This docum ent does not reflect the intent or official position of the bill sponsor or House of Representatives.
STORAGE NAME: h0121b.HCA
DATE: 3/21/2023
HOUSE OF REPRESENTATIVES STAFF ANALYSIS
BILL #: CS/HB 121 Florida Kidcare Program Eligibility
SPONSOR(S): Healthcare Regulation Subcommittee, Bartleman and others
TIED BILLS: IDEN./SIM. BILLS:
REFERENCE ACTION ANALYST STAFF DIRECTOR or
BUDGET/POLICY CHIEF
1) Healthcare Regulation Subcommittee 17 Y, 0 N, As CS Calamas McElroy
2) Health Care Appropriations Subcommittee Smith Clark
3) Health & Human Services Committee
SUMMARY ANALYSIS
The Florida Kidcare Program implements the federal Children’s Health Insurance Program (CHIP) in Florida.
The CHIP provides federal matching funds to states to subsidize health insurance coverage for children in
families with incomes too high to qualify for Medicaid and meet other eligibility requirements.
Kidcare is governed by part II of ch. 409, F.S., and is administered jointly by the Agency for Health Care
Administration (AHCA), the Department of Children and Families (DCF), the Department of Health (DOH), and
the Florida Healthy Kids Corporation (Corporation) established in ch. 624, F.S.
Eligibility for the CHIP-funded program components of Kidcare is determined by household annual income, and
set as a factor of the Federal Poverty Level (FPL). Children in families with incomes up to 200% FPL ($60,000
for a family of four) are currently eligible for CHIP-subsidized coverage.
Families enrolled in CHIP-subsidized Kidcare programs pay a monthly, per-household premium of $15 or $20,
depending on income level.
CS/HB 121 increases eligibility for CHIP-subsidized Kidcare programs to 300% FPL ($90,000) for a family of
four), with a two-year phase-in process. In addition, the bill requires the Corporation to establish new monthly
premiums for enrollees in households over 150% FPL. The Corporation must establish the new premiums in at
least three, but no more than five, income-based tiers.
The bill has a significant, recurring, negative impact on the state and federal governments, and no impact on
local governments. See Fiscal Analysis.
The bill provides an effective date of July 1, 2023.
STORAGE NAME: h0121b.HCA PAGE: 2
DATE: 3/21/2023
FULL ANALYSIS
I. SUBSTANTIVE ANALYSIS
A. EFFECT OF PROPOSED CHANGES:
Background
Florida Kidcare Program
The Florida Kidcare Program (Kidcare or Program) was created by the Florida Legislature in 1998 in
response to the passage of the Children’s Health Insurance Program (CHIP) in 1997.
1
The CHIP
provides federal funding to states to provide subsidized health insurance coverage to uninsured
children in families with incomes that are too high to qualify for Medicaid but who meet other eligibility
requirements. When created, CHIP was initially authorized and allotted funding for 10 years. However,
due the program’s capped funding structure, the federal government has had to repeatedly reauthorize
and extend funding.
2
Most recently, the 2023 Consolidated Appropriations Act extended federal funding
for CHIP through fiscal year 2029.
3
Kidcare encompasses four programs.
1. Medicaid for children
2. The Medikids program
3. The Children’s Medical Services Network (for children with special needs)
4. The Florida Healthy Kids program
Kidcare is governed by part II of ch. 409, F.S., and is administered jointly by the Agency for Health Care
Administration (AHCA), the Department of Children and Families (DCF), the Department of Health
(DOH), and the Florida Healthy Kids Corporation (Corporation) established in ch. 624, F.S. The chart
below delineates the roles of each agency and the Corporation.
State Agency Responsibilities
Agency for Health Care
Administration (AHCA)
(MediKids)
Administers the Medicaid program (Title XIX)
Administers the MediKids program (Title XXI, ages 1-4)
Serves as lead Title XXI contact with the federal Centers for Medicare
and Medicaid Services
Distributes federal funds for Title XXI programs
Manages the Florida Healthy Kids Corporation contract
Develops and maintains the Title XXI Florida Kidcare State Plan
Department of Children
and Families (DCF)
(Medicaid for Children)
Determines Medicaid (Title XIX) eligibility
Administers the CMS Behavioral Health Network (Title XXI, ages 0-18)
Department of Health
(Children’s Medical
Services)
Administers Children’s Medical Services (Titles XIX and XXI, ages 0-
18 with special health care needs)
Florida Healthy Kids
Corporation
(Healthy Kids)
Performs administrative functions for Florida Kidcare (eligibility
determination, premium collection, marketing, and customer service)
Administers Florida Healthy Kids program (Title XXI, ages 5-18)
Funding
1
CHIP w as created as part of the Balanced Budget Act of 1997 (BBA 97, Pub. L. No. 105.33, s. 4901).
