Bill Text: FL S0002 | 2015 | 1st Special Session | Engrossed
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-Engrossed.html
CS for CS for SB 2-A First Engrossed (ntc)
20152Ae1
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.
210 Evidence of participation in job placement activities must
211 include registration with CareerSource Florida and may include
212 other documentation such as, but not limited to, written
213 acknowledgment from a potential employer of receipt of an
214 employment application from the participant; confirmation from a
215 potential employer of a job interview with the participant;
216 documentation of job-seeking activities; and documentation of
217 assistance or training related to preparing a resume, completing
218 an employment application, or interviewing skills.
219 3. Educational pursuits.
220
221 A participant who is a disabled adult or the caregiver of a
222 disabled child or adult may submit a request to the department
223 for an exception to the requirements in this paragraph. Such
224 participant shall annually submit to the department a request to
225 renew the exception. The term “disabled” means any person who
226 has one or more permanent physical or mental impairments that
227 substantially limit his or her ability to perform one or more
228 major life activities of daily living, as defined by the
229 Americans with Disabilities Act, without receiving more than 8
230 hours of assistance per day.
231 (c) Engage in the activities required under paragraph (b)
232 at the following minimum levels:
233 1. For a parent of a child younger than 18 years of age, a
234 minimum of 20 hours weekly.
235 2. For a childless adult, a minimum of 30 hours weekly.
236 (d) Learn and remain informed about the choices available
237 in the FHIX marketplace or the federal exchange and the
238 allowable uses of credits in the individual accounts.
239 (e) Execute a contract with the department which
240 acknowledges that:
241 1. FHIX is not an entitlement and state and federal funding
242 may end at any time;
243 2. Failure to pay required premiums or cost sharing will
244 result in a transition to inactive status; and
245 3. Noncompliance with the participation requirements as
246 established under s. 409.723 will result in a transition to
247 inactive status.
248 (f) Select plans and other products in a timely manner.
249 (g) Comply with program rules and the prohibitions against
250 fraud, as described in s. 414.39.
251 (h) Timely make monthly premium and any other cost-sharing
252 payments.
253 (i) Meet minimum coverage requirements by selecting either
254 a high-deductible health plan combined with a health savings or
255 a reimbursement account or a combination of plans or products
256 with an actuarial value that meets or exceeds benefits available
257 under the federal exchange.
258 (5) COST SHARING.—
259 (a) Except for enrollees eligible under paragraph (1)(c),
260 enrollees are assessed monthly premiums based on their modified
261 adjusted gross income. The maximum monthly premium payments are
262 set at the following income levels:
263 1. At or below 22 percent of the federal poverty level: $3.
264 2. Greater than 22 percent, but at or below 50 percent, of
265 the federal poverty level: $8.
266 3. Greater than 50 percent, but at or below 75 percent, of
267 the federal poverty level: $15.
268 4. Greater than 75 percent, but at or below 100 percent, of
269 the federal poverty level: $20.
270 5. Greater than 100 percent of the federal poverty level:
271 $25.
272 (b) Depending on the products and services selected by the
273 enrollee, the enrollee may also incur additional cost sharing,
274 such as copayments, deductibles, or other out-of-pocket costs.
275 (c) An enrollee may be subject to charges for an
276 inappropriate emergency room visit of up to $8 for the first
277 visit and up to $25 for any subsequent visit, based on the
278 enrollee’s benefit plan, to discourage inappropriate use of the
279 emergency room.
280 (d) Cumulative annual cost sharing per enrollee may not
281 exceed 5 percent of an enrollee’s annual modified adjusted gross
282 income.
283 (e) If, after a 30-day grace period, a full premium payment
284 has not been received, the enrollee shall be transitioned from
285 coverage to inactive status and may not reenroll for a minimum
286 of 6 months, unless a hardship exception has been granted.
287 Enrollees may seek a hardship exception under the Medicaid Fair
288 Hearing Process.
289 (f) Enrollees eligible under paragraph (1)(c) must pay
290 premiums according to the Title XXI state plan amendment and
291 follow disenrollment criteria for noncompliance in accordance
292 with s. 624.91.
293 Section 6. Section 409.724, Florida Statutes, is created to
294 read:
295 409.724 Available assistance.—
296 (1) PREMIUM CREDITS.—
297 (a) Standard amount.—The agency shall develop a monthly
298 premium credit structure appropriate to a benefit plan that
299 meets the bronze metal standard of the Affordable Care Act.
300 (b) Supplemental funding.—Subject to federal approval,
301 additional resources may be made available to enrollees and
302 incorporated into FHIX.
303 (c) Savings accounts.—In addition to the benefits provided
304 under this section, the corporation must offer each enrollee
305 access to an individual account that qualifies as a health
306 reimbursement account or a health savings account.
307 1. Unexpended funds.—Eligible unexpended funds from the
308 monthly premium credit must be deposited into each enrollee’s
309 individual account in a timely manner. Funds deposited into
310 these individual accounts may be used to pay cost-sharing
311 obligations or to purchase other health-related items to the
312 extent permitted under federal and state law.
313 2. Healthy behaviors.—Enrollees may receive credits to
314 their individual accounts for healthy behaviors, adherence to
315 wellness programs, and other activities that demonstrate
316 compliance with prevention or disease management guidelines.
317 3. Enrollee contributions.—The enrollee may make deposits
318 to his or her account at any time to supplement the premium
319 credit, to purchase additional FHIX products, or to offset other
320 cost-sharing obligations.
321 4. Third parties.—Third parties, including, but not limited
322 to, an employer or relative, may also make deposits on behalf of
323 the enrollee into the enrollee’s FHIX marketplace account. The
324 enrollee may not withdraw any funds as a refund, except those
325 funds the enrollee has deposited into his or her account.
326 (2) CHOICE COUNSELING.—The agency, in consultation with the
327 Florida Healthy Kids Corporation and the corporation, shall
328 develop a choice counseling program for FHIX. The choice
329 counseling program must ensure that participants have
330 information about the FHIX marketplace program, the federal
331 exchange, products, and services and that participants know
332 where and whom to call for questions or to make their plan
333 selections. The choice counseling program must provide
334 culturally sensitive materials and must take into consideration
335 the demographics of the projected population.
336 (3) EDUCATION CAMPAIGN.—The agency, the corporation, and
337 the Florida Healthy Kids Corporation must coordinate in advance
338 of Phase One an ongoing education campaign to inform
339 participants, at a minimum, of the following:
340 (a) How the FHIX marketplace operates and the timeline for
341 enrollment.
342 (b) Plans that are available and how to find information
343 about these plans.
344 (c) Information about other available insurance
345 affordability programs for the participant and his or her
346 family.
347 (d) Information about health benefits coverage, provider
348 networks, and cost sharing for available plans in each region.
349 (e) Information on how to complete the required annual
350 renewal process, including renewal dates and deadlines.
351 (f) Information on how to update eligibility if the
352 participant’s data have changed since his or her last renewal or
353 application date.
354 (4) CUSTOMER SUPPORT.—The Florida Healthy Kids Corporation
355 shall provide customer support for FHIX, including, but not
356 limited to, general program information, financial information,
357 and enrollee payments. Customer support must also provide a
358 toll-free telephone number and maintain a website that is
359 available in multiple languages and that meets the needs of the
360 enrollee population.
361 (5) INACTIVE PARTICIPANTS.—The corporation must inform the
362 inactive participant about other insurance affordability
363 programs and electronically refer the participant to the federal
364 exchange or other insurance affordability programs, as
365 appropriate.
366 Section 7. Section 409.725, Florida Statutes, is created to
367 read:
368 409.725 Available products and services.—The FHIX
369 marketplace shall offer the following products and services:
370 (1) Products and services authorized pursuant to s.
