Bill Text: FL S2512 | 2015 | Regular Session | Introduced
NOTE: There are more recent revisions of this legislation. Read Latest Draft
Bill Title: Medicaid
Spectrum: Committee Bill
Status: (Failed) 2015-05-01 - Died in returning Messages [S2512 Detail]
Download: Florida-2015-S2512-Introduced.html
Bill Title: Medicaid
Spectrum: Committee Bill
Status: (Failed) 2015-05-01 - Died in returning Messages [S2512 Detail]
Download: Florida-2015-S2512-Introduced.html
Florida Senate - 2015 SB 2512
By the Committee on Appropriations
576-02872-15 20152512__
1 A bill to be entitled
2 An act relating to Medicaid; amending s. 395.602,
3 F.S.; revising the term “rural hospital”; amending s.
4 409.908, F.S.; deleting provisions that authorized the
5 agency to receive funds from certain state entities,
6 local governments, and other political subdivisions
7 for a specific purpose; providing that the Agency for
8 Health Care Administration is authorized to receive
9 intergovernmental transfers of funds from governmental
10 entities for specified purposes; requiring the agency
11 to seek Medicaid waiver authority for the use of local
12 intergovernmental transfers under certain parameters;
13 revising the list of provider types that are subject
14 to certain statutory provisions relating to the
15 establishment of rates; amending s. 409.909, F.S.;
16 revising definitions; altering the annual allocation
17 cap for hospitals participating in the Statewide
18 Medicaid Residency Program; creating the Graduate
19 Medical Education Startup Bonus Program; providing
20 allocations for the program; amending s. 409.911,
21 F.S.; updating references to data used for calculating
22 disproportionate share program payments to certain
23 hospitals for the 2015-2016 fiscal year; repealing s.
24 409.97, F.S, relating to state and local Medicaid
25 partnerships; amending s. 409.983, F.S.; providing
26 parameters for the reconciliation of managed care plan
27 payments in the long-term care managed care program;
28 amending s. 408.07, F.S.; conforming a cross
29 reference; creating s. 409.720, F.S.; providing a
30 short title; creating s. 409.721, F.S.; creating the
31 Florida Health Insurance Affordability Exchange
32 Program or FHIX in the Agency for Health Care
33 Administration; providing program authority and
34 principles; creating s. 409.722, F.S.; defining terms;
35 creating s. 409.723, F.S.; providing eligibility and
36 enrollment criteria; providing patient rights and
37 responsibilities; providing premium levels; creating
38 s. 409.724, F.S.; providing for premium credits and
39 choice counseling; establishing an education campaign;
40 providing for customer support and disenrollment;
41 creating s. 409.725, F.S.; providing for available
42 products and services; creating s. 409.726, F.S.;
43 providing for program accountability; creating s.
44 409.727, F.S.; providing an implementation schedule;
45 creating s. 409.728, F.S.; providing program operation
46 and management duties; creating s. 409.729, F.S.;
47 providing for the development of a long-term
48 reorganization plan and the formation of the FHIX
49 Workgroup; creating s. 409.730, F.S.; authorizing the
50 agency to seek federal approval; creating s. 409.731,
51 F.S.; providing for program expiration; repealing s.
52 408.70, F.S., relating to legislative findings
53 regarding access to affordable health care; amending
54 s. 408.910, F.S.; revising legislative intent;
55 redefining terms; revising the scope of the Florida
56 Health Choices Program and the pricing of services
57 under the program; providing requirements for
58 operation of the marketplace; providing additional
59 duties for the corporation to perform; requiring an
60 annual report to the Governor and the Legislature;
61 amending s. 409.904, F.S.; establishing a date when
62 new enrollment in the Medically Needy program is
63 suspended; providing an expiration date for the
64 program; amending s. 624.91, F.S.; revising
65 eligibility requirements for state-funded assistance;
66 revising the duties and powers of the Florida Healthy
67 Kids Corporation; revising provisions for the
68 appointment of members of the board of the Florida
69 Healthy Kids Corporation; requiring transition plans;
70 repealing s. 624.915, F.S., relating to the operating
71 fund of the Florida Healthy Kids Corporation;
72 providing effective dates.
73
74 Be It Enacted by the Legislature of the State of Florida:
75
76 Section 1. Paragraph (e) of subsection (2) of section
77 395.602, Florida Statutes, is amended to read:
78 395.602 Rural hospitals.—
79 (2) DEFINITIONS.—As used in this part, the term:
80 (e) “Rural hospital” means an acute care hospital licensed
81 under this chapter, having 100 or fewer licensed beds and an
82 emergency room, which is:
83 1. The sole provider within a county with a population
84 density of up to 100 persons per square mile;
85 2. An acute care hospital, in a county with a population
86 density of up to 100 persons per square mile, which is at least
87 30 minutes of travel time, on normally traveled roads under
88 normal traffic conditions, from any other acute care hospital
89 within the same county;
90 3. A hospital supported by a tax district or subdistrict
91 whose boundaries encompass a population of up to 100 persons per
92 square mile;
93 4. A hospital classified as a sole community hospital under
94 42 C.F.R. s. 412.92 which has up to 340 licensed beds;
95 4.5. A hospital with a service area that has a population
96 of up to 100 persons per square mile. As used in this
97 subparagraph, the term “service area” means the fewest number of
98 zip codes that account for 75 percent of the hospital’s
99 discharges for the most recent 5-year period, based on
100 information available from the hospital inpatient discharge
101 database in the Florida Center for Health Information and Policy
102 Analysis at the agency; or
103 5.6. A hospital designated as a critical access hospital,
104 as defined in s. 408.07.
105
106 Population densities used in this paragraph must be based upon
107 the most recently completed United States census. A hospital
108 that received funds under s. 409.9116 for a quarter beginning no
109 later than July 1, 2002, is deemed to have been and shall
110 continue to be a rural hospital from that date through June 30,
111 2021 2015, if the hospital continues to have up to 100 licensed
112 beds and an emergency room. An acute care hospital that has not
113 previously been designated as a rural hospital and that meets
114 the criteria of this paragraph shall be granted such designation
115 upon application, including supporting documentation, to the
116 agency. A hospital that was licensed as a rural hospital during
117 the 2010-2011 or 2011-2012 fiscal year shall continue to be a
118 rural hospital from the date of designation through June 30,
119 2021 2015, if the hospital continues to have up to 100 licensed
120 beds and an emergency room.
121 Section 2. Effective upon this act becoming a law,
122 subsection (1) of section 409.908, Florida Statutes, is amended
123 to read:
124 409.908 Reimbursement of Medicaid providers.—Subject to
125 specific appropriations, the agency shall reimburse Medicaid
126 providers, in accordance with state and federal law, according
127 to methodologies set forth in the rules of the agency and in
128 policy manuals and handbooks incorporated by reference therein.
129 These methodologies may include fee schedules, reimbursement
130 methods based on cost reporting, negotiated fees, competitive
131 bidding pursuant to s. 287.057, and other mechanisms the agency
132 considers efficient and effective for purchasing services or
133 goods on behalf of recipients. If a provider is reimbursed based
134 on cost reporting and submits a cost report late and that cost
135 report would have been used to set a lower reimbursement rate
136 for a rate semester, then the provider’s rate for that semester
137 shall be retroactively calculated using the new cost report, and
138 full payment at the recalculated rate shall be effected
139 retroactively. Medicare-granted extensions for filing cost
140 reports, if applicable, shall also apply to Medicaid cost
141 reports. Payment for Medicaid compensable services made on
142 behalf of Medicaid eligible persons is subject to the
143 availability of moneys and any limitations or directions
144 provided for in the General Appropriations Act or chapter 216.
145 Further, nothing in this section shall be construed to prevent
146 or limit the agency from adjusting fees, reimbursement rates,
147 lengths of stay, number of visits, or number of services, or
148 making any other adjustments necessary to comply with the
149 availability of moneys and any limitations or directions
150 provided for in the General Appropriations Act, provided the
151 adjustment is consistent with legislative intent.
152 (1) Reimbursement to hospitals licensed under part I of
153 chapter 395 must be made prospectively or on the basis of
154 negotiation.
155 (a) Reimbursement for inpatient care is limited as provided
156 in s. 409.905(5), except as otherwise provided in this
157 subsection.
158 1. If authorized by the General Appropriations Act, the
159 agency may modify reimbursement for specific types of services
160 or diagnoses, recipient ages, and hospital provider types.
161 2. The agency may establish an alternative methodology to
162 the DRG-based prospective payment system to set reimbursement
163 rates for:
164 a. State-owned psychiatric hospitals.
165 b. Newborn hearing screening services.
166 c. Transplant services for which the agency has established
167 a global fee.
168 d. Recipients who have tuberculosis that is resistant to
169 therapy who are in need of long-term, hospital-based treatment
170 pursuant to s. 392.62.
171 3. The agency shall modify reimbursement according to other
172 methodologies recognized in the General Appropriations Act.
173
174 The agency may receive funds from state entities, including, but
175 not limited to, the Department of Health, local governments, and
176 other local political subdivisions, for the purpose of making
177 special exception payments, including federal matching funds,
178 through the Medicaid inpatient reimbursement methodologies.
179 Funds received for this purpose shall be separately accounted
180 for and may not be commingled with other state or local funds in
181 any manner. The agency may certify all local governmental funds
182 used as state match under Title XIX of the Social Security Act,
183 to the extent and in the manner authorized under the General
184 Appropriations Act and pursuant to an agreement between the
185 agency and the local governmental entity. In order for the
186 agency to certify such local governmental funds, a local
187 governmental entity must submit a final, executed letter of
188 agreement to the agency, which must be received by October 1 of
189 each fiscal year and provide the total amount of local
190 governmental funds authorized by the entity for that fiscal year
191 under this paragraph, paragraph (b), or the General
192 Appropriations Act. The local governmental entity shall use a
193 certification form prescribed by the agency. At a minimum, the
194 certification form must identify the amount being certified and
195 describe the relationship between the certifying local
196 governmental entity and the local health care provider. The
197 agency shall prepare an annual statement of impact which
198 documents the specific activities undertaken during the previous
199 fiscal year pursuant to this paragraph, to be submitted to the
200 Legislature annually by January 1.
201 (b) Reimbursement for hospital outpatient care is limited
202 to $1,500 per state fiscal year per recipient, except for:
203 1. Such care provided to a Medicaid recipient under age 21,
204 in which case the only limitation is medical necessity.
205 2. Renal dialysis services.
206 3. Other exceptions made by the agency.
207
208 The agency is authorized to receive funds from state entities,
209 including, but not limited to, the Department of Health, the
210 Board of Governors of the State University System, local
211 governments, and other local political subdivisions, for the
212 purpose of making payments, including federal matching funds,
213 through the Medicaid outpatient reimbursement methodologies.
214 Funds received from state entities and local governments for
215 this purpose shall be separately accounted for and shall not be
216 commingled with other state or local funds in any manner.
217 (c)1. The agency may receive intergovernmental transfers of
218 funds from governmental entities, including, but not limited to,
219 the Department of Health, local governments, and other local
220 political subdivisions, for the purpose of making special
221 exception payments or to enhance provider reimbursement,
222 including federal matching funds, through the Medicaid inpatient
223 or outpatient reimbursement methodologies. Funds received by
224 intergovernmental transfer for these purposes shall be
225 separately accounted for and may not be commingled with other
226 state or local funds in any manner. The agency may certify all
227 local intergovernmental transfers used as state match under
228 Title XIX of the Social Security Act to the extent and in the
229 manner authorized under the General Appropriations Act and
230 pursuant to an agreement between the agency and the local
231 governmental entity. In order for the agency to certify such
232 local intergovernmental transfers, a local governmental entity
233 must submit a final, executed letter of agreement to the agency
234 which must be received by October 1 of each fiscal year and
235 provide the total amount of intergovernmental transfers
236 authorized by the entity for that fiscal year under this
237 paragraph or the General Appropriations Act. The local
238 governmental entity shall use a certification form prescribed by
239 the agency. At a minimum, the certification form must identify
240 the amount being certified.
