Florida Senate - 2015 SB 968
By Senator Detert
28-01017-15 2015968__
1 A bill to be entitled
2 An act relating to employee health care plans;
3 amending s. 627.6699, F.S.; revising definitions;
4 removing provisions requiring certain insurance
5 carriers to provide semiannual reports to the Office
6 of Insurance Regulation; repealing requirements that
7 certain insurance carriers offer standard, basic, high
8 deductible, and limited health benefit plans; making
9 conforming changes; creating s. 627.66997, F.S.;
10 authorizing certain small employer insurance policies
11 to provide stop-loss coverage; providing requirements
12 for such policies; amending ss. 627.642, 627.6475, and
13 627.657, F.S.; conforming cross-references; amending
14 ss. 627.6571, 627.6675, 641.31074, and 641.3922, F.S.;
15 conforming provisions to changes made by the act;
16 providing an effective date.
17
18 Be It Enacted by the Legislature of the State of Florida:
19
20 Section 1. Subsection (2) of section 627.6699, Florida
21 Statutes, is amended, present paragraphs (c) through (x) of
22 subsection (3) are redesignated as paragraphs (b) through (w),
23 respectively, and present paragraphs (b) and (o) of that
24 subsection, subsection (5), paragraph (b) of subsection (6),
25 paragraphs (g), (h), (j), and (l) through (o) of subsection
26 (11), subsections (12) through (14), paragraph (k) of subsection
27 (15), and subsections (16) through (18) of that section are
28 amended, to read:
29 627.6699 Employee Health Care Access Act.—
30 (2) PURPOSE AND INTENT.—The purpose and intent of this
31 section is to promote the availability of health insurance
32 coverage to small employers regardless of their claims
33 experience or their employees’ health status, to establish rules
34 regarding renewability of that coverage, to establish
35 limitations on the use of exclusions for preexisting conditions,
36 to provide for development of a standard health benefit plan and
37 a basic health benefit plan to be offered to all small
38 employers, to provide for establishment of a reinsurance program
39 for coverage of small employers, and to improve the overall
40 fairness and efficiency of the small group health insurance
41 market.
42 (3) DEFINITIONS.—As used in this section, the term:
43 (b) “Basic health benefit plan” and “standard health
44 benefit plan” mean low-cost health care plans developed pursuant
45 to subsection (12).
46 (n)(o) “Modified community rating” means a method used to
47 develop carrier premiums which spreads financial risk across a
48 large population; allows the use of separate rating factors for
49 age, gender, family composition, tobacco usage, and geographic
50 area as determined under paragraph (5)(f) (5)(j); and allows
51 adjustments for: claims experience, health status, or duration
52 of coverage as permitted under subparagraph (6)(b)5.; and
53 administrative and acquisition expenses as permitted under
54 subparagraph (6)(b)5.
55 (5) AVAILABILITY OF COVERAGE.—
56 (a) Beginning January 1, 1993, every small employer carrier
57 issuing new health benefit plans to small employers in this
58 state must, as a condition of transacting business in this
59 state, offer to eligible small employers a standard health
60 benefit plan and a basic health benefit plan. Such a small
61 employer carrier shall issue a standard health benefit plan or a
62 basic health benefit plan to every eligible small employer that
63 elects to be covered under such plan, agrees to make the
64 required premium payments under such plan, and to satisfy the
65 other provisions of the plan.
66 (a)(b) In the case of A small employer carrier that which
67 does not, on or after January 1, 1993, offer coverage but renews
68 or continues which does, on or after January 1, 1993, renew or
69 continue coverage in force must, such carrier shall be required
70 to provide coverage to newly eligible employees and dependents
71 on the same basis as small employer carriers that offer which
72 are offering coverage on or after January 1, 1993.
73 (b)(c) Every small employer carrier must, as a condition of
74 transacting business in this state,:
75 1. offer and issue all small employer health benefit plans
76 on a guaranteed-issue basis to every eligible small employer,
77 with 2 to 50 eligible employees, that elects to be covered under
78 such plan, agrees to make the required premium payments, and
79 satisfies the other provisions of the plan. A rider for
80 additional or increased benefits may be medically underwritten
81 and may only be added to the standard health benefit plan. The
82 increased rate charged for the additional or increased benefit
83 must be rated in accordance with this section.
84 2. In the absence of enrollment availability in the Florida
85 Health Insurance Plan, offer and issue basic and standard small
86 employer health benefit plans and a high-deductible plan that
87 meets the requirements of a health savings account plan or
88 health reimbursement account as defined by federal law, on a
89 guaranteed-issue basis, during a 31-day open enrollment period
90 of August 1 through August 31 of each year, to every eligible
91 small employer, with fewer than two eligible employees, which
92 small employer is not formed primarily for the purpose of buying
93 health insurance and which elects to be covered under such plan,
94 agrees to make the required premium payments, and satisfies the
95 other provisions of the plan. Coverage provided under this
96 subparagraph shall begin on October 1 of the same year as the
97 date of enrollment, unless the small employer carrier and the
98 small employer agree to a different date. A rider for additional
99 or increased benefits may be medically underwritten and may only
100 be added to the standard health benefit plan. The increased rate
101 charged for the additional or increased benefit must be rated in
102 accordance with this section. For purposes of this subparagraph,
103 a person, his or her spouse, and his or her dependent children
104 constitute a single eligible employee if that person and spouse
105 are employed by the same small employer and either that person
106 or his or her spouse has a normal work week of less than 25
107 hours. Any right to an open enrollment of health benefit
108 coverage for groups of fewer than two employees, pursuant to
109 this section, shall remain in full force and effect in the
110 absence of the availability of new enrollment into the Florida
111 Health Insurance Plan.
112 3. This paragraph does not limit a carrier’s ability to
113 offer other health benefit plans to small employers if the
114 standard and basic health benefit plans are offered and
115 rejected.
116 (d) A small employer carrier must file with the office, in
117 a format and manner prescribed by the committee, a standard
118 health care plan, a high deductible plan that meets the federal
119 requirements of a health savings account plan or a health
120 reimbursement arrangement, and a basic health care plan to be
121 used by the carrier. The provisions of this section requiring
122 the filing of a high deductible plan are effective September 1,
123 2004.
124 (e) The office at any time may, after providing notice and
125 an opportunity for a hearing, disapprove the continued use by
126 the small employer carrier of the standard or basic health
127 benefit plan on the grounds that such plan does not meet the
128 requirements of this section.
129 (c)(f) Except as provided in paragraph (d) (g), a health
130 benefit plan covering small employers must comply with
131 preexisting condition provisions specified in s. 627.6561 or,
132 for health maintenance contracts, in s. 641.31071.
133 (d)(g) A health benefit plan covering small employers,
134 issued or renewed on or after January 1, 1994, must comply with
135 the following conditions:
136 1. All health benefit plans must be offered and issued on a
137 guaranteed-issue basis, except that benefits purchased through
138 riders as provided in paragraph (c) may be medically
139 underwritten for the group, but may not be individually
140 underwritten as to the employees or the dependents of such
141 employees. Additional or increased benefits may only be offered
142 by riders.