371 408.910.
372 (2) Products authorized by the federal exchange.
373 (3) Products authorized by the Florida Healthy Kids
374 Corporation pursuant to s. 624.91.
375 (4) Premium credits for participation in employer-sponsored
376 plans.
377 Section 8. Section 409.726, Florida Statutes, is created to
378 read:
379 409.726 Program accountability.—
380 (1) All managed care plans that participate in FHIX must
381 collect and maintain encounter level data in accordance with the
382 encounter data requirements under s. 409.967(2)(d) and are
383 subject to the accompanying penalties under s. 409.967(2)(h)2.
384 The agency is responsible for the collection and maintenance of
385 the encounter level data.
386 (2) The corporation, in consultation with the agency, shall
387 establish access and network standards for contracts on the FHIX
388 marketplace, shall ensure that contracted plans have sufficient
389 providers to meet enrollee needs, and shall develop quality of
390 coverage and provider standards specific to the adult
391 population.
392 (3) The department shall develop accountability measures
393 and performance standards to be applied to initial and renewal
394 FHIX applications that are submitted online, by mail, by
395 facsimile, or through referrals from a third party. The minimum
396 performance standards are:
397 (a) Application processing speed.—Ninety percent of all
398 applications, regardless of the method of submission, must be
399 processed within 45 days.
400 (b) Application processing speed from online sources.
401 Ninety-five percent of all applications received from online
402 sources must be processed within 45 days.
403 (c) Renewal application processing speed.—Ninety percent of
404 all renewals, regardless of the method of submission, must be
405 processed within 45 days.
406 (d) Renewal application processing speed from online
407 sources.—Ninety-five percent of all applications received from
408 online sources must be processed within 45 days.
409 (4) The agency, the department, and the Florida Healthy
410 Kids Corporation must meet the following standards for their
411 respective roles in the program:
412 (a) Eighty-five percent of calls must be answered in 20
413 seconds or less.
414 (b) All contacts, including, but not limited to, telephone
415 calls, faxed documents and requests, and e-mails, must be
416 handled within 2 business days.
417 (c) Any self-service tools available to participants, such
418 as interactive voice response systems, must be operational 7
419 days a week, 24 hours a day, at least 98 percent of each month.
420 (5) The agency, the department, and the Florida Healthy
421 Kids Corporation shall conduct an annual satisfaction survey to
422 address all measures that require participant input specific to
423 the FHIX marketplace program. The parties may elect to
424 incorporate these elements into the annual report required under
425 subsection (7).
426 (6) The agency and the corporation shall post online
427 monthly enrollment reports for FHIX.
428 (7) Beginning in 2016, an annual report is due no later
429 than July 1 to the Governor, the President of the Senate, and
430 the Speaker of the House of Representatives. The annual report
431 must be coordinated by the agency and the corporation and must
432 include at least the following:
433 (a) Enrollment and application trends and issues.
434 (b) Utilization and cost data.
435 (c) Customer satisfaction.
436 (d) Funding sources in health savings accounts or health
437 reimbursement accounts.
438 (e) Enrollee use of funds in health savings accounts or
439 health reimbursement accounts.
440 (f) Types of products and plans purchased.
441 (g) Movement of enrollees across different insurance
442 affordability programs.
443 (h) Recommendations for program improvement.
444 Section 9. Section 409.727, Florida Statutes, is created to
445 read:
446 409.727 Readiness review and implementation schedule.—The
447 agency, the corporation, the department, and the Florida Healthy
448 Kids Corporation shall begin implementation of FHIX on the
449 effective date of this act, with enrollment for Phase One
450 beginning by January 1, 2016.
451 (1) READINESS REVIEW.—Before implementation of any phase
452 under this part or in any region, the agency shall conduct a
453 readiness review in consultation with the FHIX Workgroup
454 established pursuant to s. 409.729. The agency shall determine,
455 at a minimum, the following readiness milestones:
456 (a) Functional readiness of the service delivery platform.
457 (b) Plan availability and presence of plan choice.
458 (c) Provider network capacity and adequacy of the available
459 plans.
460 (d) Availability of customer support.
461 (e) Other factors critical to the success of FHIX.
462 (2) PHASE ONE.—The agency, the corporation, and the Florida
463 Healthy Kids Corporation shall coordinate implementation
464 activities to ensure that enrollment begins by January 1, 2016,
465 and is available in all regions by July 1, 2016.
466 (a) Beginning no later than January 1, 2016, and contingent
467 upon federal approval, participants may enroll in health
468 benefits coverage under the FHIX marketplace or the federal
469 exchange, if eligible.
470 (b) To be eligible for enrollment during this phase, a
471 participant must meet the requirements under s. 409.723(1)(a)
472 and (b).
473 (c) An enrollee may select any benefit, service, or product
474 available in the region.
475 (d) The corporation shall notify an enrollee of his or her
476 premium credit amount and how to access the FHIX marketplace
477 selection process or the federal exchange.
478 (e) An enrollee must have a choice of at least two managed
479 care plans in each region which meet or exceed the Affordable
480 Care Act’s requirements and which qualify for a premium credit
481 on the FHIX marketplace or federal exchange.
482 (f) Choice counseling and customer service must be provided
483 in accordance with s. 409.724(2) and (4).
484 (3) PHASE TWO.—
485 (a) No later than July 1, 2016, the corporation and the
486 Florida Healthy Kids Corporation shall begin the transition of
487 enrollees under s. 624.91 to the FHIX marketplace.
488 (b) Eligibility during this phase is based on meeting the
489 requirements of s. 409.723(1)(c) and (4).
490 (c) An enrollee may select any available benefit, service,
491 or product available under s. 409.725.
492 (d) A Florida Healthy Kids enrollee who selects a FHIX
493 marketplace plan or federal exchange plan shall be provided a
494 premium credit equivalent to the average capitation rate paid in
495 his or her county of residence under Florida Healthy Kids as of
496 June 30, 2016. The enrollee is responsible for any difference in
497 costs and may use any unexpended funds deposited in his or her
498 savings account under s. 409.724(1)(c) for supplemental benefits
499 on the FHIX marketplace or federal exchange.
500 (e) The corporation shall notify an enrollee of his or her
501 premium credit amount and how to access the FHIX marketplace
502 selection process or federal exchange.
503 (f) Choice counseling and customer service must be provided
504 in accordance with s. 409.724(2) and (4).
505 (g) Enrollees under s. 624.91 must transition to the FHIX
506 marketplace and coverage under s. 409.725 by September 30, 2016.
507 (h) A provision that is applicable to an individual under
508 s. 624.91 is available and applicable to an enrollee who is
509 eligible under s. 409.723(1)(c).
510 Section 10. Section 409.728, Florida Statutes, is created
511 to read:
512 409.728 Program operation and management.—In order to
513 implement ss. 409.72-409.731:
514 (1) The agency shall do all of the following:
515 (a) Contract with the corporation for the development,
516 implementation, and administration of the Florida Health
517 Insurance Affordability Exchange Program and for the release of
518 any federal, state, or other funds appropriated to the
519 corporation.
520 (b) Provide administrative support to the FHIX Workgroup
521 established pursuant to s. 409.729.
522 (c) Consult with stakeholders that serve low-income
523 individuals and families during implementation, using a public
524 input process.
525 (d) Timely transmit enrollee information to the
526 corporation.
527 (e) Annually determine the appropriate premium credit based
528 on the difference in the price of a benchmark product on the
529 FHIX marketplace and the enrollee premium contribution as
530 outlined in s. 409.723(5)(a). For purposes of this paragraph,
531 the benchmark product on the FHIX marketplace is the bronze
532 level plan under the Affordable Care Act. For plans on the FHIX
533 marketplace, the agency shall annually establish a retroactive
534 methodology to adjust premium revenue to the relative clinical
535 risk profile of each plan’s enrollees.
