SECTION 409.815. Health benefits coverage; limitations.

• (1) MEDICAID BENEFITS.-For purposes of the Florida Kidcare program, benefits available under Medicaid and Medikids include those goods and services provided under the medical assistance program authorized by Title XIX of the Social Security Act, and regulations thereunder, as administered in this state by the agency. This includes those mandatory Medicaid services authorized under s. 409.905 and optional Medicaid services authorized under s. 409.906, rendered on behalf of eligible individuals by qualified providers, in accordance with federal requirements for Title XIX, subject to any limitations or directions provided for in the General Appropriations Act or chapter 216, and according to methodologies and limitations set forth in agency rules and policy manuals and handbooks incorporated by reference thereto.
  (2) BENCHMARK BENEFITS.-In order for health benefits coverage to qualify for premium assistance payments for an eligible child under ss. 409.810-409.821, the health benefits coverage, except for coverage under Medicaid and Medikids, must include the following minimum benefits, as medically necessary.

  (a) Preventive health services.-Covered services include:

  1. Well-child care, including services recommended in the Guidelines for Health Supervision of Children and Youth as developed by the American Academy of Pediatrics;

  2. Immunizations and injections;

  3. Health education counseling and clinical services;

  4. Vision screening; and

  5. Hearing screening.

  (b) Inpatient hospital services.-All covered services provided for the medical care and treatment of an enrollee who is admitted as an inpatient to a hospital licensed under part I of chapter 395, with the following exceptions:

  1. All admissions must be authorized by the enrollee’s health benefits coverage provider.

  2. The length of the patient stay shall be determined based on the medical condition of the enrollee in relation to the necessary and appropriate level of care.

  3. Room and board may be limited to semiprivate accommodations, unless a private room is considered medically necessary or semiprivate accommodations are not available.

  4. Admissions for rehabilitation and physical therapy are limited to 15 days per contract year.

  (c) Emergency services.-Covered services include visits to an emergency room or other licensed facility if needed immediately due to an injury or illness and delay means risk of permanent damage to the enrollee’s health. Health maintenance organizations shall comply with the provisions of s. 641.513.

  (d) Maternity services.-Covered services include maternity and newborn care, including prenatal and postnatal care, with the following limitations:

  1. Coverage may be limited to the fee for vaginal deliveries; and

  2. Initial inpatient care for newborn infants of enrolled adolescents shall be covered, including normal newborn care, nursery charges, and the initial pediatric or neonatal examination, and the infant may be covered for up to 3 days following birth.

  (e) Organ transplantation services.-Covered services include pretransplant, transplant, and postdischarge services and treatment of complications after transplantation for transplants deemed necessary and appropriate within the guidelines set by the Organ Transplant Advisory Council under s. 765.53 or the Bone Marrow Transplant Advisory Panel under s. 627.4236.

  (f) Outpatient services.-Covered services include preventive, diagnostic, therapeutic, palliative care, and other services provided to an enrollee in the outpatient portion of a health facility licensed under chapter 395, except for the following limitations:

  1. Services must be authorized by the enrollee’s health benefits coverage provider; and

  2. Treatment for temporomandibular joint disease (TMJ) is specifically excluded.

  (g) Behavioral health services.-

  1. Mental health benefits include:

  a. Inpatient services, limited to 30 inpatient days per contract year for psychiatric admissions, or residential services in facilities licensed under s. 394.875(6) or s. 395.003 in lieu of inpatient psychiatric admissions; however, a minimum of 10 of the 30 days shall be available only for inpatient psychiatric services if authorized by a physician; and

  b. Outpatient services, including outpatient visits for psychological or psychiatric evaluation, diagnosis, and treatment by a licensed mental health professional, limited to 40 outpatient visits each contract year.

  2. Substance abuse services include:

  a. Inpatient services, limited to 7 inpatient days per contract year for medical detoxification only and 30 days of residential services; and

  b. Outpatient services, including evaluation, diagnosis, and treatment by a licensed practitioner, limited to 40 outpatient visits per contract year.

  Covered services include inpatient and outpatient services for mental and nervous disorders as defined in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders published by the American Psychiatric Association. Such benefits include psychological or psychiatric evaluation, diagnosis, and treatment by a licensed mental health professional and inpatient, outpatient, and residential treatment of substance abuse disorders. Any benefit limitations, including duration of services, number of visits, or number of days for hospitalization or residential services, shall not be any less favorable than those for physical illnesses generally. The program may also implement appropriate financial incentives, peer review, utilization requirements, and other methods used for the management of benefits provided for other medical conditions in order to reduce service costs and utilization without compromising quality of care.

  (h) Durable medical equipment.-Covered services include equipment and devices that are medically indicated to assist in the treatment of a medical condition and specifically prescribed as medically necessary, with the following limitations:

  1. Low-vision and telescopic aides are not included.

  2. Corrective lenses and frames may be limited to one pair every 2 years, unless the prescription or head size of the enrollee changes.

  3. Hearing aids shall be covered only when medically indicated to assist in the treatment of a medical condition.

  4. Covered prosthetic devices include artificial eyes and limbs, braces, and other artificial aids.

  (i) Health practitioner services.-Covered services include services and procedures rendered to an enrollee when performed to diagnose and treat diseases, injuries, or other conditions, including care rendered by health practitioners acting within the scope of their practice, with the following exceptions:

  1. Chiropractic services shall be provided in the same manner as in the Florida Medicaid program.

  2. Podiatric services may be limited to one visit per day totaling two visits per month for specific foot disorders.

  (j) Home health services.-Covered services include prescribed home visits by both registered and licensed practical nurses to provide skilled nursing services on a part-time intermittent basis, subject to the following limitations:

  1. Coverage may be limited to include skilled nursing services only;

  2. Meals, housekeeping, and personal comfort items may be excluded; and

  3. Private duty nursing is limited to circumstances where such care is medically necessary.

  (k) Hospice services.-Covered services include reasonable and necessary services for palliation or management of an enrollee’s terminal illness, with the following exceptions:

  1. Once a family elects to receive hospice care for an enrollee, other services that treat the terminal condition will not be covered; and

  2. Services required for conditions totally unrelated to the terminal condition are covered to the extent that the services are included in this section.

