IV of
868 chapter 626 are eligible to voluntarily participate as buyers’
869 representatives. A buyer’s representative acts on behalf of an
870 individual purchasing health insurance and health services
871 through the program by providing information about products and
872 services available through the program and assisting the
873 individual with both the decision and the procedure of selecting
874 specific products. Serving as a buyer’s representative does not
875 constitute a conflict of interest with continuing
876 responsibilities as a health insurance agent if the relationship
877 between each agent and any participating vendor is disclosed
878 before advising an individual participant about the products and
879 services available through the program. In order to participate,
880 a health insurance agent shall comply with the procedures
881 established by the corporation, including:
882 1. Completion of training requirements.
883 2. Execution of a participation agreement specifying the
884 terms and conditions of participation.
885 3. Disclosure of any appointments to solicit insurance or
886 procure applications for vendors participating in the program.
887 4. Arrangements to receive payment from the corporation for
888 services as a buyer’s representative.
889 (5) PRODUCTS.—
890 (a) The products that may be made available for purchase
891 through the program include, but are not limited to:
892 1. Health insurance policies.
893 2. Health maintenance contracts.
894 3. Limited benefit plans.
895 4. Prepaid clinic services.
896 5. Service contracts.
897 6. Arrangements for purchase of specific amounts and types
898 of health services and treatments.
899 7. Flexible spending accounts.
900 (b) Health insurance policies, health maintenance
901 contracts, limited benefit plans, prepaid service contracts, and
902 other contracts for services must ensure the availability of
903 covered services.
904 (c) Products may be offered for multiyear periods provided
905 the price of the product is specified for the entire period or
906 for each separately priced segment of the policy or contract.
907 (d) The corporation shall provide a disclosure form for
908 consumers to acknowledge their understanding of the nature of,
909 and any limitations to, the benefits provided by the products
910 and services being purchased by the consumer.
911 (e) The corporation must determine that making the plan
912 available through the program is in the interest of eligible
913 individuals and eligible employers in the state.
914 (6) PRICING.—Prices for the products and services sold
915 through the program must be transparent to participants and
916 established by the vendors. The corporation may shall annually
917 assess a surcharge for each premium or price set by a
918 participating vendor. Any The surcharge may not be more than 2.5
919 percent of the price and shall be used to generate funding for
920 administrative services provided by the corporation and payments
921 to buyers’ representatives; however, a surcharge may not be
922 assessed for products and services sold in the FHIX marketplace.
923 (7) THE MARKETPLACE PROCESS.—The program shall provide a
924 single, centralized market for purchase of health insurance,
925 health maintenance contracts, and other health products and
926 services. Purchases may be made by participating individuals
927 over the Internet or through the services of a participating
928 health insurance agent. Information about each product and
929 service available through the program shall be made available
930 through printed material and an interactive Internet website.
931 (a) Marketplace purchasing.—A participant needing personal
932 assistance to select products and services shall be referred to
933 a participating agent in his or her area.
934 1.(a) Participation in the program may begin at any time
935 during a year after the employer completes enrollment and meets
936 the requirements specified by the corporation pursuant to
937 paragraph (4)(c).
938 2.(b) Initial selection of products and services must be
939 made by an individual participant within the applicable open
940 enrollment period.
941 3.(c) Initial enrollment periods for each product selected
942 by an individual participant must last at least 12 months,
943 unless the individual participant specifically agrees to a
944 different enrollment period.
945 4.(d) If an individual has selected one or more products
946 and enrolled in those products for at least 12 months or any
947 other period specifically agreed to by the individual
948 participant, changes in selected products and services may only
949 be made during the annual enrollment period established by the
950 corporation.
951 5.(e) The limits established in subparagraphs 2., 3., and
952 4. paragraphs (b)-(d) apply to any risk-bearing product that
953 promises future payment or coverage for a variable amount of
954 benefits or services. The limits do not apply to initiation of
955 flexible spending plans if those plans are not associated with
956 specific high-deductible insurance policies or the use of
957 spending accounts for any products offering individual
958 participants specific amounts and types of health services and
959 treatments at a contracted price.
960 (b) FHIX marketplace purchasing.—
961 1. Participation in the FHIX marketplace may begin at any
962 time during the year.