536 (f) Transfer funds allocated for premium credits by General
537 Appropriations Act to the corporation.
538 (g) Adopt rules in coordination with the corporation and
539 the Florida Healthy Kids Corporation in order to implement FHIX,
540 including modifying existing rules implementing the Children’s
541 Health Insurance Program and adapting adult focused provisions
542 for children to accommodate the seamless transition of Healthy
543 Kids enrollees to FHIX.
544 (2) The department shall, in coordination with the
545 corporation, the agency, and the Florida Healthy Kids
546 Corporation, determine eligibility of applications and
547 application renewals for FHIX in accordance with s. 409.902 and
548 shall transmit eligibility determination information on a timely
549 basis to the agency and corporation.
550 (3) The Florida Healthy Kids Corporation shall do all of
551 the following:
552 (a) Retain its duties and responsibilities under s. 624.91
553 during Phase One of the program.
554 (b) In coordination with the agency and the corporation,
555 provide customer service for the FHIX marketplace.
556 (c) Transfer funds and provide financial support to the
557 FHIX marketplace, including the collection of monthly cost
558 sharing payments.
559 (d) Conduct financial reporting related to such activities,
560 in coordination with the corporation and the agency.
561 (e) Coordinate program activities with the agency, the
562 department, and the corporation.
563 (4) Florida Health Choices, Inc., shall do all of the
564 following:
565 (a) Develop and maintain the FHIX marketplace.
566 (b) Implement and administer Phase One and Phase Two of the
567 FHIX marketplace and the ongoing operations of the program.
568 (c) Offer health benefits coverage packages on the FHIX
569 marketplace, including plans compliant with the Affordable Care
570 Act.
571 (d) Offer FHIX enrollees a choice of at least two plans per
572 county at each benefit level which meet the requirements under
573 the Affordable Care Act.
574 (e) Offer the opportunity to participate in the federal
575 exchange.
576 (f) Offer enhanced or customized benefits to FHIX
577 marketplace enrollees.
578 (g) Provide sufficient staff and resources to meet the
579 program needs of enrollees.
580 (h) Provide an opportunity for plans contracted with or
581 previously contracted with the Florida Healthy Kids Corporation
582 under s. 624.91 to participate with FHIX if those plans meet the
583 requirements of the program.
584 (i) Encourage insurance agents licensed under chapter 626
585 to identify and assist enrollees. This act does not prohibit
586 these agents from receiving usual and customary commissions from
587 insurers and health maintenance organizations that offer plans
588 in the FHIX marketplace.
589 Section 11. Section 409.729, Florida Statutes, is created
590 to read:
591 409.729 Long-term reorganization.—The FHIX Workgroup is
592 created to facilitate the implementation of FHIX and to plan for
593 the reorganization of the state’s insurance affordability
594 programs. The FHIX Workgroup consists of two representatives
595 each from the agency, the department, the Florida Healthy Kids
596 Corporation, and the corporation. An additional representative
597 of the agency serves as chair. The FHIX Workgroup must hold its
598 organizational meeting no later than 30 days after the effective
599 date of this act and must meet at least bimonthly. The role of
600 the FHIX Workgroup is to make recommendations to the agency. The
601 responsibilities of the workgroup include, but are not limited
602 to:
603 (1) Developing and presenting a final implementation plan
604 that meets the requirements of this part in a report submitted
605 to the Governor, the President of the Senate, and the Speaker of
606 the House of Representatives no later than November 1, 2015.
607 (2) Reviewing network and access standards for plans and
608 products.
609 (3) Assessing readiness and recommending actions needed to
610 reorganize the state’s insurance affordability programs for each
611 phase or region. If a phase or region receives a nonreadiness
612 recommendation, the agency shall notify the Legislature of that
613 recommendation, the reasons for such a recommendation, and
614 proposed plans for achieving readiness.
615 (4) Recommending any proposed change to the Title XIX
616 funded or Title XXI-funded programs based on the continued
617 availability and reauthorization of the Title XXI program and
618 its federal funding.
619 (5) Identifying duplication of services by the corporation,
620 the agency, and the Florida Healthy Kids Corporation currently
621 and under FHIX’s proposed Phase Two program.
622 (6) Evaluating any fiscal impacts based on the proposed
623 transition plan under Phase Two.
624 (7) Compiling a schedule of impacted contracts, leases, and
625 other assets.
626 (8) Determining staff requirements for Phase Two.
627 Section 12. Section 409.73, Florida Statutes, is created to
628 read:
629 409.73 Legislative review.—The agency may seek federal
630 approval to implement FHIX as provided in ss. 409.72-409.731.
631 The agency is prohibited from implementing the FHIX waiver
632 without specific legislative approval unless the terms and
633 conditions of the approved waiver are substantially consistent
634 with the statutory requirements for this program.
635 Section 13. Section 409.731, Florida Statutes, is created
636 to read:
637 409.731 Program expiration.—
638 (1) The Florida Health Insurance Affordability Exchange
639 Program expires at the end of the state fiscal year in which any
640 of these conditions occurs:
641 (a) The federal match contribution for the newly eligible
642 under the Affordable Care Act falls below 90 percent.
643 (b) The federal match contribution falls below the
644 increased Federal Medical Assistance Percentage for medical
645 assistance for newly eligible mandatory individuals as specified
646 in the Affordable Care Act.
647 (c) The federal match for the FHIX program and the Medicaid
648 program are blended under federal law or regulation in such a
649 manner that causes the overall federal contribution to diminish
650 when compared to separate, nonblended federal contributions.
651 (2) Provided the conditions specified in subsection (1)
652 have not previously occurred, the Florida Health Insurance
653 Affordability Exchange Program shall expire on July 1, 2018,
654 unless reviewed and reenacted by the Legislature.
655 (3) The Health Outcomes Review Commission is established to
656 assess the following indicators:
657 (a) Patient outcomes.—Selected measures from the National
658 Healthcare Quality Report or similarly credible sources will be
659 applied to FHIX enrollees and compared to outcomes for Managed
660 Medical Assistance enrollees and uninsured patients.
661 (b) Fiscal impact.—Actual annual state general revenue
662 expenditures for the FHIX program will be compared to predicted
663 expenditures.
664 (c) Access to care.—Potentially preventable hospitalization
665 rates for acute and chronic conditions and potentially
666 preventable emergency department visits among FHIX enrollees
667 will be compared to Managed Medical Assistance enrollees and
668 uninsured patients.
669 (4) The Health Outcomes Review Commission shall consist of
670 nine members appointed by the Governor, the President of the
671 Senate, and the Speaker of the House. The Governor and each
672 presiding officer shall appoint one healthcare professional, one
673 private business representative, and one elected official.
674 (5) The commission shall be appointed no later than January
675 1, 2017, and shall meet regularly to select specific indicators,
676 review preliminary data, and develop a framework for a final
677 report. Staff support shall be provided to the commission by the
678 Agency for Health Care Administration.
679 (6) The commission’s final report shall be submitted to the
680 Governor, the President of the Senate, and the Speaker of the
681 House by January 1, 2018.
682 Section 14. Section 408.70, Florida Statutes, is repealed.
683 Section 15. Section 408.910, Florida Statutes, is amended
684 to read:
685 408.910 Florida Health Choices Program.—
686 (1) LEGISLATIVE INTENT.—The Legislature finds that a
687 significant number of the residents of this state do not have
688 adequate access to affordable, quality health care. The
689 Legislature further finds that increasing access to affordable,
690 quality health care can be best accomplished by establishing a
691 competitive market for purchasing health insurance and health
692 services. It is therefore the intent of the Legislature to
693 create and expand the Florida Health Choices Program to:
694 (a) Expand opportunities for Floridians to purchase
695 affordable health insurance and health services.