241 2. The agency shall seek Medicaid waiver authority to use
242 local intergovernmental transfers for the advancement of the
243 Medicaid program and for enhancing or supplementing provider
244 reimbursement under this part and part IV in ways that incent
245 donations of local intergovernmental transfers and prevent
246 providers from being penalized in the calculations of Medicaid
247 cost limits by virtue of having donated intergovernmental
248 transfers under waiver authority granted under this paragraph.
249 The agency shall prepare an annual statement of impact which
250 documents the specific activities undertaken during the previous
251 fiscal year pursuant to this paragraph, to be submitted to the
252 Legislature annually by January 1.
253 (d)(c) Hospitals that provide services to a
254 disproportionate share of low-income Medicaid recipients, or
255 that participate in the regional perinatal intensive care center
256 program under chapter 383, or that participate in the statutory
257 teaching hospital disproportionate share program may receive
258 additional reimbursement. The total amount of payment for
259 disproportionate share hospitals shall be fixed by the General
260 Appropriations Act. The computation of these payments must be
261 made in compliance with all federal regulations and the
262 methodologies described in ss. 409.911 and 409.9113.
263 (e)(d) The agency is authorized to limit inflationary
264 increases for outpatient hospital services as directed by the
265 General Appropriations Act.
266 Section 3. Paragraph (c) of subsection (23) of section
267 409.908, Florida Statutes, is amended to read:
268 409.908 Reimbursement of Medicaid providers.—Subject to
269 specific appropriations, the agency shall reimburse Medicaid
270 providers, in accordance with state and federal law, according
271 to methodologies set forth in the rules of the agency and in
272 policy manuals and handbooks incorporated by reference therein.
273 These methodologies may include fee schedules, reimbursement
274 methods based on cost reporting, negotiated fees, competitive
275 bidding pursuant to s. 287.057, and other mechanisms the agency
276 considers efficient and effective for purchasing services or
277 goods on behalf of recipients. If a provider is reimbursed based
278 on cost reporting and submits a cost report late and that cost
279 report would have been used to set a lower reimbursement rate
280 for a rate semester, then the provider’s rate for that semester
281 shall be retroactively calculated using the new cost report, and
282 full payment at the recalculated rate shall be effected
283 retroactively. Medicare-granted extensions for filing cost
284 reports, if applicable, shall also apply to Medicaid cost
285 reports. Payment for Medicaid compensable services made on
286 behalf of Medicaid eligible persons is subject to the
287 availability of moneys and any limitations or directions
288 provided for in the General Appropriations Act or chapter 216.
289 Further, nothing in this section shall be construed to prevent
290 or limit the agency from adjusting fees, reimbursement rates,
291 lengths of stay, number of visits, or number of services, or
292 making any other adjustments necessary to comply with the
293 availability of moneys and any limitations or directions
294 provided for in the General Appropriations Act, provided the
295 adjustment is consistent with legislative intent.
296 (23)
297 (c) This subsection applies to the following provider
298 types:
299 1. Inpatient hospitals.
300 2. Outpatient hospitals.
301 3. Nursing homes.
302 4. County health departments.
303 5. Community intermediate care facilities for the
304 developmentally disabled.
305 5.6. Prepaid health plans.
306 Section 4. Section 409.909, Florida Statutes, is amended to
307 read:
308 409.909 Statewide Medicaid Residency Program.—
309 (1) The Statewide Medicaid Residency Program is established
310 to improve the quality of care and access to care for Medicaid
311 recipients, expand graduate medical education on an equitable
312 basis, and increase the supply of highly trained physicians
313 statewide. The agency shall make payments to hospitals licensed
314 under part I of chapter 395 for graduate medical education
315 associated with the Medicaid program. This system of payments is
316 designed to generate federal matching funds under Medicaid and
317 distribute the resulting funds to participating hospitals on a
318 quarterly basis in each fiscal year for which an appropriation
319 is made.
320 (2) On or before September 15 of each year, the agency
321 shall calculate an allocation fraction to be used for
322 distributing funds to participating hospitals. On or before the
323 final business day of each quarter of a state fiscal year, the
324 agency shall distribute to each participating hospital one
325 fourth of that hospital’s annual allocation calculated under
326 subsection (4). The allocation fraction for each participating
327 hospital is based on the hospital’s number of full-time
328 equivalent residents and the amount of its Medicaid payments. As
329 used in this section, the term:
330 (a) “Full-time equivalent,” or “FTE,” means a resident who
331 is in his or her residency period, with the initial residency
332 period, which is defined as the minimum number of years of
333 training required before the resident may become eligible for
334 board certification by the American Osteopathic Association
335 Bureau of Osteopathic Specialists or the American Board of
336 Medical Specialties in the specialty in which he or she first
337 began training, not to exceed 5 years. The residency specialty
338 is defined as reported using the current resident code in the
339 Intern and Resident Information System (IRIS), required by
340 Medicare. A resident training beyond the initial residency
341 period is counted as 0.5 FTE, unless his or her chosen specialty
342 is in general surgery or primary care, in which case the
343 resident is counted as 1.0 FTE. For the purposes of this
344 section, primary care specialties include:
345 1. Family medicine;
346 2. General internal medicine;
347 3. General pediatrics;
348 4. Preventive medicine;
349 5. Geriatric medicine;
350 6. Osteopathic general practice;
351 7. Obstetrics and gynecology; and
352 8. Emergency medicine; and
353 9. General surgery.
354 (b) “Medicaid payments” means the estimated total payments
355 for reimbursing a hospital for direct inpatient services for the
356 fiscal year in which the allocation fraction is calculated based
357 on the hospital inpatient appropriation and the parameters for
358 the inpatient diagnosis-related group base rate, including
359 applicable intergovernmental transfers, specified in the General
360 Appropriations Act, as determined by the agency.
361 (c) “Resident” means a medical intern, fellow, or resident
362 enrolled in a program accredited by the Accreditation Council
363 for Graduate Medical Education, the American Association of
364 Colleges of Osteopathic Medicine, or the American Osteopathic
365 Association at the beginning of the state fiscal year during
366 which the allocation fraction is calculated, as reported by the
367 hospital to the agency.
368 (3) The agency shall use the following formula to calculate
369 a participating hospital’s allocation fraction:
370
371 HAF=[0.9 x (HFTE/TFTE)] + [0.1 x (HMP/TMP)]
372
373 Where:
374 HAF=A hospital’s allocation fraction.
375 HFTE=A hospital’s total number of FTE residents.
376 TFTE=The total FTE residents for all participating
377 hospitals.
378 HMP=A hospital’s Medicaid payments.
379 TMP=The total Medicaid payments for all participating
380 hospitals.
381
382 (4) A hospital’s annual allocation shall be calculated by
383 multiplying the funds appropriated for the Statewide Medicaid
384 Residency Program in the General Appropriations Act by that
385 hospital’s allocation fraction. If the calculation results in an
386 annual allocation that exceeds 2 times the average $50,000 per
387 FTE resident amount for all hospitals, the hospital’s annual
388 allocation shall be reduced to a sum equaling no more than 2
389 times the average $50,000 per FTE resident. The funds calculated
390 for that hospital in excess of 2 times the average $50,000 per
391 FTE resident amount for all hospitals shall be redistributed to
392 participating hospitals whose annual allocation does not exceed
393 2 times the average $50,000 per FTE resident amount for all
394 hospitals, using the same methodology and payment schedule
395 specified in this section.
396 (5) Graduate Medical Education Startup Bonus Program—
397 Hospitals eligible for participation in subsection (1) are
398 eligible to participate in the graduate medical education
399 startup bonus program established under this subsection.
400 Notwithstanding subsection (4) or an FTE’s residency period, and
401 in any state fiscal year in which funds are appropriated for the
402 startup bonus program, the agency shall allocate a $100,000
403 startup bonus for each newly created resident position that is
404 authorized by the Accreditation Council for Graduate Medical
405 Education or Osteopathic Postdoctoral Training Institution in an
406 initial or established accredited training program that is in a
407 physician specialty in statewide supply/demand deficit. In any
408 year in which funding is not sufficient to provide $100,000 for
409 each newly created resident position, funding shall be reduced
410 pro rata across all newly created resident positions in
411 physician specialties in statewide supply/demand deficit.
412 (a) Hospitals applying for a startup bonus must submit to
413 the agency by March 1 their Accreditation Council for Graduate
414 Medical Education or Osteopathic Postdoctoral Training
415 Institution approval validating the new resident positions
416 approved in physician specialties in statewide supply/demand
417 deficit in the current fiscal year. An applicant hospital may
418 validate a change in the number of residents by comparing the
419 prior period Accreditation Council for Graduate Medical
420 Education or Osteopathic Postdoctoral Training Institution
421 approval to the current year.
422 (b) Any unobligated startup bonus funds on April 15 of each
423 fiscal year shall be proportionally allocated to hospitals
424 participating under subsection (3) for existing FTE residents in
425 the physician specialties in statewide supply/demand deficit.
426 This nonrecurring allocation shall be in addition to the funds
427 allocated in subsection (4). Notwithstanding subsection (4), the
428 allocation under this subsection shall not exceed $100,000 per
429 FTE resident.
430 (c) For purposes of this subsection, physician specialties
431 and subspecialties, both adult and pediatric, in statewide
432 supply/demand deficit are those identified in the General
433 Appropriations Act.
434 (d) The agency shall distribute all funds authorized under
435 the Graduate Medical Education Startup Bonus program on or
436 before the final business day of the fourth quarter of a state
437 fiscal year.
438 (6)(5) Beginning in the 2015-2016 state fiscal year, the
439 agency shall reconcile each participating hospital’s total
440 number of FTE residents calculated for the state fiscal year 2
441 years prior with its most recently available Medicare cost
442 reports covering the same time period. Reconciled FTE counts
443 shall be prorated according to the portion of the state fiscal
444 year covered by a Medicare cost report. Using the same
445 definitions, methodology, and payment schedule specified in this
446 section, the reconciliation shall apply any differences in
447 annual allocations calculated under subsection (4) to the
448 current year’s annual allocations.
449 (7)(6) The agency may adopt rules to administer this
450 section.
451 Section 5. Paragraph (a) of subsection (2) of section
452 409.911, Florida Statutes, is amended to read:
453 409.911 Disproportionate share program.—Subject to specific
454 allocations established within the General Appropriations Act
455 and any limitations established pursuant to chapter 216, the
456 agency shall distribute, pursuant to this section, moneys to
457 hospitals providing a disproportionate share of Medicaid or
458 charity care services by making quarterly Medicaid payments as
459 required. Notwithstanding the provisions of s. 409.915, counties
460 are exempt from contributing toward the cost of this special
461 reimbursement for hospitals serving a disproportionate share of
462 low-income patients.
463 (2) The Agency for Health Care Administration shall use the
464 following actual audited data to determine the Medicaid days and
465 charity care to be used in calculating the disproportionate
466 share payment:
467 (a) The average of the 2005, 2006, and 2007, 2008, and 2009
468 audited disproportionate share data to determine each hospital’s
469 Medicaid days and charity care for the 2015-2016 2014-2015 state
470 fiscal year.
