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State Children’s Health Insurance Program

Phase 1 Effective Date: April 1, 1998 125 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 or a change in coverage under the KidCare benefits package that affects all applicants or enrollees or a group of applicants or enrollees with regard to their individual circumstances, then those actions are not considered disputable.

All actions related to application processing for Florida KidCare, such as enrollment, disenrollment, payment of premiums, and provider choice are communicated to applicants/enrollees in writing.

Description of the Florida KidCare Review Process All applicants and all enrollees initiate impartial review in the same way, regardless of the level of complaint. Since eligibility is determined by the Healthy Kids’ computer system, impartial review is triggered for the first time when the individual calls with a complaint and speaks to a Healthy Kids staff person.

That first contact can be either in writing or by telephone with FHKC, expressing their dissatisfaction with a disputable action. In those cases where the applicant/participant requests a hearing to resolve a dispute, a comprehensive series of procedures has been developed to address the matter in question. The procedures are detailed in attachment B, “Florida KidCare Dispute Review Process.”

The Dispute Review Process addresses the denial of eligibility and failure to make a timely determination of eligibility, as well as termination of enrollment. Regarding disenrollment for failure to pay cost sharing, families required to pay a monthly premium are advised that the premium is due on the first of the month prior to coverage (the premium for February coverage is due January 1st). If payment is not received by the 7th, a late notice is sent out to the family. Families have the opportunity to call if they have any questions or to advise FHKC that they have already submitted payment. Families are afforded every opportunity to submit their payment in a timely manner. Enrollees will have coverage the following month if the premium payment is received by the last day of the current payment month (the premium for February coverage must be paid by January 31).

The following table illustrates the established review processes for each component of Florida KidCare.