696 (b) Preserve the benefits of employment-sponsored insurance
697 while easing the administrative burden for employers who offer
698 these benefits.
699 (c) Enable individual choice in both the manner and amount
700 of health care purchased.
701 (d) Provide for the purchase of individual, portable health
702 care coverage.
703 (e) Disseminate information to consumers on the price and
704 quality of health services.
705 (f) Sponsor a competitive market that stimulates product
706 innovation, quality improvement, and efficiency in the
707 production and delivery of health services.
708 (2) DEFINITIONS.—As used in this section, the term:
709 (a) “Corporation” means the Florida Health Choices, Inc.,
710 established under this section.
711 (b) “Corporation’s marketplace” means the single,
712 centralized market established by the program that facilitates
713 the purchase of products made available in the marketplace.
714 (c) “Florida Health Insurance Affordability Exchange
715 Program” or “FHIX” is the program created under ss. 409.72
716 409.731 for low-income, uninsured residents of this state.
717 (d)(c) “Health insurance agent” means an agent licensed
718 under part IV of chapter 626.
719 (e)(d) “Insurer” means an entity licensed under chapter 624
720 which offers an individual health insurance policy or a group
721 health insurance policy, a preferred provider organization as
722 defined in s. 627.6471, an exclusive provider organization as
723 defined in s. 627.6472, or a health maintenance organization
724 licensed under part I of chapter 641, or a prepaid limited
725 health service organization or discount medical plan
726 organization licensed under chapter 636.
727 (f) “Patient Protection and Affordable Care Act” or
728 “Affordable Care Act” means Pub. L. No. 111-148, as further
729 amended by the Health Care and Education Reconciliation Act of
730 2010, Pub. L. No. 111-152, and regulations adopted pursuant to
731 those acts.
732 (g)(e) “Program” means the Florida Health Choices Program
733 established by this section.
734 (3) PROGRAM PURPOSE AND COMPONENTS.—The Florida Health
735 Choices Program is created as a single, centralized market for
736 the sale and purchase of various products that enable
737 individuals to pay for health care. These products include, but
738 are not limited to, health insurance plans, health maintenance
739 organization plans, prepaid services, service contracts, and
740 flexible spending accounts. The components of the program
741 include:
742 (a) Enrollment of employers.
743 (b) Administrative services for participating employers,
744 including:
745 1. Assistance in seeking federal approval of cafeteria
746 plans.
747 2. Collection of premiums and other payments.
748 3. Management of individual benefit accounts.
749 4. Distribution of premiums to insurers and payments to
750 other eligible vendors.
751 5. Assistance for participants in complying with reporting
752 requirements.
753 (c) Services to individual participants, including:
754 1. Information about available products and participating
755 vendors.
756 2. Assistance with assessing the benefits and limits of
757 each product, including information necessary to distinguish
758 between policies offering creditable coverage and other products
759 available through the program.
760 3. Account information to assist individual participants
761 with managing available resources.
762 4. Services that promote healthy behaviors.
763 5. Health benefits coverage information about health
764 insurance plans compliant with the Affordable Care Act.
765 6. Consumer assistance with web-based information services
766 for the Florida Health Insurance Affordability Exchange Program,
767 or (”FHIX”).
768 (d) Recruitment of vendors, including insurers, health
769 maintenance organizations, prepaid clinic service providers,
770 provider service networks, and other providers.
771 (e) Certification of vendors to ensure capability,
772 reliability, and validity of offerings.
773 (f) Collection of data, monitoring, assessment, and
774 reporting of vendor performance.
775 (g) Information services for individuals and employers.
776 (h) Program evaluation.
777 (4) ELIGIBILITY AND PARTICIPATION.—Participation in the
778 program is voluntary and shall be available to employers,
779 individuals, vendors, and health insurance agents as specified
780 in this subsection.
781 (a) Employers eligible to enroll in the program include
782 those employers that meet criteria established by the
783 corporation and elect to make their employees eligible through
784 the program.
785 (b) Individuals eligible to participate in the program
786 include:
787 1. Individual employees of enrolled employers.
788 2. Other individuals that meet criteria established by the
789 corporation.
790 (c) Employers who choose to participate in the program may
791 enroll by complying with the procedures established by the
792 corporation. The procedures must include, but are not limited
793 to:
794 1. Submission of required information.
795 2. Compliance with federal tax requirements for the
796 establishment of a cafeteria plan, pursuant to s. 125 of the
797 Internal Revenue Code, including designation of the employer’s
798 plan as a premium payment plan, a salary reduction plan that has
799 flexible spending arrangements, or a salary reduction plan that
800 has a premium payment and flexible spending arrangements.
801 3. Determination of the employer’s contribution, if any,
802 per employee, provided that such contribution is equal for each
803 eligible employee.
804 4. Establishment of payroll deduction procedures, subject
805 to the agreement of each individual employee who voluntarily
806 participates in the program.
807 5. Designation of the corporation as the third-party
808 administrator for the employer’s health benefit plan.
809 6. Identification of eligible employees.
810 7. Arrangement for periodic payments.
811 8. Employer notification to employees of the intent to
812 transfer from an existing employee health plan to the program at
813 least 90 days before the transition.
814 (d) All eligible vendors who choose to participate and the
815 products and services that the vendors are permitted to sell are
816 as follows:
817 1. Insurers licensed under chapter 624 may sell health
818 insurance policies, limited benefit policies, other risk-bearing
819 coverage, and other products or services.
820 2. Health maintenance organizations licensed under part I
821 of chapter 641 may sell health maintenance contracts, limited
822 benefit policies, other risk-bearing products, and other
823 products or services.
824 3. Prepaid limited health service organizations may sell
825 products and services as authorized under part I of chapter 636,
826 and discount medical plan organizations may sell products and
827 services as authorized under part II of chapter 636.
828 4. Prepaid health clinic service providers licensed under
829 part II of chapter 641 may sell prepaid service contracts and
830 other arrangements for a specified amount and type of health
831 services or treatments.
832 5. Health care providers, including hospitals and other
833 licensed health facilities, health care clinics, licensed health
834 professionals, pharmacies, and other licensed health care
835 providers, may sell service contracts and arrangements for a
836 specified amount and type of health services or treatments.
837 6. Provider organizations, including service networks,
838 group practices, professional associations, and other
839 incorporated organizations of providers, may sell service
840 contracts and arrangements for a specified amount and type of
841 health services or treatments.
842 7. Corporate entities providing specific health services in
843 accordance with applicable state law may sell service contracts
844 and arrangements for a specified amount and type of health
845 services or treatments.
846
847 A vendor described in subparagraphs 3.-7. may not sell products
848 that provide risk-bearing coverage unless that vendor is
849 authorized under a certificate of authority issued by the Office
850 of Insurance Regulation and is authorized to provide coverage in
851 the relevant geographic area. Otherwise eligible vendors may be
852 excluded from participating in the program for deceptive or
853 predatory practices, financial insolvency, or failure to comply
854 with the terms of the participation agreement or other standards
855 set by the corporation.
856 (e) Eligible individuals may participate in the program
857 voluntarily. Individuals who join the program may participate by
858 complying with the procedures established by the corporation.
859 These procedures must include, but are not limited to:
860 1. Submission of required information.
861 2. Authorization for payroll deduction, if applicable.
862 3. Compliance with federal tax requirements.
863 4. Arrangements for payment.
864 5. Selection of products and services.