471 Section 6. Section 409.97, Florida Statutes, is repealed.
472 Section 7. Subsection (6) of section 409.983, Florida
473 Statutes, is amended to read:
474 409.983 Long-term care managed care plan payment.—In
475 addition to the payment provisions of s. 409.968, the agency
476 shall provide payment to plans in the long-term care managed
477 care program pursuant to this section.
478 (6) The agency shall establish nursing-facility-specific
479 payment rates for each licensed nursing home based on facility
480 costs adjusted for inflation and other factors as authorized in
481 the General Appropriations Act. Payments to long-term care
482 managed care plans shall be reconciled to reimburse actual
483 payments to nursing facilities resulting from changes in nursing
484 home per diem rates but may not be reconciled to actual days
485 experienced by the long-term care managed care plans.
486 Section 8. Subsection (43) of section 408.07, Florida
487 Statutes, is amended to read:
488 408.07 Definitions.—As used in this chapter, with the
489 exception of ss. 408.031-408.045, the term:
490 (43) “Rural hospital” means an acute care hospital licensed
491 under chapter 395, having 100 or fewer licensed beds and an
492 emergency room, and which is:
493 (a) The sole provider within a county with a population
494 density of no greater than 100 persons per square mile;
495 (b) An acute care hospital, in a county with a population
496 density of no greater than 100 persons per square mile, which is
497 at least 30 minutes of travel time, on normally traveled roads
498 under normal traffic conditions, from another acute care
499 hospital within the same county;
500 (c) A hospital supported by a tax district or subdistrict
501 whose boundaries encompass a population of 100 persons or fewer
502 per square mile;
503 (d) A hospital with a service area that has a population of
504 100 persons or fewer per square mile. As used in this paragraph,
505 the term “service area” means the fewest number of zip codes
506 that account for 75 percent of the hospital’s discharges for the
507 most recent 5-year period, based on information available from
508 the hospital inpatient discharge database in the Florida Center
509 for Health Information and Policy Analysis at the Agency for
510 Health Care Administration; or
511 (e) A critical access hospital.
512
513 Population densities used in this subsection must be based upon
514 the most recently completed United States census. A hospital
515 that received funds under s. 409.9116 for a quarter beginning no
516 later than July 1, 2002, is deemed to have been and shall
517 continue to be a rural hospital from that date through June 30,
518 2015, if the hospital continues to have 100 or fewer licensed
519 beds and an emergency room, or meets the criteria of s.
520 395.602(2)(e)4. An acute care hospital that has not previously
521 been designated as a rural hospital and that meets the criteria
522 of this subsection shall be granted such designation upon
523 application, including supporting documentation, to the Agency
524 for Health Care Administration.
525 Section 9. Effective upon this act becoming a law, the
526 Division of Law Revision and Information is directed to rename
527 part II of chapter 409, Florida Statutes, as “Insurance
528 Affordability Programs” and to incorporate ss. 409.720-409.731,
529 Florida Statutes, under this part.
530 Section 10. Effective upon this act becoming a law, section
531 409.720, Florida Statutes, is created to read:
532 409.720 Short title.—Sections 409.720-409.731 may be cited
533 as the “Florida Health Insurance Affordability Exchange Program”
534 or “FHIX.”
535 Section 11. Effective upon this act becoming a law, section
536 409.721, Florida Statutes, is created to read:
537 409.721 Program authority.—The Florida Health Insurance
538 Affordability Exchange Program, or FHIX, is created in the
539 agency to assist Floridians in purchasing health benefits
540 coverage and gaining access to health services. The products and
541 services offered by FHIX are based on the following principles:
542 (1) FAIR VALUE.—Financial assistance will be rationally
543 allocated regardless of differences in categorical eligibility.
544 (2) CONSUMER CHOICE.—Participants will be offered
545 meaningful choices in the way they can redeem the value of the
546 available assistance.
547 (3) SIMPLICITY.—Obtaining assistance will be consumer
548 friendly, and customer support will be available when needed.
549 (4) PORTABILITY.—Participants can continue to access the
550 services and products of FHIX despite changes in their
551 circumstances.
552 (5) PROMOTES EMPLOYMENT.—Assistance will be offered in a
553 way that incentivizes employment.
554 (6) CONSUMER EMPOWERMENT.—Assistance will be offered in a
555 manner that maximizes individual control over available
556 resources.
557 (7) RISK ADJUSTMENT.—The amount of assistance will reflect
558 participants’ medical risk.
559 Section 12. Effective upon this act becoming a law, section
560 409.722, Florida Statutes, is created to read:
561 409.722 Definitions.—As used in ss. 409.720-409.731, the
562 term:
563 (1) “Agency” means the Agency for Health Care
564 Administration.
565 (2) “Applicant” means an individual who applies for
566 determination of eligibility for health benefits coverage under
567 this part.
568 (3) “Corporation” means Florida Health Choices, Inc., as
569 established under s. 408.910.
570 (4) “Enrollee” means an individual who has been determined
571 eligible for and is receiving health benefits coverage under
572 this part.
573 (5) “FHIX marketplace” or “marketplace” means the single,
574 centralized market established under s. 408.910 which
575 facilitates health benefits coverage.
576 (6) “Florida Health Insurance Affordability Exchange
577 Program” or “FHIX” means the program created under ss. 409.720
578 409.731.
579 (7) “Florida Healthy Kids Corporation” means the entity
580 created under s. 624.91.
581 (8) “Florida Kidcare program” or “Kidcare program” means
582 the health benefits coverage administered through ss. 409.810
583 409.821.
584 (9) “Health benefits coverage” means the payment of
585 benefits for covered health care services or the availability,
586 directly or through arrangements with other persons, of covered
587 health care services on a prepaid per capita basis or on a
588 prepaid aggregate fixed-sum basis.
589 (10) “Inactive status” means the enrollment status of a
590 participant previously enrolled in health benefits coverage
591 through the FHIX marketplace who lost coverage through the
592 marketplace for non-payment, but maintains access to his or her
593 balance in a health savings account or health reimbursement
594 account.
595 (11) “Medicaid” means the medical assistance program
596 authorized by Title XIX of the Social Security Act, and
597 regulations thereunder, and part III and part IV of this
598 chapter, as administered in this state by the agency.
599 (l2) “Modified adjusted gross income” means the
600 individual’s or household’s annual adjusted gross income as
601 defined in s. 36B(d)(2) of the Internal Revenue Code of 1986 and
602 which is used to determine eligibility for FHIX.
603 (13) “Patient Protection and Affordable Care Act” or
604 “Affordable Care Act” means Pub. L. No. 111-148, as further
605 amended by the Health Care and Education Reconciliation Act of
606 2010, Pub. L. No. 111-152, and any amendments to, and
607 regulations or guidance under, those acts.
608 (14) “Premium credit” means the monthly amount paid by the
609 agency per enrollee in the Florida Health Insurance
610 Affordability Exchange Program toward health benefits coverage.
611 (15) “Qualified alien” means an alien as defined in 8
612 U.S.C. s. 1641(b) or (c).
613 (16) “Resident” means a United States citizen or qualified
614 alien who is domiciled in this state.
615 Section 13. Effective upon this act becoming a law, section
616 409.723, Florida Statutes, is created to read:
617 409.723 Participation.—
618 (1) ELIGIBILITY.—In order to participate in FHIX, an
619 individual must be a resident and must meet the following
620 requirements, as applicable:
621 (a) Qualify as a newly eligible enrollee, who must be an
622 individual as described in s. 1902(a)(10)(A)(i)(VIII) of the
623 Social Security Act or s. 2001 of the Affordable Care Act and as
624 may be further defined by federal regulation.
625 (b) Meet and maintain the responsibilities under subsection
626 (4).
627 (c) Qualify as a participant in the Florida Healthy Kids
628 program under s. 624.91, subject to the implementation of Phase
629 Three under s. 409.727.
630 (2) ENROLLMENT.—To enroll in FHIX, an applicant must submit
631 an application to the department for an eligibility
632 determination.
633 (a) Applications may be submitted by mail, fax, online, or
634 any other method permitted by law or regulation.
635 (b) The department is responsible for any eligibility
636 correspondence and status updates to the participant and other
637 agencies.
638 (c) The department shall review a participant’s eligibility
639 every 12 months.
640 (d) An application or renewal is deemed complete when the
641 participant has met all the requirements under subsection (4).
642 (3) PARTICIPANT RIGHTS.—A participant has all of the
643 following rights:
644 (a) Access to the FHIX marketplace to select the scope,
645 amount, and type of health care coverage and other services to
646 purchase.
647 (b) Continuity and portability of coverage to avoid
648 disruption of coverage and other health care services when the
649 participant’s economic circumstances change.
650 (c) Retention of applicable unspent credits in the
651 participant’s health savings or health reimbursement account
652 following a change in the participant’s eligibility status.
653 Credits are valid for an inactive status participant for up to 5
654 years after the participant first enters an inactive status.
655 (d) Ability to select more than one product or plan on the
656 FHIX marketplace.
657 (e) Choice of at least two health benefits products that
658 meet the requirements of the Affordable Care Act.
659 (4) PARTICIPANT RESPONSIBILITIES.—A participant has all of
660 the following responsibilities:
661 (a) Complete an initial application for health benefits
662 coverage and an annual renewal process;
663 (b) Annually provide evidence of participation in one of
664 the following activities at the levels required under paragraph
665 (c):
666 1. Proof of employment.
667 2. On-the-job training or job placement activities.
668 3. Pursuit of educational opportunities.
669 (c) Engage in the activities required under paragraph (b)
670 at the following minimum levels:
671 1. For a parent of a child younger than 18 years of age, a
672 minimum of 20 hours weekly.
673 2. For a childless adult, a minimum of 30 hours weekly.
674
675 A participant who is a disabled adult or a caregiver of a
676 disabled child or adult may submit a request for an exception to
677 these requirements to the corporation and, thereafter, shall
678 annually submit to the department a request to renew the
679 exception to the hourly level requirements.
680 (d) Learn and remain informed about the choices available
681 on the FHIX marketplace and the uses of credits in the
682 individual accounts.
683 (e) Execute a contract with the department to acknowledge
684 that:
685 1. FHIX is not an entitlement and state and federal funding
686 may end at any time;
687 2. Failure to pay required premiums or cost sharing will
688 result in a transition to inactive status; and
689 3. Noncompliance with work or educational requirements will
690 result in a transition to inactive status.
691 (f) Select plans and other products in a timely manner.
692 (g) Comply with program rules and the prohibitions against
693 fraud, as described in s. 414.39.
694 (h) Timely make monthly premium and any other cost-sharing
695 payments.
696 (i) Meet minimum coverage requirements by selecting a high
697 deductible health plan combined with a health savings or health
698 reimbursement account if not selecting a plan offering more
699 extensive coverage.
700 (5) COST SHARING.—
701 (a) Enrollees are assessed monthly premiums based on their
702 modified adjusted gross income. The maximum monthly premium
703 payments are set at the following income levels:
704 1. At or below 22 percent of the federal poverty level: $3.
705 2. Greater than 22 percent, but at or below 50 percent, of
706 the federal poverty level: $8.
707 3. Greater than 50 percent, but at or below 75 percent, of
708 the federal poverty level: $15.
709 4. Greater than 75 percent, but at or below 100 percent, of
710 the federal poverty level: $20.
711 5. Greater than 100 percent of the federal poverty level:
712 $25.