143 2. The provisions of Paragraph (c) applies (f) apply to
144 health benefit plans issued to a small employer who has two or
145 more eligible employees, and to health benefit plans that are
146 issued to a small employer who has fewer than two eligible
147 employees and that cover an employee who has had creditable
148 coverage continually to a date not more than 63 days before the
149 effective date of the new coverage.
150 3. For health benefit plans that are issued to a small
151 employer who has fewer than two employees and that cover an
152 employee who has not been continually covered by creditable
153 coverage within 63 days before the effective date of the new
154 coverage, preexisting condition provisions must not exclude
155 coverage for a period beyond 24 months following the employee’s
156 effective date of coverage and may relate only to:
157 a. Conditions that, during the 24-month period immediately
158 preceding the effective date of coverage, had manifested
159 themselves in such a manner as would cause an ordinarily prudent
160 person to seek medical advice, diagnosis, care, or treatment or
161 for which medical advice, diagnosis, care, or treatment was
162 recommended or received; or
163 b. A pregnancy existing on the effective date of coverage.
164 (e)(h) All health benefit plans issued under this section
165 must comply with the following conditions:
166 1. For employers who have fewer than two employees, a late
167 enrollee may be excluded from coverage for no longer than 24
168 months if he or she was not covered by creditable coverage
169 continually to a date not more than 63 days before the effective
170 date of his or her new coverage.
171 2. Any requirement used by a small employer carrier in
172 determining whether to provide coverage to a small employer
173 group, including requirements for minimum participation of
174 eligible employees and minimum employer contributions, must be
175 applied uniformly among all small employer groups having the
176 same number of eligible employees applying for coverage or
177 receiving coverage from the small employer carrier, except that
178 a small employer carrier that participates in, administers, or
179 issues health benefits pursuant to s. 381.0406 which do not
180 include a preexisting condition exclusion may require as a
181 condition of offering such benefits that the employer has had no
182 health insurance coverage for its employees for a period of at
183 least 6 months. A small employer carrier may vary application of
184 minimum participation requirements and minimum employer
185 contribution requirements only by the size of the small employer
186 group.
187 3. In applying minimum participation requirements with
188 respect to a small employer, a small employer carrier shall not
189 consider as an eligible employee employees or dependents who
190 have qualifying existing coverage in an employer-based group
191 insurance plan or an ERISA qualified self-insurance plan in
192 determining whether the applicable percentage of participation
193 is met. However, a small employer carrier may count eligible
194 employees and dependents who have coverage under another health
195 plan that is sponsored by that employer.
196 4. A small employer carrier shall not increase any
197 requirement for minimum employee participation or any
198 requirement for minimum employer contribution applicable to a
199 small employer at any time after the small employer has been
200 accepted for coverage, unless the employer size has changed, in
201 which case the small employer carrier may apply the requirements
202 that are applicable to the new group size.
203 5. If a small employer carrier offers coverage to a small
204 employer, it must offer coverage to all the small employer’s
205 eligible employees and their dependents. A small employer
206 carrier may not offer coverage limited to certain persons in a
207 group or to part of a group, except with respect to late
208 enrollees.
209 6. A small employer carrier may not modify any health
210 benefit plan issued to a small employer with respect to a small
211 employer or any eligible employee or dependent through riders,
212 endorsements, or otherwise to restrict or exclude coverage for
213 certain diseases or medical conditions otherwise covered by the
214 health benefit plan.
215 7. An initial enrollment period of at least 30 days must be
216 provided. An annual 30-day open enrollment period must be
217 offered to each small employer’s eligible employees and their
218 dependents. A small employer carrier must provide special
219 enrollment periods as required by s. 627.65615.
220 (i)1. A small employer carrier need not offer coverage or
221 accept applications pursuant to paragraph (a):
222 a. To a small employer if the small employer is not
223 physically located in an established geographic service area of
224 the small employer carrier, provided such geographic service
225 area shall not be less than a county;
226 b. To an employee if the employee does not work or reside
227 within an established geographic service area of the small
228 employer carrier; or
229 c. To a small employer group within an area in which the
230 small employer carrier reasonably anticipates, and demonstrates
231 to the satisfaction of the office, that it cannot, within its
232 network of providers, deliver service adequately to the members
233 of such groups because of obligations to existing group contract
234 holders and enrollees.
235 2. A small employer carrier that cannot offer coverage
236 pursuant to sub-subparagraph 1.c. may not offer coverage in the
237 applicable area to new cases of employer groups having more than
238 50 eligible employees or small employer groups until the later
239 of 180 days following each such refusal or the date on which the
240 carrier notifies the office that it has regained its ability to
241 deliver services to small employer groups.
242 3.a. A small employer carrier may deny health insurance
243 coverage in the small-group market if the carrier has
244 demonstrated to the office that:
245 (I) It does not have the financial reserves necessary to
246 underwrite additional coverage; and
247 (II) It is applying this sub-subparagraph uniformly to all
248 employers in the small-group market in this state consistent
249 with this section and without regard to the claims experience of
250 those employers and their employees and their dependents or any
251 health-status-related factor that relates to such employees and
252 dependents.
253 b. A small employer carrier, upon denying health insurance
254 coverage in connection with health benefit plans in accordance
255 with sub-subparagraph a., may not offer coverage in connection
256 with group health benefit plans in the small-group market in
257 this state for a period of 180 days after the date such coverage
258 is denied or until the insurer has demonstrated to the office
259 that the insurer has sufficient financial reserves to underwrite
260 additional coverage, whichever is later. The office may provide
261 for the application of this sub-subparagraph on a service-area
262 specific basis.
263 4. The commission shall, by rule, require each small
264 employer carrier to report, on or before March 1 of each year,
265 its gross annual premiums for all health benefit plans issued to
266 small employers during the previous calendar year, and also to
267 report its gross annual premiums for new, but not renewal,
268 standard and basic health benefit plans subject to this section
269 issued during the previous calendar year. No later than May 1 of
270 each year, the office shall calculate each carrier’s percentage
271 of all small employer group health premiums for the previous
272 calendar year and shall calculate the aggregate gross annual
273 premiums for new, but not renewal, standard and basic health
274 benefit plans for the previous calendar year.
275 (f)(j) The boundaries of geographic areas used by a small
276 employer carrier must coincide with county lines. A carrier may
277 not apply different geographic rating factors to the rates of
278 small employers located within the same county.
279 (6) RESTRICTIONS RELATING TO PREMIUM RATES.—
280 (b) For all small employer health benefit plans that are
281 subject to this section and issued by small employer carriers on
282 or after January 1, 1994, premium rates for health benefit plans
283 are subject to the following:
284 1. Small employer carriers must use a modified community
285 rating methodology in which the premium for each small employer
286 is determined solely on the basis of the eligible employee’s and
287 eligible dependent’s gender, age, family composition, tobacco
288 use, or geographic area as determined under paragraph (5)(f)
289 (5)(j) and in which the premium may be adjusted as permitted by
290 this paragraph. A small employer carrier is not required to use
291 gender as a rating factor for a nongrandfathered health plan.
292 2. Rating factors related to age, gender, family
293 composition, tobacco use, or geographic location may be
294 developed by each carrier to reflect the carrier’s experience.