865 (f) Vendors who choose to participate in the program may
866 enroll by complying with the procedures established by the
867 corporation. These procedures may include, but are not limited
868 to:
869 1. Submission of required information, including a complete
870 description of the coverage, services, provider network, payment
871 restrictions, and other requirements of each product offered
872 through the program.
873 2. Execution of an agreement to comply with requirements
874 established by the corporation.
875 3. Execution of an agreement that prohibits refusal to sell
876 any offered product or service to a participant who elects to
877 buy it.
878 4. Establishment of product prices based on applicable
879 criteria.
880 5. Arrangements for receiving payment for enrolled
881 participants.
882 6. Participation in ongoing reporting processes established
883 by the corporation.
884 7. Compliance with grievance procedures established by the
885 corporation.
886 (g) Health insurance agents licensed under part IV of
887 chapter 626 are eligible to voluntarily participate as buyers’
888 representatives. A buyer’s representative acts on behalf of an
889 individual purchasing health insurance and health services
890 through the program by providing information about products and
891 services available through the program and assisting the
892 individual with both the decision and the procedure of selecting
893 specific products. Serving as a buyer’s representative does not
894 constitute a conflict of interest with continuing
895 responsibilities as a health insurance agent if the relationship
896 between each agent and any participating vendor is disclosed
897 before advising an individual participant about the products and
898 services available through the program. In order to participate,
899 a health insurance agent shall comply with the procedures
900 established by the corporation, including:
901 1. Completion of training requirements.
902 2. Execution of a participation agreement specifying the
903 terms and conditions of participation.
904 3. Disclosure of any appointments to solicit insurance or
905 procure applications for vendors participating in the program.
906 4. Arrangements to receive payment from the corporation for
907 services as a buyer’s representative.
908 (5) PRODUCTS.—
909 (a) The products that may be made available for purchase
910 through the program include, but are not limited to:
911 1. Health insurance policies.
912 2. Health maintenance contracts.
913 3. Limited benefit plans.
914 4. Prepaid clinic services.
915 5. Service contracts.
916 6. Arrangements for purchase of specific amounts and types
917 of health services and treatments.
918 7. Flexible spending accounts.
919 (b) Health insurance policies, health maintenance
920 contracts, limited benefit plans, prepaid service contracts, and
921 other contracts for services must ensure the availability of
922 covered services.
923 (c) Products may be offered for multiyear periods provided
924 the price of the product is specified for the entire period or
925 for each separately priced segment of the policy or contract.
926 (d) The corporation shall provide a disclosure form for
927 consumers to acknowledge their understanding of the nature of,
928 and any limitations to, the benefits provided by the products
929 and services being purchased by the consumer.
930 (e) The corporation must determine that making the plan
931 available through the program is in the interest of eligible
932 individuals and eligible employers in the state.
933 (6) PRICING.—Prices for the products and services sold
934 through the program must be transparent to participants and
935 established by the vendors. The corporation may shall annually
936 assess a surcharge for each premium or price set by a
937 participating vendor. Any The surcharge may not be more than 2.5
938 percent of the price and shall be used to generate funding for
939 administrative services provided by the corporation and payments
940 to buyers’ representatives; however, a surcharge may not be
941 assessed for products and services sold in the FHIX marketplace.
942 (7) THE MARKETPLACE PROCESS.—The program shall provide a
943 single, centralized market for purchase of health insurance,
944 health maintenance contracts, and other health products and
945 services. Purchases may be made by participating individuals
946 over the Internet or through the services of a participating
947 health insurance agent. Information about each product and
948 service available through the program shall be made available
949 through printed material and an interactive Internet website.
950 (a) Marketplace purchasing.—A participant needing personal
951 assistance to select products and services shall be referred to
952 a participating agent in his or her area.
953 1.(a) Participation in the program may begin at any time
954 during a year after the employer completes enrollment and meets
955 the requirements specified by the corporation pursuant to
956 paragraph (4)(c).
957 2.(b) Initial selection of products and services must be
958 made by an individual participant within the applicable open
959 enrollment period.
960 3.(c) Initial enrollment periods for each product selected
961 by an individual participant must last at least 12 months,
962 unless the individual participant specifically agrees to a
963 different enrollment period.
964 4.(d) If an individual has selected one or more products
965 and enrolled in those products for at least 12 months or any
966 other period specifically agreed to by the individual
967 participant, changes in selected products and services may only
968 be made during the annual enrollment period established by the
969 corporation.
970 5.(e) The limits established in subparagraphs 2., 3., and
971 4. paragraphs (b)-(d) apply to any risk-bearing product that
972 promises future payment or coverage for a variable amount of
973 benefits or services. The limits do not apply to initiation of
974 flexible spending plans if those plans are not associated with
975 specific high-deductible insurance policies or the use of
976 spending accounts for any products offering individual
977 participants specific amounts and types of health services and
978 treatments at a contracted price.
979 (b) FHIX marketplace purchasing.—
980 1. Participation in the FHIX marketplace may begin at any
981 time during the year.
982 2. Initial enrollment periods for certain products selected
983 by an individual enrollee which are noncompliant with the
984 Affordable Care Act may be required to last at least 12 months,
985 unless the individual participant specifically agrees to a
986 different enrollment period.
987 (8) CONSUMER INFORMATION.—The corporation shall:
988 (a) Establish a secure website to facilitate the purchase
989 of products and services by participating individuals. The
990 website must provide information about each product or service
991 available through the program.
992 (b) Inform individuals about other public health care
993 programs.
994 (9) RISK POOLING.—The program may use methods for pooling
995 the risk of individual participants and preventing selection
996 bias. These methods may include, but are not limited to, a
997 postenrollment risk adjustment of the premium payments to the
998 vendors. The corporation may establish a methodology for
999 assessing the risk of enrolled individual participants based on
1000 data reported annually by the vendors about their enrollees.
1001 Distribution of payments to the vendors may be adjusted based on
1002 the assessed relative risk profile of the enrollees in each
1003 risk-bearing product for the most recent period for which data
1004 is available.
1005 (10) EXEMPTIONS.—
1006 (a) Products, other than the products set forth in
1007 subparagraphs (4)(d)1.-4., sold as part of the program are not
1008 subject to the licensing requirements of the Florida Insurance
1009 Code, as defined in s. 624.01 or the mandated offerings or
1010 coverages established in part VI of chapter 627 and chapter 641.
1011 (b) The corporation may act as an administrator as defined
1012 in s. 626.88 but is not required to be certified pursuant to
1013 part VII of chapter 626. However, a third-party third party
1014 administrator used by the corporation must be certified under
1015 part VII of chapter 626.
1016 (c) Any standard forms, website design, or marketing
1017 communication developed by the corporation and used by the
1018 corporation, or any vendor that meets the requirements of
1019 paragraph (4)(f) is not subject to the Florida Insurance Code,
1020 as established in s. 624.01.
1021 (11) CORPORATION.—There is created the Florida Health
1022 Choices, Inc., which shall be registered, incorporated,
1023 organized, and operated in compliance with part III of chapter
1024 112 and chapters 119, 286, and 617. The purpose of the
1025 corporation is to administer the program created in this section
1026 and to conduct such other business as may further the
1027 administration of the program.
1028 (a) The corporation shall be governed by a 15-member board
1029 of directors consisting of:
1030 1. Three ex officio, nonvoting members to include:
1031 a. The Secretary of Health Care Administration or a
1032 designee with expertise in health care services.
1033 b. The Secretary of Management Services or a designee with
1034 expertise in state employee benefits.
1035 c. The commissioner of the Office of Insurance Regulation
1036 or a designee with expertise in insurance regulation.
1037 2. Four members appointed by and serving at the pleasure of
1038 the Governor.