713 (b) Depending on the products and services selected by the
714 enrollee, the enrollee may also incur additional cost-sharing,
715 such as copayments, deductibles, or other out-of-pocket costs.
716 (c) An enrollee may be subject to an inappropriate
717 emergency room visit charge of up to $8 for the first visit and
718 up to $25 for any subsequent visit, based on the enrollee’s
719 benefit plan, to discourage inappropriate use of the emergency
720 room.
721 (d) Cumulative annual cost sharing per enrollee may not
722 exceed 5 percent of an enrollee’s annual modified adjusted gross
723 income.
724 (e) If, after a 30-day grace period, a full premium payment
725 has not been received, the enrollee shall be transitioned from
726 coverage to inactive status and may not reenroll for a minimum
727 of 6 months, unless a hardship exception has been granted.
728 Enrollees may seek a hardship exception under the Medicaid Fair
729 Hearing Process.
730 Section 14. Effective upon this act becoming a law, section
731 409.724, Florida Statutes, is created to read:
732 409.724 Available assistance.—
733 (1) PREMIUM CREDITS.—
734 (a) Standard amount.—The standard monthly premium credit is
735 equivalent to the applicable risk-adjusted capitation rate paid
736 to Medicaid managed care plans under part IV of this chapter.
737 (b) Supplemental funding.—Subject to federal approval,
738 additional resources may be made available to enrollees and
739 incorporated into FHIX.
740 (c) Savings accounts.—In addition to the benefits provided
741 under this section, the corporation must offer each enrollee
742 access to an individual account that qualifies as a health
743 reimbursement account or a health savings account. Eligible
744 unexpended funds from the monthly premium credit must be
745 deposited into each enrollee’s individual account in a timely
746 manner. Enrollees may also be rewarded for healthy behaviors,
747 adherence to wellness programs, and other activities established
748 by the corporation which demonstrate compliance with prevention
749 or disease management guidelines. Funds deposited into these
750 accounts may be used to pay cost-sharing obligations or to
751 purchase other health-related items to the extent permitted
752 under federal law.
753 (d) Enrollee contributions.—The enrollee may make deposits
754 to his or her account at any time to supplement the premium
755 credit, to purchase additional FHIX products, or to offset other
756 cost-sharing obligations.
757 (e) Third parties.—Third parties, including, but not
758 limited to, an employer or relative, may also make deposits on
759 behalf of the enrollee into the enrollee’s FHIX marketplace
760 account. The enrollee may not withdraw any funds as a refund,
761 except those funds the enrollee has deposited into his or her
762 account.
763 (2) CHOICE COUNSELING.—The agency and the corporation shall
764 work together to develop a choice counseling program for FHIX.
765 The choice counseling program must ensure that participants have
766 information about the FHIX marketplace program, products, and
767 services and that participants know where and whom to call for
768 questions or to make their plan selections. The choice
769 counseling program must provide culturally sensitive materials
770 and must take into consideration the demographics of the
771 projected population.
772 (3) EDUCATION CAMPAIGN.—The agency, the corporation, and
773 the Florida Healthy Kids Corporation must coordinate an ongoing
774 enrollee education campaign beginning in Phase One, as provided
775 in s. 409.27, informing participants, at a minimum:
776 (a) How the transition process to the FHIX marketplace will
777 occur and the timeline for the enrollee’s specific transition.
778 (b) What plans are available and how to research
779 information about available plans.
780 (c) Information about other available insurance
781 affordability programs for the individual and his or her family.
782 (d) Information about health benefits coverage, provider
783 networks, and cost sharing for available plans in each region.
784 (e) Information on how to complete the required annual
785 renewal process, including renewal dates and deadlines.
786 (f) Information on how to update eligibility if the
787 participant’s data have changed since his or her last renewal or
788 application date.
789 (4) CUSTOMER SUPPORT.—Beginning in Phase Two, the Florida
790 Healthy Kids Corporation shall provide customer support for
791 FHIX, shall address general program information, financial
792 information, and customer service issues, and shall provide
793 status updates on bill payments. Customer support must also
794 provide a toll-free number and maintain a website that is
795 available in multiple languages and that meets the needs of the
796 enrollee population.
797 (5) INACTIVE PARTICIPANTS.—The corporation must inform the
798 inactive participant about other insurance affordability
799 programs and electronically refer the participant to the federal
800 exchange or other insurance affordability programs, as
801 appropriate.
802 Section 15. Effective upon this act becoming a law, section
803 409.725, Florida Statutes, is created to read:
804 409.725 Available products and services.—The FHIX
805 marketplace shall offer the following products and services:
806 (1) Authorized products and services pursuant to s.
807 408.910.
808 (2) Medicaid managed care plans under part IV of this
809 chapter.
810 (3) Authorized products under the Florida Healthy Kids
811 Corporation pursuant to s. 624.91.
812 (4) Employer-sponsored plans.
813 Section 16. Effective upon this act becoming a law, section
814 409.726, Florida Statutes, is created to read:
815 409.726 Program accountability.—
816 (1) All managed care plans that participate in FHIX must
817 collect and maintain encounter level data in accordance with the
818 encounter data requirements under s. 409.967(2)(d) and are
819 subject to the accompanying penalties under s. 409.967(2)(h)2.
820 The agency is responsible for the collection and maintenance of
821 the encounter level data.
822 (2) The corporation, in consultation with the agency, shall
823 establish access and network standards for contracts on the FHIX
824 marketplace and shall ensure that contracted plans have
825 sufficient providers to meet enrollee needs. The corporation, in
826 consultation with the agency, shall develop quality of coverage
827 and provider standards specific to the adult population.
828 (3) The department shall develop accountability measures
829 and performance standards to be applied to applications and
830 renewal applications for FHIX which are submitted online, by
831 mail, by fax, or through referrals from a third party. The
832 minimum performance standards are:
833 (a) Application processing speed.—Ninety percent of all
834 applications, from all sources, must be processed within 45
835 days.
836 (b) Applications processing speed from online sources.
837 Ninety-five percent of all applications received from online
838 sources must be processed within 45 days.
839 (c) Renewal application processing speed.—Ninety percent of
840 all renewals, from all sources, must be processed within 45
841 days.
842 (d) Renewal application processing speed from online
843 sources.—Ninety-five percent of all applications received from
844 online sources must be processed within 45 days.
845 (4) The agency, the department, and the Florida Healthy
846 Kids Corporation must meet the following standards for their
847 respective roles in the program:
848 (a) Eighty-five percent of calls must be answered in 20
849 seconds or less.
850 (b) One hundred percent of all contacts, which include, but
851 are not limited to, telephone calls, faxed documents and
852 requests, and e-mails, must be handled within 2 business days.
853 (c) Any self-service tools available to participants, such
854 as interactive voice response systems, must be operational 7
855 days a week, 24 hours a day, at least 98 percent of each month.
856 (5) The agency, the department, and the Florida Healthy
857 Kids Corporation must conduct an annual satisfaction survey to
858 address all measures that require participant input specific to
859 the FHIX marketplace program. The parties may elect to
860 incorporate these elements into the annual report required under
861 subsection (7).
862 (6) The agency and the corporation shall post online
863 monthly enrollment reports for FHIX.
864 (7) An annual report is due no later than July 1 to the
865 Governor, the President of the Senate, and the Speaker of the
866 House of Representatives. The annual report must be coordinated
867 by the agency and the corporation and must include, but is not
868 limited to:
869 (a) Enrollment and application trends and issues.
870 (b) Utilization and cost data.
871 (c) Customer satisfaction.
872 (d) Funding sources in health savings accounts or health
873 reimbursement accounts.
874 (e) Enrollee use of funds in health savings accounts or
875 health reimbursement accounts.
876 (f) Types of products and plans purchased.
877 (g) Movement of enrollees across different insurance
878 affordability programs.
879 (h) Recommendations for program improvement.
880 Section 17. Effective upon this act becoming a law, section
881 409.727, Florida Statutes, is created to read:
882 409.727 Implementation schedule.—The agency, the
883 corporation, the department, and the Florida Healthy Kids
884 Corporation shall begin implementation of FHIX immediately, with
885 statewide implementation in all regions, as described in s.
886 409.966(2), by January 1, 2016.
887 (1) READINESS REVIEW.—Before implementation of any phase
888 under this section, the agency shall conduct a readiness review
889 in consultation with the FHIX Workgroup described in s. 409.729.
890 The agency must determine, at a minimum, the following readiness
891 milestones:
892 (a) Functional readiness of the service delivery platform
893 for the phase.
894 (b) Plan availability and presence of plan choice.
895 (c) Provider network capacity and adequacy of the available
896 plans in the region.
897 (d) Availability of customer support.
898 (e) Other factors critical to the success of FHIX.
899 (2) PHASE ONE.—
900 (a) Phase One begins on July 1, 2015. The agency, the
901 corporation, the department, and the Florida Healthy Kids
902 Corporation shall coordinate activities to ensure that
903 enrollment begins by July 1, 2015.
904 (b) To be eligible during this phase, a participant must
905 meet the requirements under s. 409.723(1)(a).
906 (c) An enrollee is entitled to receive health benefits
907 coverage in the same manner as provided under and through the
908 selected managed care plans in the Medicaid managed care program
909 in part IV of this chapter.
910 (d) An enrollee shall have a choice of at least two managed
911 care plans in each region.
912 (e) Choice counseling and customer service must be provided
913 in accordance with s. 409.724(2).
914 (3) PHASE TWO.—
915 (a) Beginning no later than January 1, 2016, and contingent
916 upon federal approval, participants may enroll or transition to
917 health benefits coverage under the FHIX marketplace.
918 (b) To be eligible during this phase, a participant must
919 meet the requirements under s. 409.723(1)(a) and (b).
920 (c) An enrollee may select any benefit, service, or product
921 available.
922 (d) The corporation shall notify an enrollee of his or her
923 premium credit amount and how to access the FHIX marketplace
924 selection process.
925 (e) A Phase One enrollee must be transitioned to the FHIX
926 marketplace by April 1, 2016. An enrollee who does not select a
927 plan or service on the FHIX marketplace by that deadline shall
928 be moved to inactive status.
929 (f) An enrollee shall have a choice of at least two managed
930 care plans in each region which meet or exceed the Affordable
931 Care Act’s requirements and which qualify for a premium credit
932 on the FHIX marketplace.
933 (g) Choice counseling and customer service must be provided
934 in accordance with s. 409.724(2) and (4).
935 (4) PHASE THREE.—
936 (a) No later than July 1, 2016, the corporation and the
937 Florida Healthy Kids Corporation must begin the transition of
938 enrollees under s. 624.91 to the FHIX marketplace.
939 (b) Eligibility during this phase is based on meeting the
940 requirements of Phase Two and s. 409.723(1)(c).
941 (c) An enrollee may select any benefit, service, or product
942 available under s. 409.725.
943 (d) A Florida Healthy Kids enrollee who selects a FHIX
944 marketplace plan must be provided a premium credit equivalent to
945 the average capitation rate paid in his or her county of
946 residence under Florida Healthy Kids as of June 30, 2016. The
947 enrollee is responsible for any difference in costs and may use
948 any remaining funds for supplemental benefits on the FHIX
949 marketplace.
950 (e) The corporation shall notify an enrollee of his or her
951 premium credit amount and how to access the FHIX marketplace
952 selection process.
953 (f) Choice counseling and customer service must be provided
954 in accordance with s. 409.724(2) and (4).
955 (g) Enrollees under s. 624.91 must transition to the FHIX
956 marketplace by September 30, 2016.
