2004 Florida Statutes
(1) As used in this section, the term:
(a) "Enrollment date" means, with respect to an individual covered under a group health maintenance organization contract, the date of enrollment of the individual in the plan or coverage or, if earlier, the first day of the waiting period of such enrollment.
(b) "Late enrollee" means, with respect to coverage under a group health maintenance organization contract, a participant or beneficiary who enrolls under the contract other than during:
1. The first period in which the individual is eligible to enroll under the plan.
2. A special enrollment period, as provided under s. 641.31072
(c) "Waiting period" means, with respect to a group health maintenance organization contract and an individual who is a potential participant or beneficiary under the contract, the period that must pass with respect to the individual before the individual is eligible to be covered for benefits under the terms of the contract.
(2) Subject to the exceptions specified in subsection (4), a health maintenance organization that offers group coverage, may, with respect to a participant or beneficiary, impose a preexisting condition exclusion only if:
(a) Such exclusion relates to a physical or mental condition, regardless of the cause of the condition, for which medical advice, diagnosis, care, or treatment was recommended or received within the 6-month period ending on the enrollment date;
(b) Such exclusion extends for a period of not more than 12 months, or 18 months in the case of a late enrollee, after the enrollment date; and
(c) The period of any such preexisting condition exclusion is reduced by the aggregate of the periods of creditable coverage, as defined in subsection (5), applicable to the participant or beneficiary as of the enrollment date.
(3) Genetic information shall not be treated as a condition described in paragraph (2)(a) in the absence of a diagnosis of the condition related to such information.
(4)(a) Subject to paragraph (b), a health maintenance organization that offers group coverage may not impose any preexisting condition exclusion in the case of:
1. An individual who, as of the last day of the 30-day period beginning with the date of birth, is covered under creditable coverage.
2. A child who is adopted or placed for adoption before attaining 18 years of age and who, as of the last day of the 30-day period beginning on the date of the adoption or placement for adoption, is covered under creditable coverage. This provision shall not apply to coverage before the date of such adoption or placement for adoption.
(b) Subparagraphs (a)1. and 2. do not apply to an individual after the end of the first 63-day period during all of which the individual was not covered under any creditable coverage.
(5)(a) The term "creditable coverage" means, with respect to an individual, coverage of the individual under any of the following:
1. A group health plan, as defined in s. 2791 of the Public Health Service Act.
2. Health insurance coverage consisting of medical care, provided directly, through insurance or reimbursement or otherwise, and including terms and services paid for as medical care, under any hospital or medical service policy or certificate, hospital or medical service plan contract, or health maintenance contract offered by a health insurance issuer.
3. Part A or part B of Title XVIII of the Social Security Act.
4. Title XIX of the Social Security Act, other than coverage consisting solely of benefits under s. 1928.
5. Chapter 55 of Title 10, United States Code.
6. A medical care program of the Indian Health Service or of a tribal organization.
7. The Florida Comprehensive Health Association or another state health benefit risk pool.
8. A health plan offered under chapter 89 of Title 5, United States Code.
9. A public health plan as defined by rule of the commission. To the greatest extent possible, such rules must be consistent with regulations adopted by the United States Department of Health and Human Services.
10. A health benefit plan under s. 5(e) of the Peace Corps Act (22 U.S.C. s. 2504(e)).
(b) Creditable coverage does not include coverage that consists solely of one or more or any combination thereof of the following excepted benefits:
1. Coverage only for accident, or disability income insurance, or any combination thereof.
2. Coverage issued as a supplement to liability insurance.
3. Liability insurance, including general liability insurance and automobile liability insurance.
4. Workers' compensation or similar insurance.
5. Automobile medical payment insurance.
6. Credit-only insurance.
7. Coverage for onsite medical clinics.
8. Other similar insurance coverage, specified in rules adopted by the commission, under which benefits for medical care are secondary or incidental to other insurance benefits. To the greatest extent possible, such rules must be consistent with regulations adopted by the United States Department of Health and Human Services.
(c) The following benefits are not subject to the creditable coverage requirements, if offered separately;
1. Limited scope dental or vision benefits.
2. Benefits or long-term care, nursing home care, home health care, community-based care, or any combination of these.
3. Such other similar, limited benefits as are specified in rules adopted by the commission. To the greatest extent possible, such rules must be consistent with regulations adopted by the United States Department of Health and Human Services.
(d) The following benefits are not subject to creditable coverage requirements if offered as independent, noncoordinated benefits:
1. Coverage only for a specified disease or illness.
2. Hospital indemnity or other fixed indemnity insurance.
(e) Benefits provided through Medicare supplemental health insurance, as defined under s. 1882(g)(1) of the Social Security Act, coverage supplemental to the coverage provided under chapter 55 of Title 10, United States Code, and similar supplemental coverage provided to coverage under a group health plan are not considered creditable coverage if offered as a separate insurance policy.
(6)(a) A period of creditable coverage may not be counted, with respect to enrollment of an individual under a group health maintenance organization contract, if, after such period and before the enrollment date, there was a 63-day period during all of which the individual was not covered under any creditable coverage.
(b) Any period during which an individual is in a waiting period, or in an affiliation period as defined in subsection (9), for any coverage under a group health maintenance organization contract may not be taken into account in determining the 63-day period under paragraph (a) or paragraph (4)(b).
(7)(a) Except as otherwise provided under paragraph (b), a health maintenance organization shall count a period of creditable coverage without regard to the specific benefits covered under the period.