2
The Children’s Health Insurance Program Reauthorization Act of 2009 (CHIPRA, Pub. L. No. 111–3, s.101) reauthorized CHIP through fiscal year (FY)
2013, the Patient Protection and Affordable Care Act of 2010, (ACA, Pub. L. No. 111–148, s. 10203) extended CHIP funding through FY 2015, the
Medicare Access and CHIP Reauthorization Act of 2015 (Pub. L. No. 114–10, s. 301) extended funding through FY 2017, the Healthy Kids Act extended
funding to FY 2023 (Pub. L. No. 115-120, s. 3002), and the Bipartisan Budget Act of 2018, (Pub. L. No. 115-123, s. 50101) extended funding for CHIP
through 2023 .
3
Consolidated Appropriations Act, 2023, Pub. L. No. 117-328, s. 5111. STORAGE NAME: h0121b.HCA PAGE: 3
DATE: 3/21/2023
Kidcare coverage is funded by state and federal funds through Title XIX (Medicaid) and Title XXI
(CHIP) of the federal Social Security Act. The federal government provides matching funds for state
expenditures, called the Federal Medical Assistance Percentage (FMAP). The Medicaid (Title XIX)
FMAP is approximately 60%, meaning the federal government pays 60% of service costs, while the
state pays 40%. The CHIP (Title XXI) has a higher FMAP, at approximately 72%; the state pays 28%.
4
The following chart summarizes funding by eligibility category for the programs within Kidcare.
5
Eligibility and Cost-Sharing
Eligibility is determined in part by age and household income, as a percent of the Federal Poverty Level
(FPL), as indicated by the table below.
Program Ages
Family Income Eligibility
Monthly
Premium
Copay
(some services)
FPL Threshold Annual Income
6
Medicaid for
Children
0-1 185-200% FPL $55,500-$60,000 $0 $0
Medikids 1-4 133-200% FPL $41,400-$60,000 $15
for 133-158% FPL
$20
for 158-200% FPL
(per household)
Up to $10
Healthy Kids
5 133-200% FPL $41,400-$60,000 Up to $10
6-18 100-200% FPL $30,00-$60,000 Up to $10
Children’s
Medical Services
0-18 Up to 200% FPL $0-$60,000 $0
Full-Pay
(Medikids &
Healthy Kids)
1-18 Over 200% FPL Over $60,000
$210 - Medikids
$259 - Healthy Kids
(per child)
$10 or $15
Families contribute to the monthly premium cost of the coverage under the Title XXI-funded (CHIP)
components of Kidcare based on their household size, income, and other eligibility factors. Household
4
Both program FMAPs temporarily increased as a result of time-limited pandemic funding: 6.2% in Medicaid; and 4.34% in the CHIP. The increased
FMAPs w ill phase out quarterly in 2023. See, infra, note 10.
5
Institute for Child Health Policy at University of Florida, Florida Kidcare Program Evaluation 2015, available at
https://w eb.archive.org/web/20221108221838/https://ahca.myflorida.com/medicaid/Policy_and_Quality/Policy/program_policy/FLKidcare/PDF/2015_Flori
da_Kidcare_Evaluation_Report.pdf (last viewed March 20, 2023).
6
Based on a family of four. STORAGE NAME: h0121b.HCA PAGE: 4
DATE: 3/21/2023
monthly premiums are $15 or $20, depending on income level, as indicated by the table above.
Similarly, nominal service copays are also based on income level, as indicated by the table above.
Currently, these limited premium and copay ranges reflect the only income-based tiers for enrollee
cost-sharing in the subsidized Kidcare programs.
For families with incomes above the income limits for monthly premium assistance, Kidcare also offers
an option under the Healthy Kids component (ages 5-18) and the Medikids component (ages 1-4) for
the family to obtain coverage for their children by paying the full premium. This “Full-Pay” program
premium for Healthy Kids is $259 a month, or $3,114 annually, and the Full-Pay program requires a $5
or $10 copay for some services.
7
Currently, nearly 25,000 children are in Full-Pay program (3,312 in
Medikids and over 21,000 in Healthy Kids).