957 Section 18. Effective upon this act becoming a law, section
958 409.728, Florida Statutes, is created to read:
959 409.728 Program operation and management.—In order to
960 implement ss. 409.720-409.731:
961 (1) The Agency for Health Care Administration shall do all
962 of the following:
963 (a) Contract with the corporation for the development,
964 implementation, and administration of the Florida Health
965 Insurance Affordability Exchange Program and for the release of
966 any federal, state, or other funds appropriated to the
967 corporation.
968 (b) Administer Phase One of FHIX.
969 (c) Provide administrative support to the FHIX Workgroup
970 under s. 409.729.
971 (d) Transition the FHIX enrollees to the FHIX marketplace
972 beginning January 1, 2016, in accordance with the transition
973 workplan. Stakeholders that serve low-income individuals and
974 families must be consulted during the implementation and
975 transition process through a public input process. All regions
976 must complete the transition no later than April 1, 2016.
977 (e) Timely transmit enrollee information to the
978 corporation.
979 (f) Beginning with Phase Two, determine annually the risk
980 adjusted rate to be paid per month based on historical
981 utilization and spending data for the medical and behavioral
982 health of this population, projected forward, and adjusted to
983 reflect the eligibility category, medical and dental trends,
984 geographic areas, and the clinical risk profile of the
985 enrollees.
986 (g) Transfer to the corporation such funds as approved in
987 the General Appropriations Act for the premium credits.
988 (h) Encourage Medicaid managed care plans to apply as
989 vendors to the marketplace to facilitate continuity of care and
990 family care coordination.
991 (2) The Department of Children and Families shall, in
992 coordination with the corporation, the agency, and the Florida
993 Healthy Kids Corporation, determine eligibility of applications
994 and application renewals for FHIX in accordance with s. 409.902
995 and shall transmit eligibility determination information on a
996 timely basis to the agency and corporation.
997 (3) The Florida Healthy Kids Corporation shall do all of
998 the following:
999 (a) Retain its duties and responsibilities under s. 624.91
1000 for Phase One and Phase Two of the program.
1001 (b) Provide customer service for the FHIX marketplace, in
1002 coordination with the agency and the corporation.
1003 (c) Transfer funds and provide financial support to the
1004 FHIX marketplace, including the collection of monthly cost
1005 sharing.
1006 (d) Conduct financial reporting related to such activities,
1007 in coordination with the corporation and the agency.
1008 (e) Coordinate activities for the program with the agency,
1009 the department, and the corporation.
1010 (4) Florida Health Choices, Inc., shall do all of the
1011 following:
1012 (a) Begin the development of FHIX during Phase One.
1013 (b) Implement and administer Phase Two and Phase Three of
1014 the FHIX marketplace and the ongoing operations of the program.
1015 (c) Offer health benefits coverage packages on the FHIX
1016 marketplace, including plans compliant with the Affordable Care
1017 Act.
1018 (d) Offer FHIX enrollees a choice of at least two plans per
1019 county at each benefit level which meet the requirements under
1020 the Affordable Care Act.
1021 (e) Provide an opportunity for participation in Medicaid
1022 managed care plans if those plans meet the requirements of the
1023 FHIX marketplace.
1024 (f) Offer enhanced or customized benefits to FHIX
1025 marketplace enrollees.
1026 (g) Provide sufficient staff and resources to meet the
1027 program needs of enrollees.
1028 (h) Provide an opportunity for plans contracted with or
1029 previously contracted with the Florida Healthy Kids Corporation
1030 under s. 624.91 to participate with FHIX if those plans meet the
1031 requirements of the program.
1032 (i) Encourage insurance agents licensed under chapter 626
1033 to identify and assist enrollees. This act does not prohibit
1034 these agents from receiving usual and customary commissions from
1035 insurers and health maintenance organizations that offer plans
1036 in the FHIX marketplace.
1037 Section 19. Effective upon this act becoming a law, section
1038 409.729, Florida Statutes, is created to read:
1039 409.729 Long-term reorganization.—The FHIX Workgroup is
1040 created to facilitate the implementation of FHIX and to plan for
1041 a multiyear reorganization of the state’s insurance
1042 affordability programs. The FHIX Workgroup consists of two
1043 representatives each from the agency, the department, the
1044 Florida Healthy Kids Corporation, and the corporation. An
1045 additional representative of the agency serves as chair. The
1046 FHIX Workgroup must hold its organizational meeting no later
1047 than 30 days after the effective date of this act and must meet
1048 at least bimonthly. The role of the FHIX Workgroup is to make
1049 recommendations to the agency. The responsibilities of the
1050 workgroup include, but are not limited to:
1051 (1) Recommend a Phase Two implementation plan no later than
1052 October 1, 2015.
1053 (2) Review network and access standards for plans and
1054 products.
1055 (3) Assess readiness and recommend actions needed to
1056 reorganize the state’s insurance affordability programs for each
1057 phase or region. If a phase or region receives a nonreadiness
1058 recommendation, the agency must notify the Legislature of that
1059 recommendation, the reasons for such a recommendation, and
1060 proposed plans for achieving readiness.
1061 (4) Recommend any proposed change to the Title XIX-funded
1062 or Title XXI-funded programs based on the continued availability
1063 and reauthorization of the Title XXI program and its federal
1064 funding.
1065 (5) Identify duplication of services among the corporation,
1066 the agency, and the Florida Healthy Kids Corporation currently
1067 and under FHIX’s proposed Phase Three program.
1068 (6) Evaluate any fiscal impacts based on the proposed
1069 transition plan under Phase Three.
1070 (7) Compile a schedule of impacted contracts, leases, and
1071 other assets.
1072 (8) Determine staff requirements for Phase Three.
1073 (9) Develop and present a final transition plan that
1074 incorporates all elements under this section no later than
1075 December 1, 2015, in a report to the Governor, the President of
1076 the Senate, and the Speaker of the House of Representatives.
1077 Section 20. Effective upon this act becoming a law, section
1078 409.730, Florida Statutes, is created to read:
1079 409.730 Federal participation.—The agency may seek federal
1080 approval to implement FHIX.
1081 Section 21. Effective upon this act becoming a law, section
1082 409.731, Florida Statutes, is created to read:
1083 409.731 Program expiration.—The Florida Health Insurance
1084 Affordability Exchange Program expires at the end of Phase One
1085 if the state does not receive federal approval for Phase Two or
1086 at the end of the state fiscal year in which any of these
1087 conditions occurs:
1088 (1) The federal match contribution falls below 90 percent.
1089 (2) The federal match contribution falls below the
1090 increased Federal Medical Assistance Percentage for medical
1091 assistance for newly eligible mandatory individuals as specified
1092 in the Affordable Care Act.
1093 (3) The federal match for the FHIX program and the Medicaid
1094 program are blended under federal law or regulation in such a
1095 manner that causes the overall federal contribution to diminish
1096 when compared to separate, nonblended federal contributions.
1097 Section 22. Effective upon this act becoming a law, section
1098 408.70, Florida Statutes, is repealed.
1099 Section 23. Effective upon this act becoming a law, section
1100 408.910, Florida Statutes, is amended to read:
1101 408.910 Florida Health Choices Program.—
1102 (1) LEGISLATIVE INTENT.—The Legislature finds that a
1103 significant number of the residents of this state do not have
1104 adequate access to affordable, quality health care. The
1105 Legislature further finds that increasing access to affordable,
1106 quality health care can be best accomplished by establishing a
1107 competitive market for purchasing health insurance and health
1108 services. It is therefore the intent of the Legislature to
1109 create and expand the Florida Health Choices Program to:
1110 (a) Expand opportunities for Floridians to purchase
1111 affordable health insurance and health services.
1112 (b) Preserve the benefits of employment-sponsored insurance
1113 while easing the administrative burden for employers who offer
1114 these benefits.
1115 (c) Enable individual choice in both the manner and amount
1116 of health care purchased.
1117 (d) Provide for the purchase of individual, portable health
1118 care coverage.
1119 (e) Disseminate information to consumers on the price and
1120 quality of health services.
1121 (f) Sponsor a competitive market that stimulates product
1122 innovation, quality improvement, and efficiency in the
1123 production and delivery of health services.
1124 (2) DEFINITIONS.—As used in this section, the term:
1125 (a) “Corporation” means the Florida Health Choices, Inc.,
1126 established under this section.
1127 (b) “Corporation’s marketplace” means the single,
1128 centralized market established by the program that facilitates
1129 the purchase of products made available in the marketplace.
1130 (c) “Florida Health Insurance Affordability Exchange
1131 Program” or “FHIX” is the program created under ss. 409.720
1132 409.731 for low-income, uninsured residents of this state.
1133 (d)(c) “Health insurance agent” means an agent licensed
1134 under part IV of chapter 626.
1135 (e)(d) “Insurer” means an entity licensed under chapter 624
1136 which offers an individual health insurance policy or a group
1137 health insurance policy, a preferred provider organization as
1138 defined in s. 627.6471, an exclusive provider organization as
1139 defined in s. 627.6472, or a health maintenance organization
1140 licensed under part I of chapter 641, or a prepaid limited
1141 health service organization or discount medical plan
1142 organization licensed under chapter 636, or a managed care plan
1143 contracted with the Agency for Health Care Administration under
1144 the managed medical assistance program under part IV of chapter
1145 409.
1146 (f) “Patient Protection and Affordable Care Act” or
1147 “Affordable Care Act” means Pub. L. No. 111-148, as further
1148 amended by the Health Care and Education Reconciliation Act of
1149 2010, Pub. L. No. 111-152, and any amendments to or regulations
1150 or guidance under those acts.
1151 (g)(e) “Program” means the Florida Health Choices Program
1152 established by this section.
1153 (3) PROGRAM PURPOSE AND COMPONENTS.—The Florida Health
1154 Choices Program is created as a single, centralized market for
1155 the sale and purchase of various products that enable
1156 individuals to pay for health care. These products include, but
1157 are not limited to, health insurance plans, health maintenance
1158 organization plans, prepaid services, service contracts, and
1159 flexible spending accounts. The components of the program
1160 include:
1161 (a) Enrollment of employers.
1162 (b) Administrative services for participating employers,
1163 including:
1164 1. Assistance in seeking federal approval of cafeteria
1165 plans.
1166 2. Collection of premiums and other payments.
1167 3. Management of individual benefit accounts.
1168 4. Distribution of premiums to insurers and payments to
1169 other eligible vendors.
1170 5. Assistance for participants in complying with reporting
1171 requirements.
1172 (c) Services to individual participants, including:
1173 1. Information about available products and participating
1174 vendors.
1175 2. Assistance with assessing the benefits and limits of
1176 each product, including information necessary to distinguish
1177 between policies offering creditable coverage and other products
1178 available through the program.
1179 3. Account information to assist individual participants
1180 with managing available resources.
1181 4. Services that promote healthy behaviors.
1182 5. Health benefits coverage information about health
1183 insurance plans compliant with the Affordable Care Act.
1184 6. Consumer assistance and enrollment services for the
1185 Florida Health Insurance Affordability Exchange Program, or
1186 FHIX.
1187 (d) Recruitment of vendors, including insurers, health
1188 maintenance organizations, prepaid clinic service providers,
1189 provider service networks, and other providers.
1190 (e) Certification of vendors to ensure capability,
1191 reliability, and validity of offerings.
1192 (f) Collection of data, monitoring, assessment, and
1193 reporting of vendor performance.
1194 (g) Information services for individuals and employers.
1195 (h) Program evaluation.