295 The factors used by carriers are subject to office review and
296 approval.
297 3. Small employer carriers may not modify the rate for a
298 small employer for 12 months from the initial issue date or
299 renewal date, unless the composition of the group changes or
300 benefits are changed. However, a small employer carrier may
301 modify the rate one time within the 12 months after the initial
302 issue date for a small employer who enrolls under a previously
303 issued group policy that has a common anniversary date for all
304 employers covered under the policy if:
305 a. The carrier discloses to the employer in a clear and
306 conspicuous manner the date of the first renewal and the fact
307 that the premium may increase on or after that date.
308 b. The insurer demonstrates to the office that efficiencies
309 in administration are achieved and reflected in the rates
310 charged to small employers covered under the policy.
311 4. A carrier may issue a group health insurance policy to a
312 small employer health alliance or other group association with
313 rates that reflect a premium credit for expense savings
314 attributable to administrative activities being performed by the
315 alliance or group association if such expense savings are
316 specifically documented in the insurer’s rate filing and are
317 approved by the office. Any such credit may not be based on
318 different morbidity assumptions or on any other factor related
319 to the health status or claims experience of any person covered
320 under the policy. This subparagraph does not exempt an alliance
321 or group association from licensure for activities that require
322 licensure under the insurance code. A carrier issuing a group
323 health insurance policy to a small employer health alliance or
324 other group association shall allow any properly licensed and
325 appointed agent of that carrier to market and sell the small
326 employer health alliance or other group association policy. Such
327 agent shall be paid the usual and customary commission paid to
328 any agent selling the policy.
329 5. Any adjustments in rates for claims experience, health
330 status, or duration of coverage may not be charged to individual
331 employees or dependents. For a small employer’s policy, such
332 adjustments may not result in a rate for the small employer
333 which deviates more than 15 percent from the carrier’s approved
334 rate. Any such adjustment must be applied uniformly to the rates
335 charged for all employees and dependents of the small employer.
336 A small employer carrier may make an adjustment to a small
337 employer’s renewal premium, up to 10 percent annually, due to
338 the claims experience, health status, or duration of coverage of
339 the employees or dependents of the small employer. Semiannually,
340 small group carriers shall report information on forms adopted
341 by rule by the commission, to enable the office to monitor the
342 relationship of aggregate adjusted premiums actually charged
343 policyholders by each carrier to the premiums that would have
344 been charged by application of the carrier’s approved modified
345 community rates. If the aggregate resulting from the application
346 of such adjustment exceeds the premium that would have been
347 charged by application of the approved modified community rate
348 by 4 percent for the current policy term reporting period, the
349 carrier shall limit the application of such adjustments only to
350 minus adjustments beginning within 60 days after the report is
351 sent to the office. For any subsequent policy term reporting
352 period, if the total aggregate adjusted premium actually charged
353 does not exceed the premium that would have been charged by
354 application of the approved modified community rate by 4
355 percent, the carrier may apply both plus and minus adjustments.
356 A small employer carrier may provide a credit to a small
357 employer’s premium based on administrative and acquisition
358 expense differences resulting from the size of the group. Group
359 size administrative and acquisition expense factors may be
360 developed by each carrier to reflect the carrier’s experience
361 and are subject to office review and approval.
362 6. A small employer carrier rating methodology may include
363 separate rating categories for one dependent child, for two
364 dependent children, and for three or more dependent children for
365 family coverage of employees having a spouse and dependent
366 children or employees having dependent children only. A small
367 employer carrier may have fewer, but not greater, numbers of
368 categories for dependent children than those specified in this
369 subparagraph.
370 7. Small employer carriers may not use a composite rating
371 methodology to rate a small employer with fewer than 10
372 employees. For the purposes of this subparagraph, the term
373 “composite rating methodology” means a rating methodology that
374 averages the impact of the rating factors for age and gender in
375 the premiums charged to all of the employees of a small
376 employer.
377 8. A carrier may separate the experience of small employer
378 groups with fewer than 2 eligible employees from the experience
379 of small employer groups with 2-50 eligible employees for
380 purposes of determining an alternative modified community
381 rating.
382 a. If a carrier separates the experience of small employer
383 groups, the rate to be charged to small employer groups of fewer
384 than 2 eligible employees may not exceed 150 percent of the rate
385 determined for small employer groups of 2-50 eligible employees.
386 However, the carrier may charge excess losses of the experience
387 pool consisting of small employer groups with less than 2
388 eligible employees to the experience pool consisting of small
389 employer groups with 2-50 eligible employees so that all losses
390 are allocated and the 150-percent rate limit on the experience
391 pool consisting of small employer groups with less than 2
392 eligible employees is maintained.
393 b. Notwithstanding s. 627.411(1), the rate to be charged to
394 a small employer group of fewer than 2 eligible employees,
395 insured as of July 1, 2002, may be up to 125 percent of the rate
396 determined for small employer groups of 2-50 eligible employees
397 for the first annual renewal and 150 percent for subsequent
398 annual renewals.
399 9. A carrier shall separate the experience of grandfathered
400 health plans from nongrandfathered health plans for determining
401 rates.
402 (11) SMALL EMPLOYER HEALTH REINSURANCE PROGRAM.—
403 (g) A reinsuring carrier may reinsure with the program
404 coverage of an eligible employee of a small employer, or any
405 dependent of such an employee, subject to each of the following
406 provisions:
407 1. With respect to a standard and basic health care plan,
408 the program must reinsure the level of coverage provided; and,
409 with respect to any other plan, the program must reinsure the
410 coverage up to, but not exceeding, the level of coverage
411 provided under the standard and basic health care plan.
412 1.2. Except in the case of a late enrollee, a reinsuring
413 carrier may reinsure an eligible employee or dependent within 60
414 days after the commencement of the coverage of the small
415 employer. A newly employed eligible employee or dependent of a
416 small employer may be reinsured within 60 days after the
417 commencement of his or her coverage.
418 2.3. A small employer carrier may reinsure an entire
419 employer group within 60 days after the commencement of the
420 group’s coverage under the plan. The carrier may choose to
421 reinsure newly eligible employees and dependents of the
422 reinsured group pursuant to subparagraph 1.
423 3.4. The program may not reimburse a participating carrier
424 with respect to the claims of a reinsured employee or dependent
425 until the carrier has paid incurred claims of at least $5,000 in
426 a calendar year for benefits covered by the program. In
427 addition, the reinsuring carrier shall be responsible for 10
428 percent of the next $50,000 and 5 percent of the next $100,000
429 of incurred claims during a calendar year and the program shall
430 reinsure the remainder.
431 4.5. The board annually shall adjust the initial level of
432 claims and the maximum limit to be retained by the carrier to
433 reflect increases in costs and utilization within the standard
434 market for health benefit plans within the state. The adjustment
435 shall not be less than the annual change in the medical
436 component of the “Consumer Price Index for All Urban Consumers”
437 of the Bureau of Labor Statistics of the Department of Labor,
438 unless the board proposes and the office approves a lower
439 adjustment factor.
440 5.6. A small employer carrier may terminate reinsurance for
441 all reinsured employees or dependents on any plan anniversary.
