CODING: Words stricken are deletions; words underlined are additions.House Bill 1701
Florida House of Representatives - 1997 HB 1701
By Representatives Flanagan, Wise, Murman, Burroughs,
Barreiro, Feeney, Futch, Bronson and Fasano
1 A bill to be entitled
2 An act relating to health insurance; amending
3 s. 627.6699, F.S.; providing a definition;
4 limiting certain coverage for induced abortions
5 and related procedures; providing an effective
6 date.
7
8 Be It Enacted by the Legislature of the State of Florida:
9
10 Section 1. Subsection (3) and paragraph (b) of
11 subsection (12) of section 627.6699, Florida Statutes, 1996
12 Supplement, are amended to read:
13 627.6699 Employee Health Care Access Act.--
14 (3) DEFINITIONS.--As used in this section, the term:
15 (a) "Actuarial certification" means a written
16 statement, by a member of the American Academy of Actuaries or
17 another person acceptable to the department, that a small
18 employer carrier is in compliance with subsection (6), based
19 upon the person's examination, including a review of the
20 appropriate records and of the actuarial assumptions and
21 methods used by the carrier in establishing premium rates for
22 applicable health benefit plans.
23 (b) "Basic health benefit plan" and "standard health
24 benefit plan" mean low-cost health care plans developed
25 pursuant to subsection (12).
26 (c) "Board" means the board of directors of the
27 program.
28 (d) "Carrier" means a person who provides health
29 benefit plans in this state, including an authorized insurer,
30 a health maintenance organization, a multiple-employer welfare
31 arrangement, or any other person providing a health benefit
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1 plan that is subject to insurance regulation in this state.
2 However, the term does not include a multiple-employer welfare
3 arrangement, which multiple-employer welfare arrangement
4 operates solely for the benefit of the members or the members
5 and the employees of such members, and was in existence on
6 January 1, 1992.
7 (e) "Case management program" means the specific
8 supervision and management of the medical care provided or
9 prescribed for a specific individual, which may include the
10 use of health care providers designated by the carrier.
11 (f) "Dependent" means the spouse or child of an
12 eligible employee, subject to the applicable terms of the
13 health benefit plan covering that employee.
14 (g) "Eligible employee" means an employee who works
15 full time, having a normal workweek of 25 or more hours, and
16 who has met any applicable waiting-period requirements or
17 other requirements of this act. The term includes a
18 self-employed individual, a sole proprietor, a partner of a
19 partnership, or an independent contractor, if the sole
20 proprietor, partner, or independent contractor is included as
21 an employee under a health benefit plan of a small employer,
22 but does not include a part-time, temporary, or substitute
23 employee.
24 (h) "Established geographic area" means the county or
25 counties, or any portion of a county or counties, within which
26 the carrier provides or arranges for health care services to
27 be available to its insureds, members, or subscribers.
28 (i) "Guaranteed-issue basis" means an insurance policy
29 that must be offered to an employer, employee, or dependent of
30 the employee, regardless of health status, preexisting
31 conditions, or claims history.
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1 (j) "Health benefit plan" means any hospital or
2 medical policy or certificate, hospital or medical service
3 plan contract, or health maintenance organization subscriber
4 contract. The term does not include accident-only, specified
5 disease, individual hospital indemnity, credit, dental-only,
6 vision-only, Medicare supplement, long-term care, or
7 disability income insurance; coverage issued as a supplement
8 to liability insurance; workers' compensation or similar
9 insurance; or automobile medical-payment insurance.
10 (k) "Late enrollee" means an eligible employee or
11 dependent who requests enrollment in a health benefit plan of
12 a small employer after the initial enrollment period provided
13 under the terms of the plan has ended. However, an eligible
14 employee or dependent is not considered a late enrollee if the
15 enrollee:
16 1. Was covered under another employer health benefit
17 plan at the time the individual was eligible to enroll; lost
18 coverage under that plan as a result of termination of
19 employment, the termination of the other plan's coverage, the
20 death of a spouse, or divorce; and requests enrollment within
21 30 days after coverage under that plan was terminated;
22 2. The individual is employed by an employer that
23 offers multiple health benefit plans and the individual elects
24 a different plan during an open enrollment period; or
25 3. A court has ordered that coverage be provided for a
26 spouse or minor child under a covered employee's health
27 benefit plan and a request for enrollment is made within 30
28 days after issuance of the court order.