963 2. Initial enrollment periods for certain products selected
964 by an individual enrollee which are noncompliant with the
965 Affordable Care Act may be required to last at least 12 months,
966 unless the individual participant specifically agrees to a
967 different enrollment period.
968 (8) CONSUMER INFORMATION.—The corporation shall:
969 (a) Establish a secure website to facilitate the purchase
970 of products and services by participating individuals. The
971 website must provide information about each product or service
972 available through the program.
973 (b) Inform individuals about other public health care
974 programs.
975 (9) RISK POOLING.—The program may use methods for pooling
976 the risk of individual participants and preventing selection
977 bias. These methods may include, but are not limited to, a
978 postenrollment risk adjustment of the premium payments to the
979 vendors. The corporation may establish a methodology for
980 assessing the risk of enrolled individual participants based on
981 data reported annually by the vendors about their enrollees.
982 Distribution of payments to the vendors may be adjusted based on
983 the assessed relative risk profile of the enrollees in each
984 risk-bearing product for the most recent period for which data
985 is available.
986 (10) EXEMPTIONS.—
987 (a) Products, other than the products set forth in
988 subparagraphs (4)(d)1.-4., sold as part of the program are not
989 subject to the licensing requirements of the Florida Insurance
990 Code, as defined in s. 624.01 or the mandated offerings or
991 coverages established in part VI of chapter 627 and chapter 641.
992 (b) The corporation may act as an administrator as defined
993 in s. 626.88 but is not required to be certified pursuant to
994 part VII of chapter 626. However, a third-party third party
995 administrator used by the corporation must be certified under
996 part VII of chapter 626.
997 (c) Any standard forms, website design, or marketing
998 communication developed by the corporation and used by the
999 corporation, or any vendor that meets the requirements of
1000 paragraph (4)(f) is not subject to the Florida Insurance Code,
1001 as established in s. 624.01.
1002 (11) CORPORATION.—There is created the Florida Health
1003 Choices, Inc., which shall be registered, incorporated,
1004 organized, and operated in compliance with part III of chapter
1005 112 and chapters 119, 286, and 617. The purpose of the
1006 corporation is to administer the program created in this section
1007 and to conduct such other business as may further the
1008 administration of the program.
1009 (a) The corporation shall be governed by a 15-member board
1010 of directors consisting of:
1011 1. Three ex officio, nonvoting members to include:
1012 a. The Secretary of Health Care Administration or a
1013 designee with expertise in health care services.
1014 b. The Secretary of Management Services or a designee with
1015 expertise in state employee benefits.
1016 c. The commissioner of the Office of Insurance Regulation
1017 or a designee with expertise in insurance regulation.
1018 2. Four members appointed by and serving at the pleasure of
1019 the Governor.
1020 3. Four members appointed by and serving at the pleasure of
1021 the President of the Senate.
1022 4. Four members appointed by and serving at the pleasure of
1023 the Speaker of the House of Representatives.
1024 5. Board members may not include insurers, health insurance
1025 agents or brokers, health care providers, health maintenance
1026 organizations, prepaid service providers, or any other entity,
1027 affiliate, or subsidiary of eligible vendors.
1028 (b) Members shall be appointed for terms of up to 3 years.
1029 Any member is eligible for reappointment. A vacancy on the board
1030 shall be filled for the unexpired portion of the term in the
1031 same manner as the original appointment.
1032 (c) The board shall select a chief executive officer for
1033 the corporation who shall be responsible for the selection of
1034 such other staff as may be authorized by the corporation’s
1035 operating budget as adopted by the board.
1036 (d) Board members are entitled to receive, from funds of
1037 the corporation, reimbursement for per diem and travel expenses
1038 as provided by s. 112.061. No other compensation is authorized.
1039 (e) There is no liability on the part of, and no cause of
1040 action shall arise against, any member of the board or its
1041 employees or agents for any action taken by them in the
1042 performance of their powers and duties under this section.
1043 (f) The board shall develop and adopt bylaws and other
1044 corporate procedures as necessary for the operation of the
1045 corporation and carrying out the purposes of this section. The
1046 bylaws shall:
1047 1. Specify procedures for selection of officers and
1048 qualifications for reappointment, provided that no board member
1049 shall serve more than 9 consecutive years.
1050 2. Require an annual membership meeting that provides an
1051 opportunity for input and interaction with individual
1052 participants in the program.