442 6.7. The premium rate charged for reinsurance by the
443 program to a health maintenance organization that is approved by
444 the Secretary of Health and Human Services as a federally
445 qualified health maintenance organization pursuant to 42 U.S.C.
446 s. 300e(c)(2)(A) and that, as such, is subject to requirements
447 that limit the amount of risk that may be ceded to the program,
448 which requirements are more restrictive than subparagraph 3. 4.,
449 shall be reduced by an amount equal to that portion of the risk,
450 if any, which exceeds the amount set forth in subparagraph 3. 4.
451 which may not be ceded to the program.
452 7.8. The board may consider adjustments to the premium
453 rates charged for reinsurance by the program for carriers that
454 use effective cost containment measures, including high-cost
455 case management, as defined by the board.
456 8.9. A reinsuring carrier shall apply its case-management
457 and claims-handling techniques, including, but not limited to,
458 utilization review, individual case management, preferred
459 provider provisions, other managed care provisions or methods of
460 operation, consistently with both reinsured business and
461 nonreinsured business.
462 (h)1. The board, as part of the plan of operation, shall
463 establish a methodology for determining premium rates to be
464 charged by the program for reinsuring small employers and
465 individuals pursuant to this section. The methodology shall
466 include a system for classification of small employers that
467 reflects the types of case characteristics commonly used by
468 small employer carriers in the state. The methodology shall
469 provide for the development of basic reinsurance premium rates,
470 which shall be multiplied by the factors set for them in this
471 paragraph to determine the premium rates for the program. The
472 basic reinsurance premium rates shall be established by the
473 board, subject to the approval of the office, and shall be set
474 at levels which reasonably approximate gross premiums charged to
475 small employers by small employer carriers for health benefit
476 plans with benefits similar to the standard and basic health
477 benefit plan. The premium rates set by the board may vary by
478 geographical area, as determined under this section, to reflect
479 differences in cost. The multiplying factors must be established
480 as follows:
481 a. The entire group may be reinsured for a rate that is 1.5
482 times the rate established by the board.
483 b. An eligible employee or dependent may be reinsured for a
484 rate that is 5 times the rate established by the board.
485 2. The board periodically shall review the methodology
486 established, including the system of classification and any
487 rating factors, to assure that it reasonably reflects the claims
488 experience of the program. The board may propose changes to the
489 rates which shall be subject to the approval of the office.
490 (j)1. Before July 1 of each calendar year, the board shall
491 determine and report to the office the program net loss for the
492 previous year, including administrative expenses for that year,
493 and the incurred losses for the year, taking into account
494 investment income and other appropriate gains and losses.
495 2. Any net loss for the year shall be recouped by
496 assessment of the carriers, as follows:
497 a. The operating losses of the program shall be assessed in
498 the following order subject to the specified limitations. The
499 first tier of assessments shall be made against reinsuring
500 carriers in an amount which shall not exceed 5 percent of each
501 reinsuring carrier’s premiums from health benefit plans covering
502 small employers. If such assessments have been collected and
503 additional moneys are needed, the board shall make a second tier
504 of assessments in an amount which shall not exceed 0.5 percent
505 of each carrier’s health benefit plan premiums. Except as
506 provided in paragraph (m) (n), risk-assuming carriers are exempt
507 from all assessments authorized pursuant to this section. The
508 amount paid by a reinsuring carrier for the first tier of
509 assessments shall be credited against any additional assessments
510 made.
511 b. The board shall equitably assess carriers for operating
512 losses of the plan based on market share. The board shall
513 annually assess each carrier a portion of the operating losses
514 of the plan. The first tier of assessments shall be determined
515 by multiplying the operating losses by a fraction, the numerator
516 of which equals the reinsuring carrier’s earned premium
517 pertaining to direct writings of small employer health benefit
518 plans in the state during the calendar year for which the
519 assessment is levied, and the denominator of which equals the
520 total of all such premiums earned by reinsuring carriers in the
521 state during that calendar year. The second tier of assessments
522 shall be based on the premiums that all carriers, except risk
523 assuming carriers, earned on all health benefit plans written in
524 this state. The board may levy interim assessments against
525 carriers to ensure the financial ability of the plan to cover
526 claims expenses and administrative expenses paid or estimated to
527 be paid in the operation of the plan for the calendar year prior
528 to the association’s anticipated receipt of annual assessments
529 for that calendar year. Any interim assessment is due and
530 payable within 30 days after receipt by a carrier of the interim
531 assessment notice. Interim assessment payments shall be credited
532 against the carrier’s annual assessment. Health benefit plan
533 premiums and benefits paid by a carrier that are less than an
534 amount determined by the board to justify the cost of collection
535 may not be considered for purposes of determining assessments.
536 c. Subject to the approval of the office, the board shall
537 make an adjustment to the assessment formula for reinsuring
538 carriers that are approved as federally qualified health
539 maintenance organizations by the Secretary of Health and Human
540 Services pursuant to 42 U.S.C. s. 300e(c)(2)(A) to the extent,
541 if any, that restrictions are placed on them that are not
542 imposed on other small employer carriers.
543 3. Before July 1 of each year, the board shall determine
544 and file with the office an estimate of the assessments needed
545 to fund the losses incurred by the program in the previous
546 calendar year.
547 4. If the board determines that the assessments needed to
548 fund the losses incurred by the program in the previous calendar
549 year will exceed the amount specified in subparagraph 2., the
550 board shall evaluate the operation of the program and report its
551 findings, including any recommendations for changes to the plan
552 of operation, to the office within 180 days following the end of
553 the calendar year in which the losses were incurred. The
554 evaluation shall include an estimate of future assessments, the
555 administrative costs of the program, the appropriateness of the
556 premiums charged and the level of carrier retention under the
557 program, and the costs of coverage for small employers. If the
558 board fails to file a report with the office within 180 days
559 following the end of the applicable calendar year, the office
560 may evaluate the operations of the program and implement such
561 amendments to the plan of operation the office deems necessary
562 to reduce future losses and assessments.
563 5. If assessments exceed the amount of the actual losses
564 and administrative expenses of the program, the excess shall be
565 held as interest and used by the board to offset future losses
566 or to reduce program premiums. As used in this paragraph, the
567 term “future losses” includes reserves for incurred but not
568 reported claims.
569 6. Each carrier’s proportion of the assessment shall be
570 determined annually by the board, based on annual statements and
571 other reports considered necessary by the board and filed by the
572 carriers with the board.
573 7. Provision shall be made in the plan of operation for the
574 imposition of an interest penalty for late payment of an
575 assessment.
576 8. A carrier may seek, from the office, a deferment, in
577 whole or in part, from any assessment made by the board. The
578 office may defer, in whole or in part, the assessment of a
579 carrier if, in the opinion of the office, the payment of the
580 assessment would place the carrier in a financially impaired
581 condition. If an assessment against a carrier is deferred, in
582 whole or in part, the amount by which the assessment is deferred
583 may be assessed against the other carriers in a manner
584 consistent with the basis for assessment set forth in this
585 section. The carrier receiving such deferment remains liable to
586 the program for the amount deferred and is prohibited from
587 reinsuring any individuals or groups in the program if it fails
588 to pay assessments.