1196 (4) ELIGIBILITY AND PARTICIPATION.—Participation in the
1197 program is voluntary and shall be available to employers,
1198 individuals, vendors, and health insurance agents as specified
1199 in this subsection.
1200 (a) Employers eligible to enroll in the program include
1201 those employers that meet criteria established by the
1202 corporation and elect to make their employees eligible through
1203 the program.
1204 (b) Individuals eligible to participate in the program
1205 include:
1206 1. Individual employees of enrolled employers.
1207 2. Other individuals that meet criteria established by the
1208 corporation.
1209 (c) Employers who choose to participate in the program may
1210 enroll by complying with the procedures established by the
1211 corporation. The procedures must include, but are not limited
1212 to:
1213 1. Submission of required information.
1214 2. Compliance with federal tax requirements for the
1215 establishment of a cafeteria plan, pursuant to s. 125 of the
1216 Internal Revenue Code, including designation of the employer’s
1217 plan as a premium payment plan, a salary reduction plan that has
1218 flexible spending arrangements, or a salary reduction plan that
1219 has a premium payment and flexible spending arrangements.
1220 3. Determination of the employer’s contribution, if any,
1221 per employee, provided that such contribution is equal for each
1222 eligible employee.
1223 4. Establishment of payroll deduction procedures, subject
1224 to the agreement of each individual employee who voluntarily
1225 participates in the program.
1226 5. Designation of the corporation as the third-party
1227 administrator for the employer’s health benefit plan.
1228 6. Identification of eligible employees.
1229 7. Arrangement for periodic payments.
1230 8. Employer notification to employees of the intent to
1231 transfer from an existing employee health plan to the program at
1232 least 90 days before the transition.
1233 (d) All eligible vendors who choose to participate and the
1234 products and services that the vendors are permitted to sell are
1235 as follows:
1236 1. Insurers licensed under chapter 624 may sell health
1237 insurance policies, limited benefit policies, other risk-bearing
1238 coverage, and other products or services.
1239 2. Health maintenance organizations licensed under part I
1240 of chapter 641 may sell health maintenance contracts, limited
1241 benefit policies, other risk-bearing products, and other
1242 products or services.
1243 3. Prepaid limited health service organizations may sell
1244 products and services as authorized under part I of chapter 636,
1245 and discount medical plan organizations may sell products and
1246 services as authorized under part II of chapter 636.
1247 4. Prepaid health clinic service providers licensed under
1248 part II of chapter 641 may sell prepaid service contracts and
1249 other arrangements for a specified amount and type of health
1250 services or treatments.
1251 5. Health care providers, including hospitals and other
1252 licensed health facilities, health care clinics, licensed health
1253 professionals, pharmacies, and other licensed health care
1254 providers, may sell service contracts and arrangements for a
1255 specified amount and type of health services or treatments.
1256 6. Provider organizations, including service networks,
1257 group practices, professional associations, and other
1258 incorporated organizations of providers, may sell service
1259 contracts and arrangements for a specified amount and type of
1260 health services or treatments.
1261 7. Corporate entities providing specific health services in
1262 accordance with applicable state law may sell service contracts
1263 and arrangements for a specified amount and type of health
1264 services or treatments.
1265
1266 A vendor described in subparagraphs 3.-7. may not sell products
1267 that provide risk-bearing coverage unless that vendor is
1268 authorized under a certificate of authority issued by the Office
1269 of Insurance Regulation and is authorized to provide coverage in
1270 the relevant geographic area. Otherwise eligible vendors may be
1271 excluded from participating in the program for deceptive or
1272 predatory practices, financial insolvency, or failure to comply
1273 with the terms of the participation agreement or other standards
1274 set by the corporation.
1275 (e) Eligible individuals may participate in the program
1276 voluntarily. Individuals who join the program may participate by
1277 complying with the procedures established by the corporation.
1278 These procedures must include, but are not limited to:
1279 1. Submission of required information.
1280 2. Authorization for payroll deduction, if applicable.
1281 3. Compliance with federal tax requirements.
1282 4. Arrangements for payment.
1283 5. Selection of products and services.
1284 (f) Vendors who choose to participate in the program may
1285 enroll by complying with the procedures established by the
1286 corporation. These procedures may include, but are not limited
1287 to:
1288 1. Submission of required information, including a complete
1289 description of the coverage, services, provider network, payment
1290 restrictions, and other requirements of each product offered
1291 through the program.
1292 2. Execution of an agreement to comply with requirements
1293 established by the corporation.
1294 3. Execution of an agreement that prohibits refusal to sell
1295 any offered product or service to a participant who elects to
1296 buy it.
1297 4. Establishment of product prices based on applicable
1298 criteria.
1299 5. Arrangements for receiving payment for enrolled
1300 participants.
1301 6. Participation in ongoing reporting processes established
1302 by the corporation.
1303 7. Compliance with grievance procedures established by the
1304 corporation.
1305 (g) Health insurance agents licensed under part IV of
1306 chapter 626 are eligible to voluntarily participate as buyers’
1307 representatives. A buyer’s representative acts on behalf of an
1308 individual purchasing health insurance and health services
1309 through the program by providing information about products and
1310 services available through the program and assisting the
1311 individual with both the decision and the procedure of selecting
1312 specific products. Serving as a buyer’s representative does not
1313 constitute a conflict of interest with continuing
1314 responsibilities as a health insurance agent if the relationship
1315 between each agent and any participating vendor is disclosed
1316 before advising an individual participant about the products and
1317 services available through the program. In order to participate,
1318 a health insurance agent shall comply with the procedures
1319 established by the corporation, including:
1320 1. Completion of training requirements.
1321 2. Execution of a participation agreement specifying the
1322 terms and conditions of participation.
1323 3. Disclosure of any appointments to solicit insurance or
1324 procure applications for vendors participating in the program.
1325 4. Arrangements to receive payment from the corporation for
1326 services as a buyer’s representative.
1327 (5) PRODUCTS.—
1328 (a) The products that may be made available for purchase
1329 through the program include, but are not limited to:
1330 1. Health insurance policies.
1331 2. Health maintenance contracts.
1332 3. Limited benefit plans.
1333 4. Prepaid clinic services.
1334 5. Service contracts.
1335 6. Arrangements for purchase of specific amounts and types
1336 of health services and treatments.
1337 7. Flexible spending accounts.
1338 (b) Health insurance policies, health maintenance
1339 contracts, limited benefit plans, prepaid service contracts, and
1340 other contracts for services must ensure the availability of
1341 covered services.
1342 (c) Products may be offered for multiyear periods provided
1343 the price of the product is specified for the entire period or
1344 for each separately priced segment of the policy or contract.
1345 (d) The corporation shall provide a disclosure form for
1346 consumers to acknowledge their understanding of the nature of,
1347 and any limitations to, the benefits provided by the products
1348 and services being purchased by the consumer.
1349 (e) The corporation must determine that making the plan
1350 available through the program is in the interest of eligible
1351 individuals and eligible employers in the state.
1352 (6) PRICING.—Prices for the products and services sold
1353 through the program must be transparent to participants and
1354 established by the vendors. The corporation may shall annually
1355 assess a surcharge for each premium or price set by a
1356 participating vendor. Any The surcharge may not be more than 2.5
1357 percent of the price and shall be used to generate funding for
1358 administrative services provided by the corporation and payments
1359 to buyers’ representatives; however, a surcharge may not be
1360 assessed for products and services sold in the FHIX marketplace.
1361 (7) THE MARKETPLACE PROCESS.—The program shall provide a
1362 single, centralized market for purchase of health insurance,
1363 health maintenance contracts, and other health products and
1364 services. Purchases may be made by participating individuals
1365 over the Internet or through the services of a participating
1366 health insurance agent. Information about each product and
1367 service available through the program shall be made available
1368 through printed material and an interactive Internet website.
1369 (a) Marketplace purchasing.—A participant needing personal
1370 assistance to select products and services shall be referred to
1371 a participating agent in his or her area.
1372 1.(a) Participation in the program may begin at any time
1373 during a year after the employer completes enrollment and meets
1374 the requirements specified by the corporation pursuant to
1375 paragraph (4)(c).
1376 2.(b) Initial selection of products and services must be
1377 made by an individual participant within the applicable open
1378 enrollment period.
1379 3.(c) Initial enrollment periods for each product selected
1380 by an individual participant must last at least 12 months,
1381 unless the individual participant specifically agrees to a
1382 different enrollment period.
1383 4.(d) If an individual has selected one or more products
1384 and enrolled in those products for at least 12 months or any
1385 other period specifically agreed to by the individual
1386 participant, changes in selected products and services may only
1387 be made during the annual enrollment period established by the
1388 corporation.
1389 5.(e) The limits established in subparagraphs 2., 3., and
1390 4. paragraphs (b)-(d) apply to any risk-bearing product that
1391 promises future payment or coverage for a variable amount of
1392 benefits or services. The limits do not apply to initiation of
1393 flexible spending plans if those plans are not associated with
1394 specific high-deductible insurance policies or the use of
1395 spending accounts for any products offering individual
1396 participants specific amounts and types of health services and
1397 treatments at a contracted price.
1398 (b) FHIX marketplace purchasing.—
1399 1. Participation in the FHIX marketplace may begin at any
1400 time during the year.
1401 2. Initial enrollment periods for certain products selected
1402 by an individual enrollee which are noncompliant with the
1403 Affordable Care Act may be required to last at least 12 months,
1404 unless the individual participant specifically agrees to a
1405 different enrollment period.
1406 (8) CONSUMER INFORMATION.—The corporation shall:
1407 (a) Establish a secure website to facilitate the purchase
1408 of products and services by participating individuals. The
1409 website must provide information about each product or service
1410 available through the program.
1411 (b) Inform individuals about other public health care
1412 programs.
1413 (9) RISK POOLING.—The program may use methods for pooling
1414 the risk of individual participants and preventing selection
1415 bias. These methods may include, but are not limited to, a
1416 postenrollment risk adjustment of the premium payments to the
1417 vendors. The corporation may establish a methodology for
1418 assessing the risk of enrolled individual participants based on
1419 data reported annually by the vendors about their enrollees.
1420 Distribution of payments to the vendors may be adjusted based on
1421 the assessed relative risk profile of the enrollees in each
1422 risk-bearing product for the most recent period for which data
1423 is available.
1424 (10) EXEMPTIONS.—
1425 (a) Products, other than the products set forth in
1426 subparagraphs (4)(d)1.-4., sold as part of the program are not
1427 subject to the licensing requirements of the Florida Insurance
1428 Code, as defined in s. 624.01 or the mandated offerings or
1429 coverages established in part VI of chapter 627 and chapter 641.
1430 (b) The corporation may act as an administrator as defined
1431 in s. 626.88 but is not required to be certified pursuant to
1432 part VII of chapter 626. However, a third party administrator
1433 used by the corporation must be certified under part VII of
1434 chapter 626.
1435 (c) Any standard forms, website design, or marketing
1436 communication developed by the corporation and used by the
1437 corporation, or any vendor that meets the requirements of
1438 paragraph (4)(f) is not subject to the Florida Insurance Code,
1439 as established in s. 624.01.
1440 (11) CORPORATION.—There is created the Florida Health
1441 Choices, Inc., which shall be registered, incorporated,
1442 organized, and operated in compliance with part III of chapter
1443 112 and chapters 119, 286, and 617. The purpose of the
1444 corporation is to administer the program created in this section
1445 and to conduct such other business as may further the
1446 administration of the program.