1053 3. Specify policies and procedures regarding conflicts of
1054 interest, including the provisions of part III of chapter 112,
1055 which prohibit a member from participating in any decision that
1056 would inure to the benefit of the member or the organization
1057 that employs the member. The policies and procedures shall also
1058 require public disclosure of the interest that prevents the
1059 member from participating in a decision on a particular matter.
1060 (g) The corporation may exercise all powers granted to it
1061 under chapter 617 necessary to carry out the purposes of this
1062 section, including, but not limited to, the power to receive and
1063 accept grants, loans, or advances of funds from any public or
1064 private agency and to receive and accept from any source
1065 contributions of money, property, labor, or any other thing of
1066 value to be held, used, and applied for the purposes of this
1067 section.
1068 (h) The corporation may establish technical advisory panels
1069 consisting of interested parties, including consumers, health
1070 care providers, individuals with expertise in insurance
1071 regulation, and insurers.
1072 (i) The corporation shall:
1073 1. Determine eligibility of employers, vendors,
1074 individuals, and agents in accordance with subsection (4).
1075 2. Establish procedures necessary for the operation of the
1076 program, including, but not limited to, procedures for
1077 application, enrollment, risk assessment, risk adjustment, plan
1078 administration, performance monitoring, and consumer education.
1079 3. Arrange for collection of contributions from
1080 participating employers, third parties, governmental entities,
1081 and individuals.
1082 4. Arrange for payment of premiums and other appropriate
1083 disbursements based on the selections of products and services
1084 by the individual participants.
1085 5. Establish criteria for disenrollment of participating
1086 individuals based on failure to pay the individual’s share of
1087 any contribution required to maintain enrollment in selected
1088 products.
1089 6. Establish criteria for exclusion of vendors pursuant to
1090 paragraph (4)(d).
1091 7. Develop and implement a plan for promoting public
1092 awareness of and participation in the program.
1093 8. Secure staff and consultant services necessary to the
1094 operation of the program.
1095 9. Establish policies and procedures regarding
1096 participation in the program for individuals, vendors, health
1097 insurance agents, and employers.
1098 10. Provide for the operation of a toll-free hotline to
1099 respond to requests for assistance.
1100 11. Provide for initial, open, and special enrollment
1101 periods.
1102 12. Evaluate options for employer participation which may
1103 conform to with common insurance practices.
1104 13. Administer the Florida Health Insurance Affordability
1105 Exchange Program in accordance with ss. 409.72-409.731.
1106 14. Coordinate with the Agency for Health Care
1107 Administration, the Department of Children and Families, and the
1108 Florida Healthy Kids Corporation in developing and implementing
1109 the enrollee transition plan.
1110 15. Coordinate with the federal exchange to provide FHIX
1111 enrollees with the option of selecting plans from either the
1112 FHIX marketplace or the federal exchange.
1113 (12) REPORT.—The board of the corporation shall Beginning
1114 in the 2009-2010 fiscal year, submit by February 1 an annual
1115 report to the Governor, the President of the Senate, and the
1116 Speaker of the House of Representatives documenting the
1117 corporation’s activities in compliance with the duties
1118 delineated in this section.
1119 (13) PROGRAM INTEGRITY.—To ensure program integrity and to
1120 safeguard the financial transactions made under the auspices of
1121 the program, the corporation is authorized to establish
1122 qualifying criteria and certification procedures for vendors,
1123 require performance bonds or other guarantees of ability to
1124 complete contractual obligations, monitor the performance of
1125 vendors, and enforce the agreements of the program through
1126 financial penalty or disqualification from the program.
1127 (14) EXEMPTION FROM PUBLIC RECORDS REQUIREMENTS.—
1128 (a) Definitions.—For purposes of this subsection, the term:
1129 1. “Buyer’s representative” means a participating insurance
1130 agent as described in paragraph (4)(g).
1131 2. “Enrollee” means an employer who is eligible to enroll
1132 in the program pursuant to paragraph (4)(a).
1133 3. “Participant” means an individual who is eligible to
1134 participate in the program pursuant to paragraph (4)(b).
1135 4. “Proprietary confidential business information” means
1136 information, regardless of form or characteristics, that is
1137 owned or controlled by a vendor requesting confidentiality under
1138 this section; that is intended to be and is treated by the
1139 vendor as private in that the disclosure of the information
1140 would cause harm to the business operations of the vendor; that
1141 has not been disclosed unless disclosed pursuant to a statutory
1142 provision, an order of a court or administrative body, or a
1143 private agreement providing that the information may be released
1144 to the public; and that is information concerning:
1145 a. Business plans.
