Definitions relating to Florida Kidcare Act.

As used in ss. 409.810-409.821, the term:

(1) “Actuarially equivalent” means that:

(a) The aggregate value of the benefits included in health benefits coverage is equal to the value of the benefits in the benchmark benefit plan; and

(b) The benefits included in health benefits coverage are substantially similar to the benefits included in the benchmark benefit plan, except that preventive health services must be the same as in the benchmark benefit plan.

(2) “Agency” means the Agency for Health Care Administration.

(3) “Applicant” means a parent or guardian of a child or a child whose disability of nonage has been removed under chapter 743, who applies for determination of eligibility for health benefits coverage under ss. 409.810-409.821.

(4) “Benchmark benefit plan” means the form and level of health benefits coverage established in s. 409.815.

(5) “Child” means any person under 19 years of age.

(6) “Child with special health care needs” means a child whose serious or chronic physical or developmental condition requires extensive preventive and maintenance care beyond that required by typically healthy children. Health care utilization by such a child exceeds the statistically expected usage of the normal child adjusted for chronological age, and such a child often needs complex care requiring multiple providers, rehabilitation services, and specialized equipment in a number of different settings.

(7) “Community rate” means a method used to develop premiums for a health insurance plan that spreads financial risk across a large population and allows adjustments only for age, gender, family composition, and geographic area.

(8) “Department” means the Department of Health.

(9) “Enrollee” means a child who has been determined eligible for and is receiving coverage under ss. 409.810-409.821.

(10) “Family” means the group or the individuals whose income is considered in determining eligibility for the Florida Kidcare program. The family includes a child with a parent or caretaker relative who resides in the same house or living unit or, in the case of a child whose disability of nonage has been removed under chapter 743, the child. The family may also include other individuals whose income and resources are considered in whole or in part in determining eligibility of the child.

(11) “Family income” means cash received at periodic intervals from any source, such as wages, benefits, contributions, or rental property. Income also may include any money that would have been counted as income under the Aid to Families with Dependent Children (AFDC) state plan in effect prior to August 22, 1996.

(12) “Florida Kidcare program,” “Kidcare program,” or “program” means the health benefits program administered through ss. 409.810-409.821.

(13) “Guarantee issue” means that health benefits coverage must be offered to an individual regardless of the individual’s health status, preexisting condition, or claims history.

(14) “Health benefits coverage” means protection that provides payment of benefits for covered health care services or that otherwise provides, either directly or through arrangements with other persons, covered health care services on a prepaid per capita basis or on a prepaid aggregate fixed-sum basis.

(15) “Health insurance plan” means health benefits coverage under the following:

(a) A health plan offered by any certified health maintenance organization or authorized health insurer, except a plan that is limited to the following: a limited benefit, specified disease, or specified accident; hospital indemnity; accident only; limited benefit convalescent care; Medicare supplement; credit disability; dental; vision; long-term care; disability income; coverage issued as a supplement to another health plan; workers’ compensation liability or other insurance; or motor vehicle medical payment only; or

(b) An employee welfare benefit plan that includes health benefits established under the Employee Retirement Income Security Act of 1974, as amended.

(16) “Lawfully residing child” means a child who is lawfully present in the United States, meets Medicaid or Children’s Health Insurance Program (CHIP) residency requirements, and may be eligible for medical assistance with federal financial participation as provided under s. 214 of the Children’s Health Insurance Program Reauthorization Act of 2009, Pub. L. No. 111-3, and related federal regulations.

(17) “Medicaid” means the medical assistance program authorized by Title XIX of the Social Security Act, and regulations thereunder, and ss. 409.901-409.920, as administered in this state by the agency.

(18) “Medically necessary” means the use of any medical treatment, service, equipment, or supply necessary to palliate the effects of a terminal condition, or to prevent, diagnose, correct, cure, alleviate, or preclude deterioration of a condition that threatens life, causes pain or suffering, or results in illness or infirmity and which is:

(a) Consistent with the symptom, diagnosis, and treatment of the enrollee’s condition;

(b) Provided in accordance with generally accepted standards of medical practice;

(c) Not primarily intended for the convenience of the enrollee, the enrollee’s family, or the health care provider;

(d) The most appropriate level of supply or service for the diagnosis and treatment of the enrollee’s condition; and

(e) Approved by the appropriate medical body or health care specialty involved as effective, appropriate, and essential for the care and treatment of the enrollee’s condition.

(19) “Medikids” means a component of the Florida Kidcare program of medical assistance authorized by Title XXI of the Social Security Act, and regulations thereunder, and s. 409.8132, as administered in the state by the agency.

(20) “Preexisting condition exclusion” means, with respect to coverage, a limitation or exclusion of benefits relating to a condition based on the fact that the condition was present before the date of enrollment for such coverage, whether or not any medical advice, diagnosis, care, or treatment was recommended or received before such date.

(21) “Premium” means the entire cost of a health insurance plan, including the administration fee or the risk assumption charge.

(22) “Premium assistance payment” means the monthly consideration paid by the agency per enrollee in the Florida Kidcare program towards health insurance premiums.

(23) “Resident” means a United States citizen or lawfully residing child who is domiciled in this state.

(24) “Rural county” means a county having a population density of less than 100 persons per square mile, or a county defined by the most recent United States Census as rural, in which there is no prepaid health plan participating in the Medicaid program as of July 1, 1998.

(25) “Substantially similar” means that, with respect to additional services as defined in s. 2103(c)(2) of Title XXI of the Social Security Act, these services must have an actuarial value equal to at least 75 percent of the actuarial value of the coverage for that service in the benchmark benefit plan and, with respect to the basic services as defined in s. 2103(c)(1) of Title XXI of the Social Security Act, these services must be the same as the services in the benchmark benefit plan.