1447 (a) The corporation shall be governed by a 15-member board
1448 of directors consisting of:
1449 1. Three ex officio, nonvoting members to include:
1450 a. The Secretary of Health Care Administration or a
1451 designee with expertise in health care services.
1452 b. The Secretary of Management Services or a designee with
1453 expertise in state employee benefits.
1454 c. The commissioner of the Office of Insurance Regulation
1455 or a designee with expertise in insurance regulation.
1456 2. Four members appointed by and serving at the pleasure of
1457 the Governor.
1458 3. Four members appointed by and serving at the pleasure of
1459 the President of the Senate.
1460 4. Four members appointed by and serving at the pleasure of
1461 the Speaker of the House of Representatives.
1462 5. Board members may not include insurers, health insurance
1463 agents or brokers, health care providers, health maintenance
1464 organizations, prepaid service providers, or any other entity,
1465 affiliate, or subsidiary of eligible vendors.
1466 (b) Members shall be appointed for terms of up to 3 years.
1467 Any member is eligible for reappointment. A vacancy on the board
1468 shall be filled for the unexpired portion of the term in the
1469 same manner as the original appointment.
1470 (c) The board shall select a chief executive officer for
1471 the corporation who shall be responsible for the selection of
1472 such other staff as may be authorized by the corporation’s
1473 operating budget as adopted by the board.
1474 (d) Board members are entitled to receive, from funds of
1475 the corporation, reimbursement for per diem and travel expenses
1476 as provided by s. 112.061. No other compensation is authorized.
1477 (e) There is no liability on the part of, and no cause of
1478 action shall arise against, any member of the board or its
1479 employees or agents for any action taken by them in the
1480 performance of their powers and duties under this section.
1481 (f) The board shall develop and adopt bylaws and other
1482 corporate procedures as necessary for the operation of the
1483 corporation and carrying out the purposes of this section. The
1484 bylaws shall:
1485 1. Specify procedures for selection of officers and
1486 qualifications for reappointment, provided that no board member
1487 shall serve more than 9 consecutive years.
1488 2. Require an annual membership meeting that provides an
1489 opportunity for input and interaction with individual
1490 participants in the program.
1491 3. Specify policies and procedures regarding conflicts of
1492 interest, including the provisions of part III of chapter 112,
1493 which prohibit a member from participating in any decision that
1494 would inure to the benefit of the member or the organization
1495 that employs the member. The policies and procedures shall also
1496 require public disclosure of the interest that prevents the
1497 member from participating in a decision on a particular matter.
1498 (g) The corporation may exercise all powers granted to it
1499 under chapter 617 necessary to carry out the purposes of this
1500 section, including, but not limited to, the power to receive and
1501 accept grants, loans, or advances of funds from any public or
1502 private agency and to receive and accept from any source
1503 contributions of money, property, labor, or any other thing of
1504 value to be held, used, and applied for the purposes of this
1505 section.
1506 (h) The corporation may establish technical advisory panels
1507 consisting of interested parties, including consumers, health
1508 care providers, individuals with expertise in insurance
1509 regulation, and insurers.
1510 (i) The corporation shall:
1511 1. Determine eligibility of employers, vendors,
1512 individuals, and agents in accordance with subsection (4).
1513 2. Establish procedures necessary for the operation of the
1514 program, including, but not limited to, procedures for
1515 application, enrollment, risk assessment, risk adjustment, plan
1516 administration, performance monitoring, and consumer education.
1517 3. Arrange for collection of contributions from
1518 participating employers, third parties, governmental entities,
1519 and individuals.
1520 4. Arrange for payment of premiums and other appropriate
1521 disbursements based on the selections of products and services
1522 by the individual participants.
1523 5. Establish criteria for disenrollment of participating
1524 individuals based on failure to pay the individual’s share of
1525 any contribution required to maintain enrollment in selected
1526 products.
1527 6. Establish criteria for exclusion of vendors pursuant to
1528 paragraph (4)(d).
1529 7. Develop and implement a plan for promoting public
1530 awareness of and participation in the program.
1531 8. Secure staff and consultant services necessary to the
1532 operation of the program.
1533 9. Establish policies and procedures regarding
1534 participation in the program for individuals, vendors, health
1535 insurance agents, and employers.
1536 10. Provide for the operation of a toll-free hotline to
1537 respond to requests for assistance.
1538 11. Provide for initial, open, and special enrollment
1539 periods.
1540 12. Evaluate options for employer participation which may
1541 conform to with common insurance practices.
1542 13. Administer the Florida Health Insurance Affordability
1543 Exchange Program in accordance with ss. 409.720-409.731.
1544 14. Coordinate with the Agency for Health Care
1545 Administration, the Department of Children and Families, and the
1546 Florida Healthy Kids Corporation on the transition plan for FHIX
1547 and any subsequent transition activities.
1548 (12) REPORT.—The board of the corporation shall Beginning
1549 in the 2009-2010 fiscal year, submit by February 1 an annual
1550 report to the Governor, the President of the Senate, and the
1551 Speaker of the House of Representatives documenting the
1552 corporation’s activities in compliance with the duties
1553 delineated in this section.
1554 (13) PROGRAM INTEGRITY.—To ensure program integrity and to
1555 safeguard the financial transactions made under the auspices of
1556 the program, the corporation is authorized to establish
1557 qualifying criteria and certification procedures for vendors,
1558 require performance bonds or other guarantees of ability to
1559 complete contractual obligations, monitor the performance of
1560 vendors, and enforce the agreements of the program through
1561 financial penalty or disqualification from the program.
1562 (14) EXEMPTION FROM PUBLIC RECORDS REQUIREMENTS.—
1563 (a) Definitions.—For purposes of this subsection, the term:
1564 1. “Buyer’s representative” means a participating insurance
1565 agent as described in paragraph (4)(g).
1566 2. “Enrollee” means an employer who is eligible to enroll
1567 in the program pursuant to paragraph (4)(a).
1568 3. “Participant” means an individual who is eligible to
1569 participate in the program pursuant to paragraph (4)(b).
1570 4. “Proprietary confidential business information” means
1571 information, regardless of form or characteristics, that is
1572 owned or controlled by a vendor requesting confidentiality under
1573 this section; that is intended to be and is treated by the
1574 vendor as private in that the disclosure of the information
1575 would cause harm to the business operations of the vendor; that
1576 has not been disclosed unless disclosed pursuant to a statutory
1577 provision, an order of a court or administrative body, or a
1578 private agreement providing that the information may be released
1579 to the public; and that is information concerning:
1580 a. Business plans.
1581 b. Internal auditing controls and reports of internal
1582 auditors.
1583 c. Reports of external auditors for privately held
1584 companies.
1585 d. Client and customer lists.
1586 e. Potentially patentable material.
1587 f. A trade secret as defined in s. 688.002.
1588 5. “Vendor” means a participating insurer or other provider
1589 of services as described in paragraph (4)(d).
1590 (b) Public record exemptions.—
1591 1. Personal identifying information of an enrollee or
1592 participant who has applied for or participates in the Florida
1593 Health Choices Program is confidential and exempt from s.
1594 119.07(1) and s. 24(a), Art. I of the State Constitution.
1595 2. Client and customer lists of a buyer’s representative
1596 held by the corporation are confidential and exempt from s.
1597 119.07(1) and s. 24(a), Art. I of the State Constitution.
1598 3. Proprietary confidential business information held by
1599 the corporation is confidential and exempt from s. 119.07(1) and
1600 s. 24(a), Art. I of the State Constitution.
1601 (c) Retroactive application.—The public record exemptions
1602 provided for in paragraph (b) apply to information held by the
1603 corporation before, on, or after the effective date of this
1604 exemption.
1605 (d) Authorized release.—
1606 1. Upon request, information made confidential and exempt
1607 pursuant to this subsection shall be disclosed to:
1608 a. Another governmental entity in the performance of its
1609 official duties and responsibilities.
1610 b. Any person who has the written consent of the program
1611 applicant.
1612 c. The Florida Kidcare program for the purpose of
1613 administering the program authorized in ss. 409.810-409.821.
1614 2. Paragraph (b) does not prohibit a participant’s legal
1615 guardian from obtaining confirmation of coverage, dates of
1616 coverage, the name of the participant’s health plan, and the
1617 amount of premium being paid.
1618 (e) Penalty.—A person who knowingly and willfully violates
1619 this subsection commits a misdemeanor of the second degree,
1620 punishable as provided in s. 775.082 or s. 775.083.
1621 (f) Review and repeal.—This subsection is subject to the
1622 Open Government Sunset Review Act in accordance with s. 119.15,
1623 and shall stand repealed on October 2, 2016, unless reviewed and
1624 saved from repeal through reenactment by the Legislature.
1625 Section 24. Effective upon this act becoming a law,
1626 subsection (2) of section 409.904, Florida Statutes, is amended
1627 to read:
1628 409.904 Optional payments for eligible persons.—The agency
1629 may make payments for medical assistance and related services on
1630 behalf of the following persons who are determined to be
1631 eligible subject to the income, assets, and categorical
1632 eligibility tests set forth in federal and state law. Payment on
1633 behalf of these Medicaid eligible persons is subject to the
1634 availability of moneys and any limitations established by the
1635 General Appropriations Act or chapter 216.
1636 (2) A family, a pregnant woman, a child under age 21, a
1637 person age 65 or over, or a blind or disabled person, who would
1638 be eligible under any group listed in s. 409.903(1), (2), or
1639 (3), except that the income or assets of such family or person
1640 exceed established limitations. For a family or person in one of
1641 these coverage groups, medical expenses are deductible from
1642 income in accordance with federal requirements in order to make
1643 a determination of eligibility. A family or person eligible
1644 under the coverage known as the “medically needy,” is eligible
1645 to receive the same services as other Medicaid recipients, with
1646 the exception of services in skilled nursing facilities and
1647 intermediate care facilities for the developmentally disabled.
1648 Effective October 1, 2015, persons eligible under “medically
1649 needy” shall be limited to children under the age of 21 and
1650 pregnant women. This subsection expires October 1, 2019.
1651 Section 25. Effective upon this act becoming a law, section
1652 624.91, Florida Statutes, is amended to read:
1653 624.91 The Florida Healthy Kids Corporation Act.—
1654 (1) SHORT TITLE.—This section may be cited as the “William
1655 G. ‘Doc’ Myers Healthy Kids Corporation Act.”
1656 (2) LEGISLATIVE INTENT.—
1657 (a) The Legislature finds that increased access to health
1658 care services could improve children’s health and reduce the
1659 incidence and costs of childhood illness and disabilities among
1660 children in this state. Many children do not have comprehensive,
1661 affordable health care services available. It is the intent of
1662 the Legislature that the Florida Healthy Kids Corporation
1663 provide comprehensive health insurance coverage to such
1664 children. The corporation is encouraged to cooperate with any
1665 existing health service programs funded by the public or the
1666 private sector.
1667 (b) It is the intent of the Legislature that the Florida
1668 Healthy Kids Corporation serve as one of several providers of
1669 services to children eligible for medical assistance under Title
1670 XXI of the Social Security Act. Although the corporation may
1671 serve other children, the Legislature intends the primary
1672 recipients of services provided through the corporation be
1673 school-age children with a family income below 200 percent of
1674 the federal poverty level, who do not qualify for Medicaid. It
1675 is also the intent of the Legislature that state and local
1676 government Florida Healthy Kids funds be used to continue
1677 coverage, subject to specific appropriations in the General
1678 Appropriations Act, to children not eligible for federal
1679 matching funds under Title XXI.