1146 b. Internal auditing controls and reports of internal
1147 auditors.
1148 c. Reports of external auditors for privately held
1149 companies.
1150 d. Client and customer lists.
1151 e. Potentially patentable material.
1152 f. A trade secret as defined in s. 688.002.
1153 5. “Vendor” means a participating insurer or other provider
1154 of services as described in paragraph (4)(d).
1155 (b) Public record exemptions.—
1156 1. Personal identifying information of an enrollee or
1157 participant who has applied for or participates in the Florida
1158 Health Choices Program is confidential and exempt from s.
1159 119.07(1) and s. 24(a), Art. I of the State Constitution.
1160 2. Client and customer lists of a buyer’s representative
1161 held by the corporation are confidential and exempt from s.
1162 119.07(1) and s. 24(a), Art. I of the State Constitution.
1163 3. Proprietary confidential business information held by
1164 the corporation is confidential and exempt from s. 119.07(1) and
1165 s. 24(a), Art. I of the State Constitution.
1166 (c) Retroactive application.—The public record exemptions
1167 provided for in paragraph (b) apply to information held by the
1168 corporation before, on, or after the effective date of this
1169 exemption.
1170 (d) Authorized release.—
1171 1. Upon request, information made confidential and exempt
1172 pursuant to this subsection shall be disclosed to:
1173 a. Another governmental entity in the performance of its
1174 official duties and responsibilities.
1175 b. Any person who has the written consent of the program
1176 applicant.
1177 c. The Florida Kidcare program for the purpose of
1178 administering the program authorized in ss. 409.810-409.821.
1179 2. Paragraph (b) does not prohibit a participant’s legal
1180 guardian from obtaining confirmation of coverage, dates of
1181 coverage, the name of the participant’s health plan, and the
1182 amount of premium being paid.
1183 (e) Penalty.—A person who knowingly and willfully violates
1184 this subsection commits a misdemeanor of the second degree,
1185 punishable as provided in s. 775.082 or s. 775.083.
1186 (f) Review and repeal.—This subsection is subject to the
1187 Open Government Sunset Review Act in accordance with s. 119.15,
1188 and shall stand repealed on October 2, 2016, unless reviewed and
1189 saved from repeal through reenactment by the Legislature.
1190 Section 16. Subsection (2) of section 409.904, Florida
1191 Statutes, is amended to read:
1192 409.904 Optional payments for eligible persons.—The agency
1193 may make payments for medical assistance and related services on
1194 behalf of the following persons who are determined to be
1195 eligible subject to the income, assets, and categorical
1196 eligibility tests set forth in federal and state law. Payment on
1197 behalf of these Medicaid eligible persons is subject to the
1198 availability of moneys and any limitations established by the
1199 General Appropriations Act or chapter 216.
1200 (2) A family, a pregnant woman, a child under age 21, a
1201 person age 65 or over, or a blind or disabled person, who would
1202 be eligible under any group listed in s. 409.903(1), (2), or
1203 (3), except that the income or assets of such family or person
1204 exceed established limitations. For a family or person in one of
1205 these coverage groups, medical expenses are deductible from
1206 income in accordance with federal requirements in order to make
1207 a determination of eligibility. A family or person eligible
1208 under the coverage known as the “medically needy,” is eligible
1209 to receive the same services as other Medicaid recipients, with
1210 the exception of services in skilled nursing facilities and
1211 intermediate care facilities for the developmentally disabled.
1212 Effective July 1, 2016, persons eligible under “medically needy”
1213 shall be limited to children under 21 years of age and pregnant
1214 women. This subsection expires October 1, 2019.
1215 Section 17. Section 624.91, Florida Statutes, is amended to
1216 read:
1217 624.91 The Florida Healthy Kids Corporation Act.—
1218 (1) SHORT TITLE.—This section may be cited as the “William
1219 G. ‘Doc’ Myers Healthy Kids Corporation Act.”
1220 (2) LEGISLATIVE INTENT.—
1221 (a) The Legislature finds that increased access to health
1222 care services could improve children’s health and reduce the
1223 incidence and costs of childhood illness and disabilities among
1224 children in this state. Many children do not have comprehensive,
1225 affordable health care services available. It is the intent of
1226 the Legislature that the Florida Healthy Kids Corporation
1227 provide comprehensive health insurance coverage to such
1228 children. The corporation is encouraged to cooperate with any
1229 existing health service programs funded by the public or the
1230 private sector.
