409.816 Limitations on premiums and cost sharing.—The following limitations on premiums and cost sharing are established for the program.
(1) Enrollees who receive coverage under the Medicaid program may not be required to pay:
(a) Enrollment fees, premiums, or similar charges; or
(b) Copayments, deductibles, coinsurance, or similar charges.
(2) Enrollees in families with a family income equal to or below 150 percent of the federal poverty level, who are not receiving coverage under the Medicaid program, may not be required to pay:
(a) Enrollment fees, premiums, or similar charges that exceed the maximum monthly charge permitted under s. 1916(b)(1) of the Social Security Act; or
(b) Copayments, deductibles, coinsurance, or similar charges that exceed a nominal amount, as determined consistent with regulations referred to in s. 1916(a)(3) of the Social Security Act. However, such charges may not be imposed for preventive services, including well-baby and well-child care, age-appropriate immunizations, and routine hearing and vision screenings.
1(3) Enrollees in families with a family income above 150 percent of the federal poverty level who are not receiving coverage under the Medicaid program or who are not eligible under s. 409.814(7) may be required to pay enrollment fees, premiums, copayments, deductibles, coinsurance, or similar charges on a sliding scale related to income, except that the total annual aggregate cost sharing with respect to all children in a family may not exceed 5 percent of the family’s income. However, copayments, deductibles, coinsurance, or similar charges may not be imposed for preventive services, including well-baby and well-child care, age-appropriate immunizations, and routine hearing and vision screenings. Premiums for enrollees paying enrollment fees, premiums, copayments, deductibles, coinsurance, or similar charges as provided in this subsection shall be based on at least three but no more than six tiers of uniform premiums that increase with each tier as a percentage of the applicable threshold amount of the federal poverty level, by tier.
History.—ss. 41, 57, ch. 98-288; s. 22, ch. 2003-405; s. 9, ch. 2009-113; s. 91, ch. 2010-5; s. 10, ch. 2022-150; s. 3, ch. 2023-277.
1Note.—Section 5, ch. 2024-227, provides that “[i]mplementation of chapter 2023-277, Laws of Florida, by the Agency for Health Care Administration and the Florida Healthy Kids Corporation is contingent upon federal approval through a Medicaid waiver or a state plan amendment. This section shall take effect upon this act becoming a law.”