589 (l) The board, as part of the plan of operation, shall
590 develop standards setting forth the manner and levels of
591 compensation to be paid to agents for the sale of basic and
592 standard health benefit plans. In establishing such standards,
593 the board shall take into consideration the need to assure the
594 broad availability of coverages, the objectives of the program,
595 the time and effort expended in placing the coverage, the need
596 to provide ongoing service to the small employer, the levels of
597 compensation currently used in the industry, and the overall
598 costs of coverage to small employers selecting these plans.
599 (l)(m) The board shall monitor compliance with this
600 section, including the market conduct of small employer
601 carriers, and shall report to the office any unfair trade
602 practices and misleading or unfair conduct by a small employer
603 carrier that has been reported to the board by agents,
604 consumers, or any other person. The office shall investigate all
605 reports and, upon a finding of noncompliance with this section
606 or of unfair or misleading practices, shall take action against
607 the small employer carrier as permitted under the insurance code
608 or chapter 641. The board is not given investigatory or
609 regulatory powers, but must forward all reports of cases or
610 abuse or misrepresentation to the office.
611 (m)(n) Notwithstanding paragraph (j), the administrative
612 expenses of the program shall be recouped by assessment of risk
613 assuming carriers and reinsuring carriers and such amounts shall
614 not be considered part of the operating losses of the plan for
615 the purposes of this paragraph. Each carrier’s portion of such
616 administrative expenses shall be determined by multiplying the
617 total of such administrative expenses by a fraction, the
618 numerator of which equals the carrier’s earned premium
619 pertaining to direct writing of small employer health benefit
620 plans in the state during the calendar year for which the
621 assessment is levied, and the denominator of which equals the
622 total of such premiums earned by all carriers in the state
623 during such calendar year.
624 (n)(o) The board shall advise the office, the Agency for
625 Health Care Administration, the department, other executive
626 departments, and the Legislature on health insurance issues.
627 Specifically, the board shall:
628 1. Provide a forum for stakeholders, consisting of
629 insurers, employers, agents, consumers, and regulators, in the
630 private health insurance market in this state.
631 2. Review and recommend strategies to improve the
632 functioning of the health insurance markets in this state with a
633 specific focus on market stability, access, and pricing.
634 3. Make recommendations to the office for legislation
635 addressing health insurance market issues and provide comments
636 on health insurance legislation proposed by the office.
637 4. Meet at least three times each year. One meeting shall
638 be held to hear reports and to secure public comment on the
639 health insurance market, to develop any legislation needed to
640 address health insurance market issues, and to provide comments
641 on health insurance legislation proposed by the office.
642 5. Issue a report to the office on the state of the health
643 insurance market by September 1 each year. The report shall
644 include recommendations for changes in the health insurance
645 market, results from implementation of previous recommendations,
646 and information on health insurance markets.
647 (12) STANDARD, BASIC, HIGH DEDUCTIBLE, AND LIMITED HEALTH
648 BENEFIT PLANS.—
649 (a)1. The Chief Financial Officer shall appoint a health
650 benefit plan committee composed of four representatives of
651 carriers which shall include at least two representatives of
652 HMOs, at least one of which is a staff model HMO, two
653 representatives of agents, four representatives of small
654 employers, and one employee of a small employer. The carrier
655 members shall be selected from a list of individuals recommended
656 by the board. The Chief Financial Officer may require the board
657 to submit additional recommendations of individuals for
658 appointment.
659 2. The plans shall comply with all of the requirements of
660 this subsection.
661 3. The plans must be filed with and approved by the office
662 prior to issuance or delivery by any small employer carrier.
663 4. After approval of the revised health benefit plans, if
664 the office determines that modifications to a plan might be
665 appropriate, the Chief Financial Officer shall appoint a new
666 health benefit plan committee in the manner provided in
667 subparagraph 1. to submit recommended modifications to the
668 office for approval.
669 (b)1. Each small employer carrier issuing new health
670 benefit plans shall offer to any small employer, upon request, a
671 standard health benefit plan, a basic health benefit plan, and a
672 high deductible plan that meets the requirements of a health
673 savings account plan as defined by federal law or a health
674 reimbursement arrangement as authorized by the Internal Revenue
675 Service, that meet the criteria set forth in this section.
676 2. For purposes of this subsection, the terms “standard
677 health benefit plan,” “basic health benefit plan,” and “high
678 deductible plan” mean policies or contracts that a small
679 employer carrier offers to eligible small employers that
680 contain:
681 a. An exclusion for services that are not medically
682 necessary or that are not covered preventive health services;
683 and
684 b. A procedure for preauthorization by the small employer
685 carrier, or its designees.
686 3. A small employer carrier may include the following
687 managed care provisions in the policy or contract to control
688 costs:
689 a. A preferred provider arrangement or exclusive provider
690 organization or any combination thereof, in which a small
691 employer carrier enters into a written agreement with the
692 provider to provide services at specified levels of
693 reimbursement or to provide reimbursement to specified
694 providers. Any such written agreement between a provider and a
695 small employer carrier must contain a provision under which the
696 parties agree that the insured individual or covered member has
697 no obligation to make payment for any medical service rendered
698 by the provider which is determined not to be medically
699 necessary. A carrier may use preferred provider arrangements or
700 exclusive provider arrangements to the same extent as allowed in
701 group products that are not issued to small employers.
702 b. A procedure for utilization review by the small employer
703 carrier or its designees.
704
705 This subparagraph does not prohibit a small employer carrier
706 from including in its policy or contract additional managed care
707 and cost containment provisions, subject to the approval of the
708 office, which have potential for controlling costs in a manner
709 that does not result in inequitable treatment of insureds or
710 subscribers. The carrier may use such provisions to the same
711 extent as authorized for group products that are not issued to
712 small employers.
713 4. The standard health benefit plan shall include:
714 a. Coverage for inpatient hospitalization;
715 b. Coverage for outpatient services;
716 c. Coverage for newborn children pursuant to s. 627.6575;
717 d. Coverage for child care supervision services pursuant to
718 s. 627.6579;
719 e. Coverage for adopted children upon placement in the
720 residence pursuant to s. 627.6578;
721 f. Coverage for mammograms pursuant to s. 627.6613;
722 g. Coverage for handicapped children pursuant to s.
723 627.6615;
724 h. Emergency or urgent care out of the geographic service
725 area; and
726 i. Coverage for services provided by a hospice licensed
727 under s. 400.602 in cases where such coverage would be the most
728 appropriate and the most cost-effective method for treating a
729 covered illness.
730 5. The standard health benefit plan and the basic health
731 benefit plan may include a schedule of benefit limitations for
732 specified services and procedures. If the committee develops
733 such a schedule of benefits limitation for the standard health
734 benefit plan or the basic health benefit plan, a small employer
735 carrier offering the plan must offer the employer an option for
736 increasing the benefit schedule amounts by 4 percent annually.
737 6. The basic health benefit plan shall include all of the
738 benefits specified in subparagraph 4.; however, the basic health
739 benefit plan shall place additional restrictions on the benefits
740 and utilization and may also impose additional cost containment
741 measures.