1231 (b) It is the intent of the Legislature that the Florida
1232 Healthy Kids Corporation serve as one of several providers of
1233 services to children eligible for medical assistance under Title
1234 XXI of the Social Security Act. Although the corporation may
1235 serve other children, the Legislature intends the primary
1236 recipients of services provided through the corporation be
1237 school-age children with a family income below 200 percent of
1238 the federal poverty level, who do not qualify for Medicaid. It
1239 is also the intent of the Legislature that state and local
1240 government Florida Healthy Kids funds be used to continue
1241 coverage, subject to specific appropriations in the General
1242 Appropriations Act, to children not eligible for federal
1243 matching funds under Title XXI.
1244 (3) ELIGIBILITY FOR STATE-FUNDED ASSISTANCE.—Only residents
1245 of this state are eligible the following individuals are
1246 eligible for state-funded assistance in paying Florida Healthy
1247 Kids premiums pursuant to s. 409.814.:
1248 (a) Residents of this state who are eligible for the
1249 Florida Kidcare program pursuant to s. 409.814.
1250 (b) Notwithstanding s. 409.814, legal aliens who are
1251 enrolled in the Florida Healthy Kids program as of January 31,
1252 2004, who do not qualify for Title XXI federal funds because
1253 they are not qualified aliens as defined in s. 409.811.
1254 (4) NONENTITLEMENT.—Nothing in this section shall be
1255 construed as providing an individual with an entitlement to
1256 health care services. No cause of action shall arise against the
1257 state, the Florida Healthy Kids Corporation, or a unit of local
1258 government for failure to make health services available under
1259 this section.
1260 (5) CORPORATION AUTHORIZATION, DUTIES, POWERS.—
1261 (a) There is created the Florida Healthy Kids Corporation,
1262 a not-for-profit corporation.
1263 (b) The Florida Healthy Kids Corporation shall:
1264 1. Arrange for the collection of any individual, family,
1265 local contributions, or employer payment or premium, in an
1266 amount to be determined by the board of directors, to provide
1267 for payment of premiums for comprehensive insurance coverage and
1268 for the actual or estimated administrative expenses.
1269 2. Arrange for the collection of any voluntary
1270 contributions to provide for payment of Florida Kidcare program
1271 or Florida Health Insurance Affordability Exchange Program
1272 (FHIX) premiums for children who are not eligible for medical
1273 assistance under Title XIX or Title XXI of the Social Security
1274 Act.
1275 3. Subject to the provisions of s. 409.8134, accept
1276 voluntary supplemental local match contributions that comply
1277 with the requirements of Title XXI of the Social Security Act
1278 for the purpose of providing additional Florida Kidcare coverage
1279 in contributing counties under Title XXI.
1280 4. Establish the administrative and accounting procedures
1281 for the operation of the corporation.
1282 4.5. Establish, with consultation from appropriate
1283 professional organizations, standards for preventive health
1284 services and providers and comprehensive insurance benefits
1285 appropriate to children, provided that such standards for rural
1286 areas shall not limit primary care providers to board-certified
1287 pediatricians.
1288 5.6. Determine eligibility for children seeking to
1289 participate in the Title XXI-funded components of the Florida
1290 Kidcare program consistent with the requirements specified in s.
1291 409.814, as well as the non-Title-XXI-eligible children as
1292 provided in subsection (3).
1293 6.7. Establish procedures under which providers of local
1294 match to, applicants to and participants in the program may have
1295 grievances reviewed by an impartial body and reported to the
1296 board of directors of the corporation.
1297 7.8. Establish participation criteria and, if appropriate,
1298 contract with an authorized insurer, health maintenance
1299 organization, or third-party administrator to provide
1300 administrative services to the corporation.
1301 8.9. Establish enrollment criteria that include penalties
1302 or waiting periods of 30 days for reinstatement of coverage upon
1303 voluntary cancellation for nonpayment of family or individual
1304 premiums.