1039 3. Four members appointed by and serving at the pleasure of
1040 the President of the Senate.
1041 4. Four members appointed by and serving at the pleasure of
1042 the Speaker of the House of Representatives.
1043 5. Board members may not include insurers, health insurance
1044 agents or brokers, health care providers, health maintenance
1045 organizations, prepaid service providers, or any other entity,
1046 affiliate, or subsidiary of eligible vendors.
1047 (b) Members shall be appointed for terms of up to 3 years.
1048 Any member is eligible for reappointment. A vacancy on the board
1049 shall be filled for the unexpired portion of the term in the
1050 same manner as the original appointment.
1051 (c) The board shall select a chief executive officer for
1052 the corporation who shall be responsible for the selection of
1053 such other staff as may be authorized by the corporation’s
1054 operating budget as adopted by the board.
1055 (d) Board members are entitled to receive, from funds of
1056 the corporation, reimbursement for per diem and travel expenses
1057 as provided by s. 112.061. No other compensation is authorized.
1058 (e) There is no liability on the part of, and no cause of
1059 action shall arise against, any member of the board or its
1060 employees or agents for any action taken by them in the
1061 performance of their powers and duties under this section.
1062 (f) The board shall develop and adopt bylaws and other
1063 corporate procedures as necessary for the operation of the
1064 corporation and carrying out the purposes of this section. The
1065 bylaws shall:
1066 1. Specify procedures for selection of officers and
1067 qualifications for reappointment, provided that no board member
1068 shall serve more than 9 consecutive years.
1069 2. Require an annual membership meeting that provides an
1070 opportunity for input and interaction with individual
1071 participants in the program.
1072 3. Specify policies and procedures regarding conflicts of
1073 interest, including the provisions of part III of chapter 112,
1074 which prohibit a member from participating in any decision that
1075 would inure to the benefit of the member or the organization
1076 that employs the member. The policies and procedures shall also
1077 require public disclosure of the interest that prevents the
1078 member from participating in a decision on a particular matter.
1079 (g) The corporation may exercise all powers granted to it
1080 under chapter 617 necessary to carry out the purposes of this
1081 section, including, but not limited to, the power to receive and
1082 accept grants, loans, or advances of funds from any public or
1083 private agency and to receive and accept from any source
1084 contributions of money, property, labor, or any other thing of
1085 value to be held, used, and applied for the purposes of this
1086 section.
1087 (h) The corporation may establish technical advisory panels
1088 consisting of interested parties, including consumers, health
1089 care providers, individuals with expertise in insurance
1090 regulation, and insurers.
1091 (i) The corporation shall:
1092 1. Determine eligibility of employers, vendors,
1093 individuals, and agents in accordance with subsection (4).
1094 2. Establish procedures necessary for the operation of the
1095 program, including, but not limited to, procedures for
1096 application, enrollment, risk assessment, risk adjustment, plan
1097 administration, performance monitoring, and consumer education.
1098 3. Arrange for collection of contributions from
1099 participating employers, third parties, governmental entities,
1100 and individuals.
1101 4. Arrange for payment of premiums and other appropriate
1102 disbursements based on the selections of products and services
1103 by the individual participants.
1104 5. Establish criteria for disenrollment of participating
1105 individuals based on failure to pay the individual’s share of
1106 any contribution required to maintain enrollment in selected
1107 products.
1108 6. Establish criteria for exclusion of vendors pursuant to
1109 paragraph (4)(d).
1110 7. Develop and implement a plan for promoting public
1111 awareness of and participation in the program.
1112 8. Secure staff and consultant services necessary to the
1113 operation of the program.
1114 9. Establish policies and procedures regarding
1115 participation in the program for individuals, vendors, health
1116 insurance agents, and employers.
1117 10. Provide for the operation of a toll-free hotline to
1118 respond to requests for assistance.
1119 11. Provide for initial, open, and special enrollment
1120 periods.
1121 12. Evaluate options for employer participation which may
1122 conform to with common insurance practices.
1123 13. Administer the Florida Health Insurance Affordability
1124 Exchange Program in accordance with ss. 409.72-409.731.
1125 14. Coordinate with the Agency for Health Care
1126 Administration, the Department of Children and Families, and the
1127 Florida Healthy Kids Corporation in developing and implementing
1128 the enrollee transition plan.
1129 15. Coordinate with the federal exchange to provide FHIX
1130 enrollees with the option of selecting plans from either the
1131 FHIX marketplace or the federal exchange.
1132 (12) REPORT.—The board of the corporation shall Beginning
1133 in the 2009-2010 fiscal year, submit by February 1 an annual
1134 report to the Governor, the President of the Senate, and the
1135 Speaker of the House of Representatives documenting the
1136 corporation’s activities in compliance with the duties
1137 delineated in this section.
1138 (13) PROGRAM INTEGRITY.—To ensure program integrity and to
1139 safeguard the financial transactions made under the auspices of
1140 the program, the corporation is authorized to establish
1141 qualifying criteria and certification procedures for vendors,
1142 require performance bonds or other guarantees of ability to
1143 complete contractual obligations, monitor the performance of
1144 vendors, and enforce the agreements of the program through
1145 financial penalty or disqualification from the program.
1146 (14) EXEMPTION FROM PUBLIC RECORDS REQUIREMENTS.—
1147 (a) Definitions.—For purposes of this subsection, the term:
1148 1. “Buyer’s representative” means a participating insurance
1149 agent as described in paragraph (4)(g).
1150 2. “Enrollee” means an employer who is eligible to enroll
1151 in the program pursuant to paragraph (4)(a).
1152 3. “Participant” means an individual who is eligible to
1153 participate in the program pursuant to paragraph (4)(b).
1154 4. “Proprietary confidential business information” means
1155 information, regardless of form or characteristics, that is
1156 owned or controlled by a vendor requesting confidentiality under
1157 this section; that is intended to be and is treated by the
1158 vendor as private in that the disclosure of the information
1159 would cause harm to the business operations of the vendor; that
1160 has not been disclosed unless disclosed pursuant to a statutory
1161 provision, an order of a court or administrative body, or a
1162 private agreement providing that the information may be released
1163 to the public; and that is information concerning:
1164 a. Business plans.
1165 b. Internal auditing controls and reports of internal
1166 auditors.
1167 c. Reports of external auditors for privately held
1168 companies.
1169 d. Client and customer lists.
1170 e. Potentially patentable material.
1171 f. A trade secret as defined in s. 688.002.
1172 5. “Vendor” means a participating insurer or other provider
1173 of services as described in paragraph (4)(d).
1174 (b) Public record exemptions.—
1175 1. Personal identifying information of an enrollee or
1176 participant who has applied for or participates in the Florida
1177 Health Choices Program is confidential and exempt from s.
1178 119.07(1) and s. 24(a), Art. I of the State Constitution.
1179 2. Client and customer lists of a buyer’s representative
1180 held by the corporation are confidential and exempt from s.
1181 119.07(1) and s. 24(a), Art. I of the State Constitution.
1182 3. Proprietary confidential business information held by
1183 the corporation is confidential and exempt from s. 119.07(1) and
1184 s. 24(a), Art. I of the State Constitution.
1185 (c) Retroactive application.—The public record exemptions
1186 provided for in paragraph (b) apply to information held by the
1187 corporation before, on, or after the effective date of this
1188 exemption.
1189 (d) Authorized release.—
1190 1. Upon request, information made confidential and exempt
1191 pursuant to this subsection shall be disclosed to:
1192 a. Another governmental entity in the performance of its
1193 official duties and responsibilities.
1194 b. Any person who has the written consent of the program
1195 applicant.