The increase from a $20 household-wide premium to a $259 per-child premium may be triggered by a
much lesser increase in income. For example, an income increase equating to 1% of the federal
poverty level is a $300 annual income increase (for a family of four). This small increase can move a
family from subsidized eligibility to Full-Pay eligibility, resulting in an increased annual coverage cost of
$5,748 (assuming the family of four has 2 children). This may cause a family to drop child coverage, or
limit coverage to the most medically needy child.
Enrollment
As of January, 117,092 children are enrolled in Kidcare.
8
Most of those children (80,258) are enrolled in
Healthy Kids (the Title XXI CHIP-subsidized program); 21,424 children are in the Full-Pay program.
9
Caseload growth in Kidcare is generally 2-3 percent per year; however, Fiscal Year 2023-2024
projections assume that Medicaid redeterminations,
10
which will begin in April 2023, will cause a
76.54% caseload growth in the Title XXI-funded (CHIP) part of program that year, as indicated by the
graph below.
11
7
While s. 409.814(7), F.S., requires Full-Pay enrollees to pay the entire cost of the premium, including administrative costs, in 2019 the legislature
began subsidizing those costs through the General Appropriation Act, to reduce significant premium increases caused by a shrinking risk pool. See,
Fiscal Year 2019-2020 General Appropriation Act Specific Appropriation 178, Ch. 2019-115 Law s of Florida.
8
Social Services Estimating Conference, Florida Kidcare Caseloads, Feb. 13, 2023.
9
AHCA 2023 Agency Legislative Bill Analysis, HB 121, dated Jan. 10, 2023.
10
The federal Coronavirus Aid, Relief, and Economic Security (CARES) Act provided an enhanced federal matching rate of 6.2 percentage points for
states during the COVID pandemic. The enhanced rate w as conditioned on states agreeing to provide continuous eligibility through the end of the
federally declared public health emergency. Under that requirement, Medicaid eligibility has not been review ed since March, 2020, meaning there may
be many enrollees w ho no longer meet the income eligibility requirements for the program. This contributed to a 1.8 million increase in enrollment since
2020. The federal Consolidated Appropriations Act of 2023 ended the continuous coverage policy effective April 1, 2023, and established a quarterly
reduction in the enhanced match rate through December 2023. See, Medicaid Redetermination, AHCA and DCF presentation in the Health and Human
Services Committee, Jan. 18, 2023.
11
While many families no longer eligible may no longer need health coverage, many may be at income levels too high for Medicaid but too low for other
forms of coverage. These families may enroll their children in Kidcare, resulting in this increased enrollment in FY 2023-2024. The graph also notes the
sudden decline in CHIP enrollment starting in Spring 2020, coinciding w ith the beginning of the pandemic. Many of those CHIP families may have
experienced a decline in income at that time and become eligible for Medicaid; the redetermination process may shift those families back to CHIP. STORAGE NAME: h0121b.HCA PAGE: 5
DATE: 3/21/2023
In 2021,
12
327,200 children in Florida were uninsured. Of those, 163,700 are in families with income
levels below 200% of the federal poverty level; that is, they were eligible for coverage under Kidcare (or
regular Medicaid).
13
Of the uninsured children in Florida, 42,073 children are in families with income levels between 200%
and 300% of the federal poverty level. These children are not currently eligible for (subsidized) Kidcare
coverage, but are eligible for the Full-Pay option.
Effect of Proposed Changes
CS/HB 121 expands eligibility for CHIP-funded Kidcare programs to children in families with household
incomes up to 300% of the federal poverty level (FPL), from the current 200% FPL threshold. In
addition, the bill authorizes the Florida Healthy Kids Corporation and AHCA to establish new premium
tiers for enrollees above 150% FPL, including the new expansion group.
Eligibility
The bill raises the eligibility income threshold for the CHIP-funded Medikids, Healthy Kids, and
Children’s Medical Services programs, all currently capped at 200% FPL, to 300%. The bill requires the
Corporation and AHCA to implement this expansion in two phases:
1. Expand to 250% FPL effective July 1, 2023
2. Expand to 300% FPL effective July 1, 2024
Subsidized Enrollment Impact
Assuming the higher threshold attracts more families to the subsidized program, the bill could increase
CHIP-subsidized Kidcare enrollment compared to current projections. In addition, the Medicaid
redetermination process
14
will likely increase enrollment in CHIP-subsidized Kidcare, as current
Medicaid enrollees with income levels too high for Medicaid disenroll and look for other coverage
options.