1305 9.10. Contract with authorized insurers or any provider of
1306 health care services, meeting standards established by the
1307 corporation, for the provision of comprehensive insurance
1308 coverage to participants. Such standards shall include criteria
1309 under which the corporation may contract with more than one
1310 provider of health care services in program sites.
1311 a. Health plans shall be selected through a competitive bid
1312 process. The Florida Healthy Kids Corporation shall purchase
1313 goods and services in the most cost-effective manner consistent
1314 with the delivery of quality medical care.
1315 b. The maximum administrative cost for a Florida Healthy
1316 Kids Corporation contract shall be 15 percent. For health and
1317 dental care contracts, the minimum medical loss ratio for a
1318 Florida Healthy Kids Corporation contract shall be 85 percent.
1319 The calculations must use uniform financial data collected from
1320 all plans in a format established by the corporation and shall
1321 be computed for each plan on a statewide basis. Funds shall be
1322 classified in a manner consistent with 45 C.F.R. part 158 For
1323 dental contracts, the remaining compensation to be paid to the
1324 authorized insurer or provider under a Florida Healthy Kids
1325 Corporation contract shall be no less than an amount which is 85
1326 percent of premium; to the extent any contract provision does
1327 not provide for this minimum compensation, this section shall
1328 prevail.
1329 c. The health plan selection criteria and scoring system,
1330 and the scoring results, shall be available upon request for
1331 inspection after the bids have been awarded.
1332 d. Effective July 1, 2016, health and dental services
1333 contracts of the corporation must transition to the FHIX
1334 marketplace under s. 409.722. Qualifying plans may enroll as
1335 vendors with the FHIX marketplace to maintain continuity of care
1336 for participants.
1337 10.11. Establish disenrollment criteria in the event local
1338 matching funds are insufficient to cover enrollments.
1339 11.12. Develop and implement a plan to publicize the
1340 Florida Kidcare program, the eligibility requirements of the
1341 program, and the procedures for enrollment in the program and to
1342 maintain public awareness of the corporation and the program.
1343 12.13. Secure staff necessary to properly administer the
1344 corporation. Staff costs shall be funded from state and local
1345 matching funds and such other private or public funds as become
1346 available. The board of directors shall determine the number of
1347 staff members necessary to administer the corporation.
1348 13.14. In consultation with the partner agencies, provide a
1349 report on the Florida Kidcare program annually to the Governor,
1350 the Chief Financial Officer, the Commissioner of Education, the
1351 President of the Senate, the Speaker of the House of
1352 Representatives, and the Minority Leaders of the Senate and the
1353 House of Representatives.
1354 14.15. Provide information on a quarterly basis online to
1355 the Legislature and the Governor which compares the costs and
1356 utilization of the full-pay enrolled population and the Title
1357 XXI-subsidized enrolled population in the Florida Kidcare
1358 program. The information, at a minimum, must include:
1359 a. The monthly enrollment and expenditure for full-pay
1360 enrollees in the Medikids and Florida Healthy Kids programs
1361 compared to the Title XXI-subsidized enrolled population; and
1362 b. The costs and utilization by service of the full-pay
1363 enrollees in the Medikids and Florida Healthy Kids programs and
1364 the Title XXI-subsidized enrolled population.
1365 15.16. Establish benefit packages that conform to the
1366 provisions of the Florida Kidcare program, as created in ss.
1367 409.810-409.821.
1368 16. Contract with other insurance affordability programs to
1369 provide such services that are consistent with this act.
1370 17. Annually develop performance metrics for the following
1371 focus areas:
1372 a. Administrative functions.
1373 b. Contracting with vendors.
1374 c. Customer service.
1375 d. Enrollee education.
1376 e. Financial services.
1377 f. Program integrity.
1378 (c) Coverage under the corporation’s program is secondary
1379 to any other available private coverage held by, or applicable
1380 to, the participant child or family member. Insurers under
1381 contract with the corporation are the payors of last resort and
1382 must coordinate benefits with any other third-party payor that
1383 may be liable for the participant’s medical care.
1384 (d) The Florida Healthy Kids Corporation shall be a private
1385 corporation not for profit, organized pursuant to chapter 617,
1386 and shall have all powers necessary to carry out the purposes of
1387 this act, including, but not limited to, the power to receive
1388 and accept grants, loans, or advances of funds from any public
1389 or private agency and to receive and accept from any source
1390 contributions of money, property, labor, or any other thing of
1391 value, to be held, used, and applied for the purposes of this
1392 act.