  (l) Laboratory and X-ray services.-Covered services include diagnostic testing, including clinical radiologic, laboratory, and other diagnostic tests.

  (m) Nursing facility services.-Covered services include regular nursing services, rehabilitation services, drugs and biologicals, medical supplies, and the use of appliances and equipment furnished by the facility, with the following limitations:

  1. All admissions must be authorized by the health benefits coverage provider.

  2. The length of the patient stay shall be determined based on the medical condition of the enrollee in relation to the necessary and appropriate level of care, but is limited to not more than 100 days per contract year.

  3. Room and board may be limited to semiprivate accommodations, unless a private room is considered medically necessary or semiprivate accommodations are not available.

  4. Specialized treatment centers and independent kidney disease treatment centers are excluded.

  5. Private duty nurses, television, and custodial care are excluded.

  6. Admissions for rehabilitation and physical therapy are limited to 15 days per contract year.

  (n) Prescribed drugs.-

  1. Coverage shall include drugs prescribed for the treatment of illness or injury when prescribed by a licensed health practitioner acting within the scope of his or her practice.

  2. Prescribed drugs may be limited to generics if available and brand name products if a generic substitution is not available, unless the prescribing licensed health practitioner indicates that a brand name is medically necessary.

  3. Prescribed drugs covered under this section shall include all prescribed drugs covered under the Florida Medicaid program.

  (o) Therapy services.-Covered services include rehabilitative services, including occupational, physical, respiratory, and speech therapies, with the following limitations:

  1. Services must be for short-term rehabilitation where significant improvement in the enrollee’s condition will result; and

  2. Services shall be limited to not more than 24 treatment sessions within a 60-day period per episode or injury, with the 60-day period beginning with the first treatment.

  (p) Transportation services.-Covered services include emergency transportation required in response to an emergency situation.

  (q) Dental services.-Dental services shall be covered as required under federal law and may also include those dental benefits provided to children by the Florida Medicaid program under s. 409.906(6).

  (r) Cost sharing.-Cost-sharing provisions must comply with s. 409.816.

  (s) Exclusions.-

  1. Experimental or investigational procedures that have not been clinically proven by reliable evidence are excluded;

  2. Services performed for cosmetic purposes only or for the convenience of the enrollee are excluded; and

  3. Abortion may be covered only if necessary to save the life of the mother or if the pregnancy is the result of an act of rape or incest.

  (t) Enhancements to minimum requirements.-

  1. This section sets the minimum benefits that must be included in any health benefits coverage, other than Medicaid or Medikids coverage, offered under ss. 409.810-409.821. Health benefits coverage may include additional benefits not included under this subsection, but may not include benefits excluded under paragraph (r).

  2. Health benefits coverage may extend any limitations beyond the minimum benefits described in this section.

  Except for the Children’s Medical Services Network, the agency may not increase the premium assistance payment for either additional benefits provided beyond the minimum benefits described in this section or the imposition of less restrictive service limitations.

  (u) Applicability of other state laws.-Health insurers, health maintenance organizations, and their agents are subject to the provisions of the Florida Insurance Code, except for any such provisions waived in this section.

  1. Except as expressly provided in this section, a law requiring coverage for a specific health care service or benefit, or a law requiring reimbursement, utilization, or consideration of a specific category of licensed health care practitioner, does not apply to a health insurance plan policy or contract offered or delivered under ss. 409.810-409.821 unless that law is made expressly applicable to such policies or contracts.

  2. Notwithstanding chapter 641, a health maintenance organization may issue contracts providing benefits equal to, exceeding, or actuarially equivalent to the benchmark benefit plan authorized by this section and may pay providers located in a rural county negotiated fees or Medicaid reimbursement rates for services provided to enrollees who are residents of the rural county.

  (v) Reimbursement of federally qualified health centers and rural health clinics.-Payments for services provided to enrollees by federally qualified health centers and rural health clinics under this section shall be reimbursed using the Medicaid Prospective Payment System as provided for under s. 2107(e)(1)(D) of the Social Security Act. If such services are paid for by health insurers or health care providers under contract with the Florida Healthy Kids Corporation, such entities are responsible for this payment. The agency may seek any available federal grants to assist with this transition.

History.-ss. 40, 57, ch. 98-288; s. 5, ch. 2000-253; s. 19, ch. 2001-377; s. 45, ch. 2003-1; ss. 6, 22, ch. 2003-405; s. 5, ch. 2004-1; s. 135, ch. 2007-230; s. 2, ch. 2009-55; s. 8, ch. 2009-113; s. 77, ch. 2019-3; s. 1, ch. 2020-12.

History.-ss. 40, 57, ch. 98-288; s. 5, ch. 2000-253; s. 19, ch. 2001-377; s. 45, ch. 2003-1; ss. 6, 22, ch. 2003-405; s. 5, ch. 2004-1; s. 135, ch. 2007-230; s. 2, ch. 2009-55; s. 8, ch. 2009-113; s. 77, ch. 2019-3; s. 1, ch. 2020-12.