1196 c. The Florida Kidcare program for the purpose of
1197 administering the program authorized in ss. 409.810-409.821.
1198 2. Paragraph (b) does not prohibit a participant’s legal
1199 guardian from obtaining confirmation of coverage, dates of
1200 coverage, the name of the participant’s health plan, and the
1201 amount of premium being paid.
1202 (e) Penalty.—A person who knowingly and willfully violates
1203 this subsection commits a misdemeanor of the second degree,
1204 punishable as provided in s. 775.082 or s. 775.083.
1205 (f) Review and repeal.—This subsection is subject to the
1206 Open Government Sunset Review Act in accordance with s. 119.15,
1207 and shall stand repealed on October 2, 2016, unless reviewed and
1208 saved from repeal through reenactment by the Legislature.
1209 Section 16. Subsection (2) of section 409.904, Florida
1210 Statutes, is amended to read:
1211 409.904 Optional payments for eligible persons.—The agency
1212 may make payments for medical assistance and related services on
1213 behalf of the following persons who are determined to be
1214 eligible subject to the income, assets, and categorical
1215 eligibility tests set forth in federal and state law. Payment on
1216 behalf of these Medicaid eligible persons is subject to the
1217 availability of moneys and any limitations established by the
1218 General Appropriations Act or chapter 216.
1219 (2) A family, a pregnant woman, a child under age 21, a
1220 person age 65 or over, or a blind or disabled person, who would
1221 be eligible under any group listed in s. 409.903(1), (2), or
1222 (3), except that the income or assets of such family or person
1223 exceed established limitations. For a family or person in one of
1224 these coverage groups, medical expenses are deductible from
1225 income in accordance with federal requirements in order to make
1226 a determination of eligibility. A family or person eligible
1227 under the coverage known as the “medically needy,” is eligible
1228 to receive the same services as other Medicaid recipients, with
1229 the exception of services in skilled nursing facilities and
1230 intermediate care facilities for the developmentally disabled.
1231 Effective July 1, 2016, persons eligible under “medically needy”
1232 shall be limited to children under 21 years of age and pregnant
1233 women. This subsection expires October 1, 2019.
1234 Section 17. Section 624.91, Florida Statutes, is amended to
1235 read:
1236 624.91 The Florida Healthy Kids Corporation Act.—
1237 (1) SHORT TITLE.—This section may be cited as the “William
1238 G. ‘Doc’ Myers Healthy Kids Corporation Act.”
1239 (2) LEGISLATIVE INTENT.—
1240 (a) The Legislature finds that increased access to health
1241 care services could improve children’s health and reduce the
1242 incidence and costs of childhood illness and disabilities among
1243 children in this state. Many children do not have comprehensive,
1244 affordable health care services available. It is the intent of
1245 the Legislature that the Florida Healthy Kids Corporation
1246 provide comprehensive health insurance coverage to such
1247 children. The corporation is encouraged to cooperate with any
1248 existing health service programs funded by the public or the
1249 private sector.
1250 (b) It is the intent of the Legislature that the Florida
1251 Healthy Kids Corporation serve as one of several providers of
1252 services to children eligible for medical assistance under Title
1253 XXI of the Social Security Act. Although the corporation may
1254 serve other children, the Legislature intends the primary
1255 recipients of services provided through the corporation be
1256 school-age children with a family income below 200 percent of
1257 the federal poverty level, who do not qualify for Medicaid. It
1258 is also the intent of the Legislature that state and local
1259 government Florida Healthy Kids funds be used to continue
1260 coverage, subject to specific appropriations in the General
1261 Appropriations Act, to children not eligible for federal
1262 matching funds under Title XXI.
1263 (3) ELIGIBILITY FOR STATE-FUNDED ASSISTANCE.—Only residents
1264 of this state are eligible the following individuals are
1265 eligible for state-funded assistance in paying Florida Healthy
1266 Kids premiums pursuant to s. 409.814.:
1267 (a) Residents of this state who are eligible for the
1268 Florida Kidcare program pursuant to s. 409.814.
1269 (b) Notwithstanding s. 409.814, legal aliens who are
1270 enrolled in the Florida Healthy Kids program as of January 31,
1271 2004, who do not qualify for Title XXI federal funds because
1272 they are not qualified aliens as defined in s. 409.811.
1273 (4) NONENTITLEMENT.—Nothing in this section shall be
1274 construed as providing an individual with an entitlement to
1275 health care services. No cause of action shall arise against the
1276 state, the Florida Healthy Kids Corporation, or a unit of local
1277 government for failure to make health services available under
1278 this section.
1279 (5) CORPORATION AUTHORIZATION, DUTIES, POWERS.—
1280 (a) There is created the Florida Healthy Kids Corporation,
1281 a not-for-profit corporation.
1282 (b) The Florida Healthy Kids Corporation shall:
1283 1. Arrange for the collection of any individual, family,
1284 local contributions, or employer payment or premium, in an
1285 amount to be determined by the board of directors, to provide
1286 for payment of premiums for comprehensive insurance coverage and
1287 for the actual or estimated administrative expenses.
1288 2. Arrange for the collection of any voluntary
1289 contributions to provide for payment of Florida Kidcare program
1290 or Florida Health Insurance Affordability Exchange Program
1291 (FHIX) premiums for children who are not eligible for medical
1292 assistance under Title XIX or Title XXI of the Social Security
1293 Act.
1294 3. Subject to the provisions of s. 409.8134, accept
1295 voluntary supplemental local match contributions that comply
1296 with the requirements of Title XXI of the Social Security Act
1297 for the purpose of providing additional Florida Kidcare coverage
1298 in contributing counties under Title XXI.
1299 4. Establish the administrative and accounting procedures
1300 for the operation of the corporation.
1301 4.5. Establish, with consultation from appropriate
1302 professional organizations, standards for preventive health
1303 services and providers and comprehensive insurance benefits
1304 appropriate to children, provided that such standards for rural
1305 areas shall not limit primary care providers to board-certified
1306 pediatricians.
1307 5.6. Determine eligibility for children seeking to
1308 participate in the Title XXI-funded components of the Florida
1309 Kidcare program consistent with the requirements specified in s.
1310 409.814, as well as the non-Title-XXI-eligible children as
1311 provided in subsection (3).
1312 6.7. Establish procedures under which providers of local
1313 match to, applicants to and participants in the program may have
1314 grievances reviewed by an impartial body and reported to the
1315 board of directors of the corporation.
1316 7.8. Establish participation criteria and, if appropriate,
1317 contract with an authorized insurer, health maintenance
1318 organization, or third-party administrator to provide
1319 administrative services to the corporation.
1320 8.9. Establish enrollment criteria that include penalties
1321 or waiting periods of 30 days for reinstatement of coverage upon
1322 voluntary cancellation for nonpayment of family or individual
1323 premiums.
1324 9.10. Contract with authorized insurers or any provider of
1325 health care services, meeting standards established by the
1326 corporation, for the provision of comprehensive insurance
1327 coverage to participants. Such standards shall include criteria
1328 under which the corporation may contract with more than one
1329 provider of health care services in program sites.
1330 a. Health plans shall be selected through a competitive bid
1331 process. The Florida Healthy Kids Corporation shall purchase
1332 goods and services in the most cost-effective manner consistent
1333 with the delivery of quality medical care.
1334 b. The maximum administrative cost for a Florida Healthy
1335 Kids Corporation contract shall be 15 percent. For health and
1336 dental care contracts, the minimum medical loss ratio for a
1337 Florida Healthy Kids Corporation contract shall be 85 percent.
1338 The calculations must use uniform financial data collected from
1339 all plans in a format established by the corporation and shall
1340 be computed for each plan on a statewide basis. Funds shall be
1341 classified in a manner consistent with 45 C.F.R. part 158 For
1342 dental contracts, the remaining compensation to be paid to the
1343 authorized insurer or provider under a Florida Healthy Kids
1344 Corporation contract shall be no less than an amount which is 85
1345 percent of premium; to the extent any contract provision does
1346 not provide for this minimum compensation, this section shall
1347 prevail.