742 7. Sections 627.419(2), (3), and (4), 627.6574, 627.6612,
743 627.66121, 627.66122, 627.6616, 627.6618, 627.668, and 627.66911
744 apply to the standard health benefit plan and to the basic
745 health benefit plan. However, notwithstanding said provisions,
746 the plans may specify limits on the number of authorized
747 treatments, if such limits are reasonable and do not
748 discriminate against any type of provider.
749 8. The high deductible plan associated with a health
750 savings account or a health reimbursement arrangement shall
751 include all the benefits specified in subparagraph 4.
752 9. Each small employer carrier that provides for inpatient
753 and outpatient services by allopathic hospitals may provide as
754 an option of the insured similar inpatient and outpatient
755 services by hospitals accredited by the American Osteopathic
756 Association when such services are available and the osteopathic
757 hospital agrees to provide the service.
758 (c) If a small employer rejects, in writing, the standard
759 health benefit plan, the basic health benefit plan, and the high
760 deductible health savings account plan or a health reimbursement
761 arrangement, the small employer carrier may offer the small
762 employer a limited benefit policy or contract.
763 (d)1. Upon offering coverage under a standard health
764 benefit plan, a basic health benefit plan, or a limited benefit
765 policy or contract for a small employer group, the small
766 employer carrier shall provide such employer group with a
767 written statement that contains, at a minimum:
768 a. An explanation of those mandated benefits and providers
769 that are not covered by the policy or contract;
770 b. An explanation of the managed care and cost control
771 features of the policy or contract, along with all appropriate
772 mailing addresses and telephone numbers to be used by insureds
773 in seeking information or authorization; and
774 c. An explanation of the primary and preventive care
775 features of the policy or contract.
776
777 Such disclosure statement must be presented in a clear and
778 understandable form and format and must be separate from the
779 policy or certificate or evidence of coverage provided to the
780 employer group.
781 2. Before a small employer carrier issues a standard health
782 benefit plan, a basic health benefit plan, or a limited benefit
783 policy or contract, the carrier must obtain from the prospective
784 policyholder a signed written statement in which the prospective
785 policyholder:
786 a. Certifies as to eligibility for coverage under the
787 standard health benefit plan, basic health benefit plan, or
788 limited benefit policy or contract;
789 b. Acknowledges the limited nature of the coverage and an
790 understanding of the managed care and cost control features of
791 the policy or contract;
792 c. Acknowledges that if misrepresentations are made
793 regarding eligibility for coverage under a standard health
794 benefit plan, a basic health benefit plan, or a limited benefit
795 policy or contract, the person making such misrepresentations
796 forfeits coverage provided by the policy or contract; and
797 d. If a limited plan is requested, acknowledges that the
798 prospective policyholder had been offered, at the time of
799 application for the insurance policy or contract, the
800 opportunity to purchase any health benefit plan offered by the
801 carrier and that the prospective policyholder rejected that
802 coverage.
803
804 A copy of such written statement must be provided to the
805 prospective policyholder by the time of delivery of the policy
806 or contract, and the original of such written statement must be
807 retained in the files of the small employer carrier for the
808 period of time that the policy or contract remains in effect or
809 for 5 years, whichever is longer.
810 3. Any material statement made by an applicant for coverage
811 under a health benefit plan which falsely certifies the
812 applicant’s eligibility for coverage serves as the basis for
813 terminating coverage under the policy or contract.
814 (e) A small employer carrier may not use any policy,
815 contract, form, or rate under this section, including
816 applications, enrollment forms, policies, contracts,
817 certificates, evidences of coverage, riders, amendments,
818 endorsements, and disclosure forms, until the insurer has filed
819 it with the office and the office has approved it under ss.
820 627.410 and 627.411 and this section.
821 (12)(13) STANDARDS TO ASSURE FAIR MARKETING.—
822 (a) Each small employer carrier shall actively market
823 health benefit plan coverage, including the basic and standard
824 health benefit plans, including any subsequent modifications or
825 additions to those plans, to eligible small employers in the
826 state. Before January 1, 1994, if a small employer carrier
827 denies coverage to a small employer on the basis of the health
828 status or claims experience of the small employer or its
829 employees or dependents, the small employer carrier shall offer
830 the small employer the opportunity to purchase a basic health
831 benefit plan and a standard health benefit plan. Beginning
832 January 1, 1994, Small employer carriers must offer and issue
833 all plans on a guaranteed-issue basis.
834 (b) A No small employer carrier or agent shall not,
835 directly or indirectly, engage in the following activities:
836 1. Encouraging or directing small employers to refrain from
837 filing an application for coverage with the small employer
838 carrier because of the health status, claims experience,
839 industry, occupation, or geographic location of the small
840 employer.
841 2. Encouraging or directing small employers to seek
842 coverage from another carrier because of the health status,
843 claims experience, industry, occupation, or geographic location
844 of the small employer.
845 (c) The provisions of Paragraph (a) does shall not apply
846 with respect to information provided by a small employer carrier
847 or agent to a small employer regarding the established
848 geographic service area or a restricted network provision of a
849 small employer carrier.
850 (d) A No small employer carrier shall not, directly or
851 indirectly, enter into any contract, agreement, or arrangement
852 with an agent that provides for or results in the compensation
853 paid to an agent for the sale of a health benefit plan to be
854 varied because of the health status, claims experience,
855 industry, occupation, or geographic location of the small
856 employer except if the compensation arrangement provides
857 compensation to an agent on the basis of percentage of premium,
858 provided that the percentage shall not vary because of the
859 health status, claims experience, industry, occupation, or
860 geographic area of the small employer.
861 (e) A small employer carrier shall provide reasonable
862 compensation, as provided under the plan of operation of the
863 program, to an agent, if any, for the sale of a basic or
864 standard health benefit plan.
865 (e)(f) A No small employer carrier shall not terminate,
866 fail to renew, or limit its contract or agreement of
867 representation with an agent for any reason related to the
868 health status, claims experience, occupation, or geographic
869 location of the small employers placed by the agent with the
870 small employer carrier unless the agent consistently engages in
871 practices that violate this section or s. 626.9541.
872 (f)(g) A No small employer carrier or agent shall not
873 induce or otherwise encourage a small employer to separate or
874 otherwise exclude an employee from health coverage or benefits
875 provided in connection with the employee’s employment.
876 (g)(h) Denial by a small employer carrier of an application
877 for coverage from a small employer shall be in writing and shall
878 state the reason or reasons for the denial.
879 (h)(i) The commission may establish regulations setting
880 forth additional standards to provide for the fair marketing and
881 broad availability of health benefit plans to small employers in
882 this state.
883 (i)(j) A violation of this section by a small employer
884 carrier or an agent is shall be an unfair trade practice under
885 s. 626.9541 or ss. 641.3903 and 641.3907.
886 (j)(k) If a small employer carrier enters into a contract,
887 agreement, or other arrangement with a third-party administrator
888 to provide administrative, marketing, or other services relating
889 to the offering of health benefit plans to small employers in
890 this state, the third-party administrator shall be subject to
891 this section.
892 (13)(14) DISCLOSURE OF INFORMATION.—
893 (a) In connection with the offering of a health benefit
894 plan to a small employer, a small employer carrier:
895 1. Shall make a reasonable disclosure to such employer, as
896 part of its solicitation and sales materials, of the
897 availability of information described in paragraph (b); and
898 2. Upon request of the small employer, provide such
899 information.
