Competitive procurement of postpayment claims review services and dependent eligibility verification services; public records exemption

110.12301

Competitive procurement of postpayment claims review services and dependent eligibility verification services; public records exemption.

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(1)

The Division of State Group Insurance is directed to competitively procure postpayment claims review services for the state group health insurance plans established pursuant to s. 110.123. Compensation under the contract shall be paid from amounts identified as claim overpayments that are made by or on behalf of the health plans and that are recovered by the vendor. The vendor may retain that portion of the amount recovered as provided in the contract. The contract must require the vendor to maintain all necessary documentation supporting the amounts recovered, retained, and remitted to the division; and

(2)

The department is directed to contract for dependent eligibility verification services for the state group insurance program.

(a)

The department or the contractor providing dependent eligibility verification services may require the following information from subscribers:

1.

To prove a spouse’s eligibility:

a.

If married less than 12 months and the subscriber and his or her spouse have not filed a joint federal income tax return, a government-issued marriage certificate;

b.

If married for 12 or more months, a transcript of the most recently filed federal income tax return; or

c.

If the documentation specified in sub-subparagraph a. or sub-subparagraph b. cannot be produced, an attestation of the marriage by sworn affidavit consistent with s. 92.50.

2.

To prove a biological child’s or a newborn grandchild’s eligibility:

a.

A government-issued birth certificate; or

b.

If a birth certificate cannot be produced, an attestation of the subscriber-dependent relationship by sworn affidavit consistent with s. 92.50.

3.

To prove an adopted child’s eligibility:

a.

An adoption certificate;

b.

An adoption placement agreement and a petition for adoption; or

c.

If the documentation specified in sub-subparagraph a. or sub-subparagraph b. cannot be produced, an attestation of the subscriber-dependent relationship by sworn affidavit consistent with s. 92.50.

4.

To prove a stepchild’s eligibility:

a.

A government-issued birth certificate for the stepchild; and

b.

The transcript of the subscriber’s most recently filed federal income tax return.

5.

To prove a child’s eligibility under a guardianship, a copy of the court order naming the subscriber or the subscriber’s spouse as the child’s legal guardian or custodian.

6.

To prove a foster child’s eligibility, a copy of the records showing the subscriber or the subscriber’s spouse as the dependent’s foster parent.

7.

To prove eligibility of an unmarried child age 26 to 30:

a.

A copy of the child’s government-issued birth certificate or adoption certificate naming the subscriber or the subscriber’s spouse as the child’s parent, or a copy of the court order naming the subscriber or the subscriber’s spouse as the child’s legal guardian or custodian;

b.

A copy of the Certification of Over-Age Dependent Eligibility Form; and

c.

A document confirming the child’s current enrollment as a student, including the name of the child, the name of the school, and the school term; or a bill or statement in the child’s name which is dated within the past 60 days and is mailed to the child at a Florida address.

8.

To prove eligibility for a disabled child age 26 or older:

a.

A copy of the child’s government-issued birth certificate or adoption certificate naming the subscriber or the subscriber’s spouse as the child’s parent, or a copy of the court order naming the subscriber or the subscriber’s spouse as the child’s legal guardian or custodian; and

b.

A copy of the transcript of the subscriber’s most recently filed federal income tax return listing the child’s name and the last four digits of the child’s social security number and identifying the child as the subscriber’s dependent for tax purposes.

(b)

A government-issued marriage license or marriage certificate submitted for dependent eligibility verification must include the date of the marriage between the subscriber and the spouse.

(c)

A government-issued birth certificate submitted for dependent eligibility verification must list the parents’ names.

(d)

Foreign-born subscribers unable to obtain the necessary documentation within the specified time period of producing verification documentation may provide a sworn affidavit consistent with s. 92.50 attesting to eligibility requirements.

(e)

Documentation submitted to verify eligibility may be an original or a photocopy of an original document. Before submitting a document, the subscriber may redact any information on a document which is not necessary to verify the eligibility of the dependent.

(f)

All documentation obtained by the department or the contractor to conduct the dependent eligibility verification services must be retained in accordance with the applicable records retention schedule.

(3)

Records collected for purposes of dependent eligibility verification services conducted for the state group insurance program, as authorized under subsection (2), and held by the department are confidential and exempt from s. 119.07(1) and s. 24(a), Art. I of the State Constitution. This subsection does not apply to records that are otherwise open for inspection and copying which are held by the department for purposes other than for the performance of dependent eligibility verification services. This subsection is subject to the Open Government Sunset Review Act in accordance with s. 119.15 and shall stand repealed on October 2, 2027, unless reviewed and saved from repeal through reenactment by the Legislature.

History.

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s. 1, ch. 2010-150; s. 33, ch. 2012-116; s. 1, ch. 2017-127; s. 1, ch. 2017-128; s. 1, ch. 2022-86; s. 1, ch. 2022-145; s. 11, ch. 2025-163.