1348 c. The health plan selection criteria and scoring system,
1349 and the scoring results, shall be available upon request for
1350 inspection after the bids have been awarded.
1351 d. Effective July 1, 2016, health and dental services
1352 contracts of the corporation must transition to the FHIX
1353 marketplace under s. 409.722. Qualifying plans may enroll as
1354 vendors with the FHIX marketplace to maintain continuity of care
1355 for participants.
1356 10.11. Establish disenrollment criteria in the event local
1357 matching funds are insufficient to cover enrollments.
1358 11.12. Develop and implement a plan to publicize the
1359 Florida Kidcare program, the eligibility requirements of the
1360 program, and the procedures for enrollment in the program and to
1361 maintain public awareness of the corporation and the program.
1362 12.13. Secure staff necessary to properly administer the
1363 corporation. Staff costs shall be funded from state and local
1364 matching funds and such other private or public funds as become
1365 available. The board of directors shall determine the number of
1366 staff members necessary to administer the corporation.
1367 13.14. In consultation with the partner agencies, provide a
1368 report on the Florida Kidcare program annually to the Governor,
1369 the Chief Financial Officer, the Commissioner of Education, the
1370 President of the Senate, the Speaker of the House of
1371 Representatives, and the Minority Leaders of the Senate and the
1372 House of Representatives.
1373 14.15. Provide information on a quarterly basis online to
1374 the Legislature and the Governor which compares the costs and
1375 utilization of the full-pay enrolled population and the Title
1376 XXI-subsidized enrolled population in the Florida Kidcare
1377 program. The information, at a minimum, must include:
1378 a. The monthly enrollment and expenditure for full-pay
1379 enrollees in the Medikids and Florida Healthy Kids programs
1380 compared to the Title XXI-subsidized enrolled population; and
1381 b. The costs and utilization by service of the full-pay
1382 enrollees in the Medikids and Florida Healthy Kids programs and
1383 the Title XXI-subsidized enrolled population.
1384 15.16. Establish benefit packages that conform to the
1385 provisions of the Florida Kidcare program, as created in ss.
1386 409.810-409.821.
1387 16. Contract with other insurance affordability programs to
1388 provide such services that are consistent with this act.
1389 17. Annually develop performance metrics for the following
1390 focus areas:
1391 a. Administrative functions.
1392 b. Contracting with vendors.
1393 c. Customer service.
1394 d. Enrollee education.
1395 e. Financial services.
1396 f. Program integrity.
1397 (c) Coverage under the corporation’s program is secondary
1398 to any other available private coverage held by, or applicable
1399 to, the participant child or family member. Insurers under
1400 contract with the corporation are the payors of last resort and
1401 must coordinate benefits with any other third-party payor that
1402 may be liable for the participant’s medical care.
1403 (d) The Florida Healthy Kids Corporation shall be a private
1404 corporation not for profit, organized pursuant to chapter 617,
1405 and shall have all powers necessary to carry out the purposes of
1406 this act, including, but not limited to, the power to receive
1407 and accept grants, loans, or advances of funds from any public
1408 or private agency and to receive and accept from any source
1409 contributions of money, property, labor, or any other thing of
1410 value, to be held, used, and applied for the purposes of this
1411 act.
1412 (6) BOARD OF DIRECTORS AND MANAGEMENT SUPERVISION.—
1413 (a) The Florida Healthy Kids Corporation shall operate
1414 subject to the supervision and approval of a board of directors.
1415 The board chair shall be an appointee designated by the
1416 Governor, and the board shall be chaired by the Chief Financial
1417 Officer or her or his designee, and composed of 12 other
1418 members. The Senate shall confirm the designated chair and other
1419 board appointees. The board members shall be appointed selected
1420 for 3-year terms. of office as follows:
1421 1. The Secretary of Health Care Administration, or his or
1422 her designee.
1423 2. One member appointed by the Commissioner of Education
1424 from the Office of School Health Programs of the Florida
1425 Department of Education.
1426 3. One member appointed by the Chief Financial Officer from
1427 among three members nominated by the Florida Pediatric Society.
1428 4. One member, appointed by the Governor, who represents
1429 the Children’s Medical Services Program.
1430 5. One member appointed by the Chief Financial Officer from
1431 among three members nominated by the Florida Hospital
1432 Association.
1433 6. One member, appointed by the Governor, who is an expert
1434 on child health policy.
1435 7. One member, appointed by the Chief Financial Officer,
1436 from among three members nominated by the Florida Academy of
1437 Family Physicians.
1438 8. One member, appointed by the Governor, who represents
1439 the state Medicaid program.
1440 9. One member, appointed by the Chief Financial Officer,
1441 from among three members nominated by the Florida Association of
1442 Counties.
1443 10. The State Health Officer or her or his designee.
1444 11. The Secretary of Children and Families, or his or her
1445 designee.
1446 12. One member, appointed by the Governor, from among three
1447 members nominated by the Florida Dental Association.
1448 (b) A member of the board of directors shall be appointed
1449 by and serve at the pleasure of the Governor may be removed by
1450 the official who appointed that member. The board shall appoint
1451 an executive director, who is responsible for other staff
1452 authorized by the board.
1453 (c) Board members are entitled to receive, from funds of
1454 the corporation, reimbursement for per diem and travel expenses
1455 as provided by s. 112.061.
1456 (d) There shall be no liability on the part of, and no
1457 cause of action shall arise against, any member of the board of
1458 directors, or its employees or agents, for any action they take
1459 in the performance of their powers and duties under this act.
1460 (e) Terms for board members appointed under this act are
1461 effective January 1, 2016.
1462 (7) LICENSING NOT REQUIRED; FISCAL OPERATION.—
1463 (a) The corporation shall not be deemed an insurer. The
1464 officers, directors, and employees of the corporation shall not
1465 be deemed to be agents of an insurer. Neither the corporation
1466 nor any officer, director, or employee of the corporation is
1467 subject to the licensing requirements of the insurance code or
1468 the rules of the Department of Financial Services. However, any
1469 marketing representative utilized and compensated by the
1470 corporation must be appointed as a representative of the
1471 insurers or health services providers with which the corporation
1472 contracts.
1473 (b) The board has complete fiscal control over the
1474 corporation and is responsible for all corporate operations.
1475 (c) The Department of Financial Services shall supervise
1476 any liquidation or dissolution of the corporation and shall
1477 have, with respect to such liquidation or dissolution, all power
1478 granted to it pursuant to the insurance code.
1479 (8) TRANSITION PLANS.—The corporation shall confer with the
1480 Agency for Health Care Administration, the Department of
1481 Children and Families, and Florida Health Choices, Inc., to
1482 develop transition plans for the Florida Health Insurance
1483 Affordability Exchange Program as created under ss. 409.72
1484 409.731.
1485 Section 18. Section 624.915, Florida Statutes, is repealed.
1486 Section 19. The Division of Law Revision and Information is
1487 directed to replace the phrase “the effective date of this act”
1488 wherever it occurs in this act with the date the act becomes a
1489 law.
1490 Section 20. If any law amended by this act was also amended
1491 by a law enacted during the 2015 Regular Session of the
1492 Legislature, such laws shall be construed as if enacted during
1493 the same session of the Legislature, and full effect shall be
1494 given to each if possible.
1495 Section 21. This act shall take effect upon becoming a law.