1680 (3) ELIGIBILITY FOR STATE-FUNDED ASSISTANCE.—Only residents
1681 of this state are eligible the following individuals are
1682 eligible for state-funded assistance in paying Florida Healthy
1683 Kids premiums pursuant to s. 409.814.:
1684 (a) Residents of this state who are eligible for the
1685 Florida Kidcare program pursuant to s. 409.814.
1686 (b) Notwithstanding s. 409.814, legal aliens who are
1687 enrolled in the Florida Healthy Kids program as of January 31,
1688 2004, who do not qualify for Title XXI federal funds because
1689 they are not qualified aliens as defined in s. 409.811.
1690 (4) NONENTITLEMENT.—Nothing in this section shall be
1691 construed as providing an individual with an entitlement to
1692 health care services. No cause of action shall arise against the
1693 state, the Florida Healthy Kids Corporation, or a unit of local
1694 government for failure to make health services available under
1695 this section.
1696 (5) CORPORATION AUTHORIZATION, DUTIES, POWERS.—
1697 (a) There is created the Florida Healthy Kids Corporation,
1698 a not-for-profit corporation.
1699 (b) The Florida Healthy Kids Corporation shall:
1700 1. Arrange for the collection of any individual, family,
1701 local contributions, or employer payment or premium, in an
1702 amount to be determined by the board of directors, to provide
1703 for payment of premiums for comprehensive insurance coverage and
1704 for the actual or estimated administrative expenses.
1705 2. Arrange for the collection of any voluntary
1706 contributions to provide for payment of Florida Kidcare program
1707 or Florida Health Insurance Affordability Exchange Program
1708 premiums for children who are not eligible for medical
1709 assistance under Title XIX or Title XXI of the Social Security
1710 Act.
1711 3. Subject to the provisions of s. 409.8134, accept
1712 voluntary supplemental local match contributions that comply
1713 with the requirements of Title XXI of the Social Security Act
1714 for the purpose of providing additional Florida Kidcare coverage
1715 in contributing counties under Title XXI.
1716 4. Establish the administrative and accounting procedures
1717 for the operation of the corporation.
1718 4.5. Establish, with consultation from appropriate
1719 professional organizations, standards for preventive health
1720 services and providers and comprehensive insurance benefits
1721 appropriate to children, provided that such standards for rural
1722 areas shall not limit primary care providers to board-certified
1723 pediatricians.
1724 5.6. Determine eligibility for children seeking to
1725 participate in the Title XXI-funded components of the Florida
1726 Kidcare program consistent with the requirements specified in s.
1727 409.814, as well as the non-Title-XXI-eligible children as
1728 provided in subsection (3).
1729 6.7. Establish procedures under which providers of local
1730 match to, applicants to and participants in the program may have
1731 grievances reviewed by an impartial body and reported to the
1732 board of directors of the corporation.
1733 7.8. Establish participation criteria and, if appropriate,
1734 contract with an authorized insurer, health maintenance
1735 organization, or third-party administrator to provide
1736 administrative services to the corporation.
1737 8.9. Establish enrollment criteria that include penalties
1738 or waiting periods of 30 days for reinstatement of coverage upon
1739 voluntary cancellation for nonpayment of family or individual
1740 premiums.
1741 9.10. Contract with authorized insurers or any provider of
1742 health care services, meeting standards established by the
1743 corporation, for the provision of comprehensive insurance
1744 coverage to participants. Such standards shall include criteria
1745 under which the corporation may contract with more than one
1746 provider of health care services in program sites.
1747 a. Health plans shall be selected through a competitive bid
1748 process. The Florida Healthy Kids Corporation shall purchase
1749 goods and services in the most cost-effective manner consistent
1750 with the delivery of quality medical care.
1751 b. The maximum administrative cost for a Florida Healthy
1752 Kids Corporation contract shall be 15 percent. For health and
1753 dental care contracts, the minimum medical loss ratio for a
1754 Florida Healthy Kids Corporation contract shall be 85 percent.
1755 The calculations must use uniform financial data collected from
1756 all plans in a format established by the corporation and shall
1757 be computed for each plan on a statewide basis. Funds shall be
1758 classified in a manner consistent with 45 C.F.R. part 158 For
1759 dental contracts, the remaining compensation to be paid to the
1760 authorized insurer or provider under a Florida Healthy Kids
1761 Corporation contract shall be no less than an amount which is 85
1762 percent of premium; to the extent any contract provision does
1763 not provide for this minimum compensation, this section shall
1764 prevail.
1765 c. The health plan selection criteria and scoring system,
1766 and the scoring results, shall be available upon request for
1767 inspection after the bids have been awarded.
1768 d. Effective July 1, 2016, health and dental services
1769 contracts of the corporation must transition to the FHIX
1770 marketplace under s. 409.722. Qualifying plans may enroll as
1771 vendors with the FHIX marketplace to maintain continuity of care
1772 for participants.
1773 10.11. Establish disenrollment criteria in the event local
1774 matching funds are insufficient to cover enrollments.
1775 11.12. Develop and implement a plan to publicize the
1776 Florida Kidcare program, the eligibility requirements of the
1777 program, and the procedures for enrollment in the program and to
1778 maintain public awareness of the corporation and the program.
1779 12.13. Secure staff necessary to properly administer the
1780 corporation. Staff costs shall be funded from state and local
1781 matching funds and such other private or public funds as become
1782 available. The board of directors shall determine the number of
1783 staff members necessary to administer the corporation.
1784 13.14. In consultation with the partner agencies, provide a
1785 report on the Florida Kidcare program annually to the Governor,
1786 the Chief Financial Officer, the Commissioner of Education, the
1787 President of the Senate, the Speaker of the House of
1788 Representatives, and the Minority Leaders of the Senate and the
1789 House of Representatives.
1790 14.15. Provide information on a quarterly basis online to
1791 the Legislature and the Governor which compares the costs and
1792 utilization of the full-pay enrolled population and the Title
1793 XXI-subsidized enrolled population in the Florida Kidcare
1794 program. The information, at a minimum, must include:
1795 a. The monthly enrollment and expenditure for full-pay
1796 enrollees in the Medikids and Florida Healthy Kids programs
1797 compared to the Title XXI-subsidized enrolled population; and
1798 b. The costs and utilization by service of the full-pay
1799 enrollees in the Medikids and Florida Healthy Kids programs and
1800 the Title XXI-subsidized enrolled population.
1801 15.16. Establish benefit packages that conform to the
1802 provisions of the Florida Kidcare program, as created in ss.
1803 409.810-409.821.
1804 16. Contract with other insurance affordability programs
1805 and FHIX to provide customer service or other enrollment-focused
1806 services.
1807 17. Annually develop performance metrics for the following
1808 focus areas:
1809 a. Administrative functions.
1810 b. Contracting with vendors.
1811 c. Customer service.
1812 d. Enrollee education.
1813 e. Financial services.
1814 f. Program integrity.
1815 (c) Coverage under the corporation’s program is secondary
1816 to any other available private coverage held by, or applicable
1817 to, the participant child or family member. Insurers under
1818 contract with the corporation are the payors of last resort and
1819 must coordinate benefits with any other third-party payor that
1820 may be liable for the participant’s medical care.
1821 (d) The Florida Healthy Kids Corporation shall be a private
1822 corporation not for profit, organized pursuant to chapter 617,
1823 and shall have all powers necessary to carry out the purposes of
1824 this act, including, but not limited to, the power to receive
1825 and accept grants, loans, or advances of funds from any public
1826 or private agency and to receive and accept from any source
1827 contributions of money, property, labor, or any other thing of
1828 value, to be held, used, and applied for the purposes of this
1829 act.
1830 (6) BOARD OF DIRECTORS AND MANAGEMENT SUPERVISION.—
1831 (a) The Florida Healthy Kids Corporation shall operate
1832 subject to the supervision and approval of a board of directors.
1833 The board chair shall be an appointee designated by the
1834 Governor, and the board shall be chaired by the Chief Financial
1835 Officer or her or his designee, and composed of 12 other
1836 members. The Senate shall confirm the designated chair and other
1837 board appointees. The board members shall be appointed selected
1838 for 3-year terms. of office as follows:
1839 1. The Secretary of Health Care Administration, or his or
1840 her designee.
1841 2. One member appointed by the Commissioner of Education
1842 from the Office of School Health Programs of the Florida
1843 Department of Education.
1844 3. One member appointed by the Chief Financial Officer from
1845 among three members nominated by the Florida Pediatric Society.
1846 4. One member, appointed by the Governor, who represents
1847 the Children’s Medical Services Program.
1848 5. One member appointed by the Chief Financial Officer from
1849 among three members nominated by the Florida Hospital
1850 Association.
1851 6. One member, appointed by the Governor, who is an expert
1852 on child health policy.
1853 7. One member, appointed by the Chief Financial Officer,
1854 from among three members nominated by the Florida Academy of
1855 Family Physicians.
1856 8. One member, appointed by the Governor, who represents
1857 the state Medicaid program.
1858 9. One member, appointed by the Chief Financial Officer,
1859 from among three members nominated by the Florida Association of
1860 Counties.
1861 10. The State Health Officer or her or his designee.
1862 11. The Secretary of Children and Families, or his or her
1863 designee.
1864 12. One member, appointed by the Governor, from among three
1865 members nominated by the Florida Dental Association.
1866 (b) A member of the board of directors serves at the
1867 pleasure of the Governor may be removed by the official who
1868 appointed that member. The board shall appoint an executive
1869 director, who is responsible for other staff authorized by the
1870 board.
1871 (c) Board members are entitled to receive, from funds of
1872 the corporation, reimbursement for per diem and travel expenses
1873 as provided by s. 112.061.
1874 (d) There shall be no liability on the part of, and no
1875 cause of action shall arise against, any member of the board of
1876 directors, or its employees or agents, for any action they take
1877 in the performance of their powers and duties under this act.
1878 (e) Board members who are serving as of the effective date
1879 of this act may remain on the board until January 1, 2016.
1880 (7) LICENSING NOT REQUIRED; FISCAL OPERATION.—
1881 (a) The corporation shall not be deemed an insurer. The
1882 officers, directors, and employees of the corporation shall not
1883 be deemed to be agents of an insurer. Neither the corporation
1884 nor any officer, director, or employee of the corporation is
1885 subject to the licensing requirements of the insurance code or
1886 the rules of the Department of Financial Services. However, any
1887 marketing representative utilized and compensated by the
1888 corporation must be appointed as a representative of the
1889 insurers or health services providers with which the corporation
1890 contracts.
1891 (b) The board has complete fiscal control over the
1892 corporation and is responsible for all corporate operations.
1893 (c) The Department of Financial Services shall supervise
1894 any liquidation or dissolution of the corporation and shall
1895 have, with respect to such liquidation or dissolution, all power
1896 granted to it pursuant to the insurance code.
1897 (8) TRANSITION PLANS.—The corporation shall confer with the
1898 Agency for Health Care Administration, the Department of
1899 Children and Families, and Florida Health Choices, Inc., to
1900 develop transition plans for the Florida Health Insurance
1901 Affordability Exchange Program as created under ss. 409.720
1902 409.731.
1903 Section 26. Effective upon this act becoming a law, section
1904 624.915, Florida Statutes, is repealed.
1905 Section 27. Effective upon this act becoming a law, the
1906 Division of Law Revision and Information is directed to replace
1907 the phrase “the effective date of this act” wherever it occurs
1908 in this act with the date the act becomes a law.
1909 Section 28. Except as otherwise expressly provided in this
1910 act and except for this section, which shall take effect upon
1911 this act becoming a law, this act shall take effect July 1,
1912 2015.
