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State Children’s Health Insurance Program

Phase 1 Effective Date: April 1, 1998 124 Revised: 1/26/98, 2/19/98, 3/3/98, 3/6/98 Phase 2 Effective Date: July 1, 1998

Revised: 8/20/98, 8/24/98, 10/1/99, 7/28/00, 1/31/01, 7/02/02, 7/22/02, 1/3/03, 2/13/04, 9/27/04, 11/15/05, 8/11/05, 10/1/06, 7/1/09, 7/1/10, 7/1/11, 7/1/12 Section 12. Applicant and Enrollee Protections (Sections 2101(a))

 Check here if the state elects to use funds provided under Title XXI only to provide expanded eligibility under the state’s Medicaid plan.

Eligibility and Enrollment Matters

12.1 Please describe the review process for eligibility and enrollment matters that complies with 42 CFR §457.1120.

Assurances In compliance with 42 CFR §457.1120, Florida KidCare has a program specific review that meets the requirements of §§457.1130, 457.1140, 457.1150, 457.1160, 457.1170, and 457.1180.

The review process ensures that an applicant or enrollee has an opportunity for review, consistent with §§457.1140 and 457.1150 of a –

(1) Denial of eligibility;

(2) Failure to make a timely determination of eligibility; and

(3) Suspension or termination of enrollment, including disenrollment for failure to pay cost sharing; in establishing the Florida KidCare Act in July of 1998, Florida legislators provided in Section 409.8132 (9), penalties for voluntary cancellation, that “the agency shall establish enrollment criteria that must include penalties or waiting periods of not fewer than 30 days for reinstatement of coverage upon voluntary cancellation for nonpayment of premiums.” However, if an enrollee appeals termination of coverage for non-payment KidCare codes the system for a “0” premium and continues benefits until the dispute is resolved. Coverage continues during that period. Should the situation not be resolved in the enrollee’s favor, the enrollee will be disenrolled for the 30-day period prescribed by state law.

(4) Additionally, the review process ensures that an enrollee has an opportunity for external review of a delay, denial, reduction, suspension, or termination of health services in a timely manner. Each review is conducted independently, since the individuals involved in reviews are not involved in application/eligibility processing. Should any of the above actions be the result of automatic changes in eligibility, enrollment,