Full-Pay Enrollment Impact
Currently 24,736 children are in the Full-Pay program, all with household incomes higher than 200%
FPL. The Corporation estimates 8,610 of these children (7,617 in Healthy Kids and 993 in Medikids)
have household incomes under the expansion threshold of 300% FPL.
15
Under the bill, children in this
group would automatically move from Full-Pay to subsidized status, on the effective date of the
applicable household income level. This will have a negative fiscal impact on the state and federal
governments.
The Medicaid redetermination process is already projected to increase enrollment in Full-Pay, as
current Medicaid enrollees with income levels too high for Medicaid and too high for CHIP-subsidized
Kidcare disenroll and look for other coverage options. The Corporation estimates 10,431 children with
household incomes under 300% FPL will enroll in Full-Pay Kidcare in the first phase of the bill’s
implementation, when eligibility rises to 250% FPL; 8,131 in Healthy Kids and 2,300 in Medikids.
16
Some of this increase will be a result of Medicaid redetermination; some reflecting the usual enrollment
trend.
Children moving from Medicaid to Full-Pay will have a positive fiscal impact on the state and federal
governments. However, an unknown number of these new Full-Pay children will later shift to CHIP-
subsidized status in the second phase of the bill’s implementation, when eligibility rises to 300% FPL.
12
2021 is the most recent year for w hich there is federal census data.
13
Health Insurance Coverage of Low Income Children 0-18, 2021, Kaiser Family Foundation State Health Facts Data, available at
https://www.kff.org/other/state-indicator/health-insurance-coverage-of-low-income-children-0-18-under-200-fpl/?state=FL (last viewed March 20, 2023).
14
Supra, note 10.
15
Florida Healthy Kids Corporation, 2023 Legislative Bill Analysis: HB 121, March 1, 2023.
16
Id. STORAGE NAME: h0121b.HCA PAGE: 6
DATE: 3/21/2023
This would have a negative fiscal impact on the state and federal governments (but a smaller impact
than when they were enrolled in Medicaid).
Cost-Sharing
The bill also amends the structure of household premiums for CHIP-subsidized Kidcare. Currently the
premium is $15 a month, per household, for households with incomes 133-158% FPL, and $20, per
household, for households with incomes 158-200% FPL. Current law caps premiums for households
with incomes 150%-200% FPL to no more than 5% of the household’s annual income.
The bill requires the Corporation to establish premium tiers based on household income for all
enrollees with household incomes over 150% FPL. The bill’s requirement applies both to current
enrollees at 150%-200% FPL, and to the new eligibility group at 200%-300% FPL. The Corporation
must establish at least three tiers, but no more than five tiers, of premiums.
The bill does not address copays for the new eligibility group or amend them for existing eligibility
groups.
The bill provides an effective date of July 1, 2023.
B. SECTION DIRECTORY:
Section 1: Amends s.409.8132, F.S., relating to Medikids program component.
Section 2: Amends s. 409.8132, F.S., relating to Medikids program component.
Section 3: Amends s. 409.814, F.S., relating to eligibility.
Section 4: Amends s. 409.814, F.S., relating to eligibility.
Section 5: Amends s. 409.816, F.S., relating to limitations on premiums and cost sharing.
Section 6: Amends s. 624.91, F.S., relating to the Florida Healthy Kids Corporation Act
Section 7: Amends s. 624.91, F.S., relating to the Florida Healthy Kids Corporation Act.
Section 8: Providing an effective date of July 1, 2023.
II. FISCAL ANALYSIS & ECONOMIC IMPACT STATEMENT
A. FISCAL IMPACT ON STATE GOVERNMENT:
1. Revenues:
The Corporation will experience increased revenue due to the bill requirement of new, tiered
premiums (see Fiscal Comments). The Corporation will experience reductions in revenue related to
Full-Pay families moving to subsidized coverage.
2. Expenditures:
The Corporation projects over 10,000 additional children will enroll in the first implementation phase
(250% FPL group), and assumes a six-month delay in the effective date for that group (see Fiscal
Comments). For the second implementation phase (300% FPL group), the Corporation projects
over 23,000 additional children will enroll in FY 2024-2025.
17
Expenditure data and out-year enrollment projections are reflected in the table below.
17
Id. STORAGE NAME: h0121b.HCA PAGE: 7
DATE: 3/21/2023
In addition, the Corporation estimates implementation will generate administrative costs:
$800,000 in non-recurring funds in FY 2023-2024 for third-party administrator contracted
services to implement the new eligibility tiers.
$117,793 in recurring funds in FY 2023-2024, increasing to $269,742 in recurring funds in
FY 2024-2025, for additional third-party administrator fees for enrollee services based on
the projected enrollment increase.