1393 (6) BOARD OF DIRECTORS AND MANAGEMENT SUPERVISION.—
1394 (a) The Florida Healthy Kids Corporation shall operate
1395 subject to the supervision and approval of a board of directors.
1396 The board chair shall be an appointee designated by the
1397 Governor, and the board shall be chaired by the Chief Financial
1398 Officer or her or his designee, and composed of 12 other
1399 members. The Senate shall confirm the designated chair and other
1400 board appointees. The board members shall be appointed selected
1401 for 3-year terms. of office as follows:
1402 1. The Secretary of Health Care Administration, or his or
1403 her designee.
1404 2. One member appointed by the Commissioner of Education
1405 from the Office of School Health Programs of the Florida
1406 Department of Education.
1407 3. One member appointed by the Chief Financial Officer from
1408 among three members nominated by the Florida Pediatric Society.
1409 4. One member, appointed by the Governor, who represents
1410 the Children’s Medical Services Program.
1411 5. One member appointed by the Chief Financial Officer from
1412 among three members nominated by the Florida Hospital
1413 Association.
1414 6. One member, appointed by the Governor, who is an expert
1415 on child health policy.
1416 7. One member, appointed by the Chief Financial Officer,
1417 from among three members nominated by the Florida Academy of
1418 Family Physicians.
1419 8. One member, appointed by the Governor, who represents
1420 the state Medicaid program.
1421 9. One member, appointed by the Chief Financial Officer,
1422 from among three members nominated by the Florida Association of
1423 Counties.
1424 10. The State Health Officer or her or his designee.
1425 11. The Secretary of Children and Families, or his or her
1426 designee.
1427 12. One member, appointed by the Governor, from among three
1428 members nominated by the Florida Dental Association.
1429 (b) A member of the board of directors shall be appointed
1430 by and serve at the pleasure of the Governor may be removed by
1431 the official who appointed that member. The board shall appoint
1432 an executive director, who is responsible for other staff
1433 authorized by the board.
1434 (c) Board members are entitled to receive, from funds of
1435 the corporation, reimbursement for per diem and travel expenses
1436 as provided by s. 112.061.
1437 (d) There shall be no liability on the part of, and no
1438 cause of action shall arise against, any member of the board of
1439 directors, or its employees or agents, for any action they take
1440 in the performance of their powers and duties under this act.
1441 (e) Terms for board members appointed under this act are
1442 effective January 1, 2016.
1443 (7) LICENSING NOT REQUIRED; FISCAL OPERATION.—
1444 (a) The corporation shall not be deemed an insurer. The
1445 officers, directors, and employees of the corporation shall not
1446 be deemed to be agents of an insurer. Neither the corporation
1447 nor any officer, director, or employee of the corporation is
1448 subject to the licensing requirements of the insurance code or
1449 the rules of the Department of Financial Services. However, any
1450 marketing representative utilized and compensated by the
1451 corporation must be appointed as a representative of the
1452 insurers or health services providers with which the corporation
1453 contracts.
1454 (b) The board has complete fiscal control over the
1455 corporation and is responsible for all corporate operations.
1456 (c) The Department of Financial Services shall supervise
1457 any liquidation or dissolution of the corporation and shall
1458 have, with respect to such liquidation or dissolution, all power
1459 granted to it pursuant to the insurance code.
1460 (8) TRANSITION PLANS.—The corporation shall confer with the
1461 Agency for Health Care Administration, the Department of
1462 Children and Families, and Florida Health Choices, Inc., to
1463 develop transition plans for the Florida Health Insurance
1464 Affordability Exchange Program as created under ss. 409.72
1465 409.731.
1466 Section 18. Section 624.915, Florida Statutes, is repealed.
1467 Section 19. The Division of Law Revision and Information is
1468 directed to replace the phrase “the effective date of this act”
1469 wherever it occurs in this act with the date the act becomes a
1470 law.
1471 Section 20. If any law amended by this act was also amended
1472 by a law enacted during the 2015 Regular Session of the
1473 Legislature, such laws shall be construed as if enacted during
1474 the same session of the Legislature, and full effect shall be
1475 given to each if possible.
1476 Section 21. This act shall take effect upon becoming a law.