900 (b)1. Subject to subparagraph 3., with respect to a small
901 employer carrier that offers a health benefit plan to a small
902 employer, information described in this paragraph is information
903 that concerns:
904 a. The provisions of such coverage concerning an insurer’s
905 right to change premium rates and the factors that may affect
906 changes in premium rates;
907 b. The provisions of such coverage that relate to
908 renewability of coverage;
909 c. The provisions of such coverage that relate to any
910 preexisting condition exclusions; and
911 d. The benefits and premiums available under all health
912 insurance coverage for which the employer is qualified.
913 2. Information required under this subsection shall be
914 provided to small employers in a manner determined to be
915 understandable by the average small employer, and shall be
916 sufficient to reasonably inform small employers of their rights
917 and obligations under the health insurance coverage.
918 3. An insurer is not required under this subsection to
919 disclose any information that is proprietary or a trade secret
920 under state law.
921 (14)(15) SMALL EMPLOYERS ACCESS PROGRAM.—
922 (k) Benefits.—The benefits provided by the plan shall be
923 the same as the coverage required for small employers under
924 subsection (12). Upon the approval of the office, the insurer
925 may also establish an optional mutually supported benefit plan
926 that which is an alternative plan developed within a defined
927 geographic region of this state or any other such alternative
928 plan that which will carry out the intent of this subsection.
929 Any small employer carrier issuing new health benefit plans may
930 offer a benefit plan with coverages similar to, but not less
931 than, any alternative coverage plan developed pursuant to this
932 subsection.
933 (15)(16) APPLICABILITY OF OTHER STATE LAWS.—
934 (a) Except as expressly provided in this section, a law
935 requiring coverage for a specific health care service or
936 benefit, or a law requiring reimbursement, utilization, or
937 consideration of a specific category of licensed health care
938 practitioner, does not apply to a standard or basic health
939 benefit plan policy or contract or a limited benefit policy or
940 contract offered or delivered to a small employer unless that
941 law is made expressly applicable to such policies or contracts.
942 A law restricting or limiting deductibles, coinsurance,
943 copayments, or annual or lifetime maximum payments does not
944 apply to any health plan policy, including a standard or basic
945 health benefit plan policy or contract, offered or delivered to
946 a small employer unless such law is made expressly applicable to
947 such policy or contract. However, every small employer carrier
948 must offer to eligible small employers the standard benefit plan
949 and the basic benefit plan, as required by subsection (5), as
950 such plans have been approved by the office pursuant to
951 subsection (12).
952 (b) Except as provided in this section, a standard or basic
953 health benefit plan policy or contract or limited benefit policy
954 or contract offered to a small employer is not subject to any
955 provision of this code which:
956 1. Inhibits a small employer carrier from contracting with
957 providers or groups of providers with respect to health care
958 services or benefits;
959 2. Imposes any restriction on a small employer carrier’s
960 ability to negotiate with providers regarding the level or
961 method of reimbursing care or services provided under a health
962 benefit plan; or
963 3. Requires a small employer carrier to either include a
964 specific provider or class of providers when contracting for
965 health care services or benefits or to exclude any class of
966 providers that is generally authorized by statute to provide
967 such care.
968 (b)(c) Any second tier assessment paid by a carrier
969 pursuant to paragraph (11)(j) may be credited against
970 assessments levied against the carrier pursuant to s. 627.6494.
971 (c)(d) Notwithstanding chapter 641, a health maintenance
972 organization may is authorized to issue contracts providing
973 benefits equal to the standard health benefit plan, the basic
974 health benefit plan, and the limited benefit policy authorized
975 by this section.
976 (16)(17) RESTRICTIONS ON COVERAGE.—
977 (a) A plan under which coverage is purchased in whole or in
978 part with any state or federal funds through an exchange created
979 pursuant to the federal Patient Protection and Affordable Care
980 Act, Pub. L. No. 111-148, may not provide coverage for an
981 abortion, as defined in s. 390.011(1), except if the pregnancy
982 is the result of an act of rape or incest, or in the case where
983 a woman suffers from a physical disorder, physical injury, or
984 physical illness, including a life-endangering physical
985 condition caused by or arising from the pregnancy itself, which
986 would, as certified by a physician, place the woman in danger of
987 death unless an abortion is performed. Coverage is deemed to be
988 purchased with state or federal funds if any tax credit or cost
989 sharing credit is applied toward the plan.
990 (b) This subsection does not prohibit a plan from providing
991 any person or entity with separate coverage for an abortion if
992 such coverage is not purchased in whole or in part with state or
993 federal funds.
994 (c) As used in this section, the term “state” means this
995 state or any political subdivision of the state.
996 (17)(18) RULEMAKING AUTHORITY.—The commission may adopt
997 rules to administer this section, including rules governing
998 compliance by small employer carriers and small employers.
999 Section 2. Section 627.66997, Florida Statutes, is created
1000 to read:
1001 627.66997 Stop-loss insurance.—
1002 (1) A plan established or maintained by an individual small
1003 employer in accordance with the Employee Retirement Income
1004 Security Act of 1974 (ERISA), Pub. L. No. 93-406, may provide a
1005 policy of stop–loss coverage, as defined in s. 627.6482, in lieu
1006 of the requirements of s. 627.6699 if the policy has an
1007 aggregate attachment point that is lower than the greatest of:
1008 (a) Two thousand dollars times the number of employees;
1009 (b) One hundred twenty percent of expected claims; or
1010 (c) Ten thousand dollars.
1011 (2) Health insurance providers shall use a consistent
1012 method of determining the number of covered employees of an
1013 employer. Such method may include, but is not limited to, the
1014 average number of employees employed on an annual basis or the
1015 number of employees employed on a uniform annual date.
1016 Section 3. Subsection (3) of section 627.642, Florida
1017 Statutes, is amended to read:
1018 627.642 Outline of coverage.—
1019 (3) In addition to the outline of coverage, a policy as
1020 specified in s. 627.6699(3)(k) 627.6699(3)(l) must be
1021 accompanied by an identification card that contains, at a
1022 minimum:
1023 (a) The name of the organization issuing the policy or the
1024 name of the organization administering the policy, whichever
1025 applies.
1026 (b) The name of the contract holder.
1027 (c) The type of plan only if the plan is filed in the
1028 state, an indication that the plan is self-funded, or the name
1029 of the network.
1030 (d) The member identification number, contract number, and
1031 policy or group number, if applicable.
1032 (e) A contact phone number or electronic address for
1033 authorizations and admission certifications.
1034 (f) A phone number or electronic address whereby the
1035 covered person or hospital, physician, or other person rendering
1036 services covered by the policy may obtain benefits verification
1037 and information in order to estimate patient financial
1038 responsibility, in compliance with privacy rules under the
1039 Health Insurance Portability and Accountability Act.
1040 (g) The national plan identifier, in accordance with the
1041 compliance date set forth by the federal Department of Health
1042 and Human Services.
1043
1044 The identification card must present the information in a
1045 readily identifiable manner or, alternatively, the information
1046 may be embedded on the card and available through magnetic
1047 stripe or smart card. The information may also be provided
1048 through other electronic technology.