(b) A health maintenance organization may elect to count as creditable coverage, coverage of benefits within each of several classes or categories of benefits specified in rules adopted by the commission rather than as provided under paragraph (a). Such election shall be made on a uniform basis for all participants and beneficiaries. Under such election, a health maintenance organization shall count a period of creditable coverage with respect to any class or category of benefits if any level of benefits is covered within such class or category.
(c) In the case of an election with respect to a health maintenance organization under paragraph (b), the organization shall:
1. Prominently state in 10-point type or larger in any disclosure statements concerning the contract, and state to each enrollee at the time of enrollment under the contract, that the organization has made such election; and
2. Include in such statements a description of the effect of this election.
(8)(a) Periods of creditable coverage with respect to an individual shall be established through presentation of certifications described in this subsection or in such other manner as may be specified in rules adopted by the commission.
(b) A health maintenance organization that offers group coverage shall provide the certification described in paragraph (a):
1. At the time an individual ceases to be covered under the plan or otherwise becomes covered under a COBRA continuation provision or continuation pursuant to s. 627.6692
2. In the case of an individual becoming covered under a COBRA continuation provision or pursuant to s. 627.6692, at the time the individual ceases to be covered under such a provision.
3. Upon the request on behalf of an individual made not later than 24 months after the date of cessation of the coverage described in this paragraph.
The certification under subparagraph 1. may be provided, to the extent practicable, at a time consistent with notices required under any applicable COBRA continuation provision or continuation pursuant to s. 627.6692
(c) The certification is a written certification of:
1. The period of creditable coverage of the individual under the contract and the coverage, if any, under such COBRA continuation provision or continuation pursuant to s. 627.6692; and
2. The waiting period, if any, imposed with respect to the individual for any coverage under such contract.
(d) In the case of an election described in subsection (7) by a health maintenance organization, if the organization enrolls an individual for coverage under the plan and the individual provides a certification of coverage of the individual, as provided by this subsection:
1. Upon request of such health maintenance organization, the insurer or health maintenance organization that issued the certification provided by the individual shall promptly disclose to such requesting organization information on coverage of classes and categories of health benefits available under such insurer's or health maintenance organization's plan or coverage.
2. Such insurer or health maintenance organization may charge the requesting organization for the reasonable cost of disclosing such information.
(e) The commission shall adopt rules to prevent an insurer's or health maintenance organization's failure to provide information under this subsection with respect to previous coverage of an individual from adversely affecting any subsequent coverage of the individual under another group health plan or health maintenance organization coverage.
(9)(a) A health maintenance organization may provide for an affiliation period with respect to coverage through the organization only if:
1. No preexisting condition exclusion is imposed with respect to coverage through the organization;
2. The period is applied uniformly without regard to any health-status-related factors; and
3. Such period does not exceed 2 months or 3 months in the case of a late enrollee.
(b) For the purposes of this section, the term "affiliation period" means a period that, under the terms of the coverage offered by the health maintenance organization, must expire before the coverage becomes effective. The organization is not required to provide health care services or benefits during such period, and no premium may be charged to the participant or beneficiary for any coverage during the period. Such period begins on the enrollment date and runs concurrently with any waiting period under the plan.
(c) As an alternative to the method authorized by paragraph (a), a health maintenance organization may address adverse selection in a method approved by the office.
(10)(a) Except as provided in paragraph (b), no period before July 1, 1996, shall be taken into account in determining creditable coverage.
(b) The commission shall adopt rules that provide a process whereby individuals who need to establish creditable coverage for periods before July 1, 1996, and who would have such coverage credited but for paragraph (a), may be given credit for creditable coverage for such periods through the presentation of documents or other means.
(11) Except as otherwise provided in this subsection, the requirements of paragraph (8)(b) shall apply to events that occur on or after July 1, 1996.
(a) In no case is a certification required to be provided under paragraph (8)(b) prior to June 1, 1997.
(b) In the case of an event that occurs on or after July 1, 1996, and before October 1, 1996, a certification is not required to be provided under paragraph (8)(b), unless an individual, with respect to whom the certification is required to be made, requests such certification in writing.
(12) In the case of an individual who seeks to establish creditable coverage for any period for which certification is not required because it relates to an event occurring before July 1, 1996:
(a) The individual may present other creditable coverage in order to establish the period of creditable coverage.
(b) A health maintenance organization is not subject to any penalty or enforcement action with respect to the organization's crediting, or not crediting, such coverage if the organization has sought to comply in good faith with applicable provisions of this section.
(13) For purposes of subsection (10), any plan amendment made pursuant to a collective bargaining agreement relating to the plan which amends the plan solely to conform to any requirement of this section may not be treated as a termination of such collective bargaining agreement.
History.--s. 25, ch. 97-179; s. 55, ch. 99-3; s. 1580, ch. 2003-261.
1Note.--Section 34(2), ch. 97-179, provides that:
"(2) Except as provided in section 627.6561(9), (10), and (11), and section 641.31071(10), (11), and (12), Florida Statutes, in the case of a group health plan or group health insurance contract maintained pursuant to one or more collective bargaining agreements between employee representatives and one or more employers which is ratified before this act becomes a law, sections 627.6561, 627.65615, 627.65625, 627.6571, 627.6699, 641.31071, 641.31072, 641.31073, and 641.31074, Florida Statutes, except for section 627.6561(8)(b), Florida Statutes, as amended or created by this act, apply to policies or contracts with plan years that begin on or after the later of:
"(a) The date on which the last of any collective bargaining agreement that relates to the plan terminates, determined without regard to any extension thereof, which is agreed to after the date this act becomes a law; or
"(b) July 1, 1997."