Similarly, AHCA anticipates indeterminate one-time administrative implementation costs to update
the Florida Medicaid Management Information System (FMMIS).
18
B. FISCAL IMPACT ON LOCAL GOVERNMENTS:
1. Revenues:
18
Agency for Health Care Administration, 2023 Legislative Bill Analysis: HB 121, Jan. 10, 2023 (received Feb. 16, 2023). The AHCA analysis appears to
incorporate both AHCA and Corporation administrative costs, w ithout breaking out the FMMIS update item. STORAGE NAME: h0121b.HCA PAGE: 8
DATE: 3/21/2023
None.
2. Expenditures:
None.
C. DIRECT ECONOMIC IMPACT ON PRIVATE SECTOR:
Additional subsidized coverage at the income levels established in the bill may reduce use of employer-
based dependent child coverage, assuming any newly-eligible family uses such coverage now.
D. FISCAL COMMENTS:
The Corporation’s fiscal analysis is based on some policy assumptions not directly addressed in the bill.
1. The bill requires the Corporation to establish “at least three but no more than five” tiers of premiums
scaled to household income for enrollees with incomes over 150% of the federal poverty level. This
would apply to an income group currently eligible for subsidized Kidcare: those with incomes 150%-
200% of the federal poverty level.
The Corporation’s fiscal estimate assumes that the bill’s directive to develop tiered premiums does
not apply to the current 150%-200% FLP group, but instead applies only to the new eligibility
category (the 200%-300% FPL group). In addition, the Corporation applied two premium tiers, not
the minimum three required by the bill. The Corporation may need additional statutory guidance on
these points.
2. Current law requires the Corporation to set cost-sharing totaling no higher than 5% of a family’s
annual income.
Addressing only the new eligibility group, the Corporation established two premium tiers: one at 2%
of annual income (for households at 200-250% FPL) and one at 3% of annual income (for
households at 250-300% FPL). Both premium tiers are a factor of the highest income in the tier.
3. The current subsidized program uses a per-household monthly premium of $15 or $20 (depending
on income level), and does not vary the premium by the number of people, or children, in the
household. Current law does not specify the per-household approach, but that model has been
used historically in the program. By contrast, the current Full-Pay program uses a per-child
premium, for actuarial soundness.
The bill is silent as to which approach should be used for the new eligibility group. The
Corporation’s fiscal impact estimate uses a per-household premium, and varies the premium by
number of people in the household (not the number of children enrolled).
These assumptions generated the tiered premium structure in the table below.
Household
Size
Tier 1
250% FPL at 2%
Monthly
Premium
Tier 2
300% FPL at 3%
Monthly
Premium
1 $36,450 $60.75 $43,740 $109.35
2 $49,300 $82.17 $59,160 $147.90
3 $62,150 $103.58 $74,580 $186.45
4 $75,000 $125.00 $90,000 $225.00
5 $87,850 $146.42 $105,420 $263.55
6 $100,700 $167.83 $120,840 $302.10
7 $113,550 $189.25 $136,260 $340.65 STORAGE NAME: h0121b.HCA PAGE: 9
DATE: 3/21/2023
8 $126,400 $210.67 $151,680 $379.20
4. According to the Corporation, implementation of the first phase will take six months, making
the July 1, 2023, effective date for the first eligibility group administratively unreasonable.
The Corporation assumed a January 1, 2024, effective date for the first phase (250% FPL
group), and the bill’s July 1, 2024, effective date for the second phase (300% FPL group).
The Corporation’s fiscal analysis applies the two-step implementation required by the bill. However, the
Corporation recommends implementation to the 300% FPL level in one step, to avoid unnecessary
administrative costs.
III. COMMENTS
A. CONSTITUTIONAL ISSUES:
1. Applicability of Municipality/County Mandates Provision:
Not Applicable. This bill does not appear to affect county or municipal governments.
2. Other:
None.
B. RULE-MAKING AUTHORITY:
AHCA has sufficient rule-making authority to implement the provisions of the bill, if necessary.
C. DRAFTING ISSUES OR OTHER COMMENTS:
None.
IV. AMENDMENTS/COMMITTEE SUBSTITUTE CHANGES
On March 16, 2023, the Healthcare Regulation Subcommittee adopted one amendment and reported
the bill favorably as a committee substitute. The committee substitute corrected a drafting error to
change a reference to a percent of the federal poverty level to conform to like changes elsewhere in the
bill.