1049 Section 4. Paragraph (g) of subsection (7) and paragraph
1050 (a) of subsection (8) of section 627.6475, Florida Statutes, are
1051 amended to read:
1052 627.6475 Individual reinsurance pool.—
1053 (7) INDIVIDUAL HEALTH REINSURANCE PROGRAM.—
1054 (g) Except as otherwise provided in this section, the board
1055 and the office shall have all powers, duties, and
1056 responsibilities with respect to carriers that issue and
1057 reinsure individual health insurance, as specified for the board
1058 and the office in s. 627.6699(11) with respect to small employer
1059 carriers, including, but not limited to, the provisions of s.
1060 627.6699(11) relating to:
1061 1. Use of assessments that exceed the amount of actual
1062 losses and expenses.
1063 2. The annual determination of each carrier’s proportion of
1064 the assessment.
1065 3. Interest for late payment of assessments.
1066 4. Authority for the office to approve deferment of an
1067 assessment against a carrier.
1068 5. Limited immunity from legal actions or carriers.
1069 6. Development of standards for compensation to be paid to
1070 agents. Such standards shall be limited to those specifically
1071 enumerated in s. 627.6699(12)(d) 627.6699(13)(d).
1072 7. Monitoring compliance by carriers with this section.
1073 (8) STANDARDS TO ASSURE FAIR MARKETING.—
1074 (a) Each health insurance issuer that offers individual
1075 health insurance shall actively market coverage to eligible
1076 individuals in the state. The provisions of s. 627.6699(12)
1077 627.6699(13) that apply to small employer carriers that market
1078 policies to small employers shall also apply to health insurance
1079 issuers that offer individual health insurance with respect to
1080 marketing policies to individuals.
1081 Section 5. Subsection (2) of section 627.657, Florida
1082 Statutes, is amended to read:
1083 627.657 Provisions of group health insurance policies.—
1084 (2) The medical policy as specified in s. 627.6699(3)(k)
1085 627.6699(3)(l) must be accompanied by an identification card
1086 that contains, at a minimum:
1087 (a) The name of the organization issuing the policy or name
1088 of the organization administering the policy, whichever applies.
1089 (b) The name of the certificateholder.
1090 (c) The type of plan only if the plan is filed in the
1091 state, an indication that the plan is self-funded, or the name
1092 of the network.
1093 (d) The member identification number, contract number, and
1094 policy or group number, if applicable.
1095 (e) A contact phone number or electronic address for
1096 authorizations and admission certifications.
1097 (f) A phone number or electronic address whereby the
1098 covered person or hospital, physician, or other person rendering
1099 services covered by the policy may obtain benefits verification
1100 and information in order to estimate patient financial
1101 responsibility, in compliance with privacy rules under the
1102 Health Insurance Portability and Accountability Act.
1103 (g) The national plan identifier, in accordance with the
1104 compliance date set forth by the federal Department of Health
1105 and Human Services.
1106
1107 The identification card must present the information in a
1108 readily identifiable manner or, alternatively, the information
1109 may be embedded on the card and available through magnetic
1110 stripe or smart card. The information may also be provided
1111 through other electronic technology.
1112 Section 6. Paragraph (e) of subsection (2) of section
1113 627.6571, Florida Statutes, is amended to read:
1114 627.6571 Guaranteed renewability of coverage.—
1115 (2) An insurer may nonrenew or discontinue a group health
1116 insurance policy based only on one or more of the following
1117 conditions:
1118 (e) In the case of an insurer that offers health insurance
1119 coverage through a network plan, there is no longer any enrollee
1120 in connection with such plan who lives, resides, or works in the
1121 service area of the insurer or in the area in which the insurer
1122 is authorized to do business and, in the case of the small-group
1123 market, the insurer would deny enrollment with respect to such
1124 plan under s. 627.6699(5)(i).
1125 Section 7. Subsection (11) of section 627.6675, Florida
1126 Statutes, is amended to read:
1127 627.6675 Conversion on termination of eligibility.—Subject
1128 to all of the provisions of this section, a group policy
1129 delivered or issued for delivery in this state by an insurer or
1130 nonprofit health care services plan that provides, on an
1131 expense-incurred basis, hospital, surgical, or major medical
1132 expense insurance, or any combination of these coverages, shall
1133 provide that an employee or member whose insurance under the
1134 group policy has been terminated for any reason, including
1135 discontinuance of the group policy in its entirety or with
1136 respect to an insured class, and who has been continuously
1137 insured under the group policy, and under any group policy
1138 providing similar benefits that the terminated group policy
1139 replaced, for at least 3 months immediately prior to
1140 termination, shall be entitled to have issued to him or her by
1141 the insurer a policy or certificate of health insurance,
1142 referred to in this section as a “converted policy.” A group
1143 insurer may meet the requirements of this section by contracting
1144 with another insurer, authorized in this state, to issue an
1145 individual converted policy, which policy has been approved by
1146 the office under s. 627.410. An employee or member shall not be
1147 entitled to a converted policy if termination of his or her
1148 insurance under the group policy occurred because he or she
1149 failed to pay any required contribution, or because any
1150 discontinued group coverage was replaced by similar group
1151 coverage within 31 days after discontinuance.
1152 (11) ALTERNATIVE PLANS.—The insurer shall, in addition to
1153 the option required by subsection (10), offer the standard
1154 health benefit plan, as established pursuant to s. 627.6699(12).
1155 The insurer may, at its option, also offer alternative plans for
1156 group health conversion in addition to the plans required by
1157 this section.
1158 Section 8. Paragraph (e) of subsection (2) of section
1159 641.31074, Florida Statutes, is amended to read:
1160 641.31074 Guaranteed renewability of coverage.—
1161 (2) A health maintenance organization may nonrenew or
1162 discontinue a contract based only on one or more of the
1163 following conditions:
1164 (e) There is no longer any enrollee in connection with such
1165 plan who lives, resides, or works in the service area of the
1166 health maintenance organization or in the area in which the
1167 health maintenance organization is authorized to do business
1168 and, in the case of the small group market, the organization
1169 would deny enrollment with respect to such plan under s.
1170 627.6699(5)(i).
1171 Section 9. Subsection (10) of section 641.3922, Florida
1172 Statutes, is amended to read:
1173 641.3922 Conversion contracts; conditions.—Issuance of a
1174 converted contract shall be subject to the following conditions:
1175 (10) ALTERNATE PLANS.—The health maintenance organization
1176 shall offer a standard health benefit plan as established
1177 pursuant to s. 627.6699(12). The health maintenance organization
1178 may, at its option, also offer alternative plans for group
1179 health conversion in addition to those required by this section,
1180 provided any alternative plan is approved by the office or is a
1181 converted policy, approved under s. 627.6675 and issued by an
1182 insurance company authorized to transact insurance in this
1183 state. Approval by the office of an alternative plan shall be
1184 based on compliance by the alternative plan with the provisions
1185 of this part and the rules promulgated thereunder, applicable
1186 provisions of the Florida Insurance Code and rules promulgated
1187 thereunder, and any other applicable law.
1188 Section 10. This act shall take effect July 1, 2015.