29 (l) "Limited benefit policy or contract" means a
30 policy or contract that provides coverage for each person
31 insured under the policy for a specifically named disease or
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1 diseases, a specifically named accident, or a specifically
2 named limited market that fulfills an experimental or
3 reasonable need, such as the small group market.
4 (m) "Medically necessary" means, for purposes of
5 covering procedures related to termination of pregnancy, those
6 procedures and accompanying services necessary to save the
7 life of the mother.
8 (n)(m) "Modified community rating" means a method used
9 to develop carrier premiums which spreads financial risk
10 across a large population and allows adjustments for age,
11 gender, family composition, tobacco usage, and geographic area
12 as determined under paragraph (5)(k).
13 (o)(n) "Participating carrier" means any carrier that
14 issues health benefit plans in this state except a small
15 employer carrier that elects to be a risk-assuming carrier.
16 (p)(o) "Plan of operation" means the plan of operation
17 of the program, including articles, bylaws, and operating
18 rules, adopted by the board under subsection (11).
19 (q)(p) "Preexisting condition provision" means a
20 policy provision that excludes coverage for charges or
21 expenses incurred during a specified period following the
22 insured's effective date of coverage, as to:
23 1. A condition that, during a specified period
24 immediately preceding the effective date of coverage, had
25 manifested itself in such a manner as would cause an
26 ordinarily prudent person to seek medical advice, diagnosis,
27 care, or treatment or for which medical advice, diagnosis,
28 care, or treatment was recommended or received as to that
29 condition; or
30 2. Pregnancy existing on the effective date of
31 coverage.
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1 (r)(q) "Program" means the Florida Small Employer
2 Carrier Reinsurance Program created under subsection (11).
3 (s)(r) "Qualifying previous coverage" and "qualifying
4 existing coverage" mean benefits or coverage provided under:
5 1. An employer-based health insurance or health
6 benefit arrangement that provides benefits similar to or
7 exceeding benefits provided under the basic health plan; or
8 2. An individual health insurance policy, including
9 coverage issued by a health maintenance organization, a
10 fraternal benefit society, or a multiple-employer welfare
11 arrangement, that provides benefits similar to or exceeding
12 the benefits provided under the basic health benefit plan,
13 provided that such policy has been in effect for a period of
14 at least 1 year.
15 (t)(s) "Rating period" means the calendar period for
16 which premium rates established by a small employer carrier
17 are assumed to be in effect.
18 (u)(t) "Reinsuring carrier" means a small employer
19 carrier that elects to comply with the requirements set forth
20 in subsection (11).
21 (v)(u) "Risk-assuming carrier" means a small employer
22 carrier that elects to comply with the requirements set forth
23 in subsection (10).
24 (w)(v) "Self-employed individual" means an individual
25 or sole proprietor who derives his or her income from a trade
26 or business carried on by the individual or sole proprietor
27 which results in taxable income as indicated on IRS Form 1040,
28 schedule C or F, and which generated taxable income in one of
29 the 2 previous years.
30 (x)(w) "Small employer" means any person, sole
31 proprietor, self-employed individual, independent contractor,
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1 firm, corporation, partnership, or association that is
2 actively engaged in business and that, on at least 50 percent
3 of its working days during the preceding calendar quarter,
4 employed not more than 50 eligible employees, the majority of
5 whom were employed within this state. In determining the
6 number of eligible employees, companies that are affiliated
7 companies, or that are eligible to file a combined tax return
8 for purposes of state taxation, may be considered a single
9 employer. For purposes of this section, a sole proprietor, an
10 independent contractor, or a self-employed individual is
11 considered a small employer only if all of the conditions and
12 criteria established in this section are met.
13 (y)(x) "Small employer carrier" means a carrier that
14 offers health benefit plans covering eligible employees of one
15 or more small employers.
16 (12) STANDARD, BASIC, AND LIMITED HEALTH BENEFIT
17 PLANS.--
18 (b)1. Each small employer carrier issuing new health
19 benefit plans shall offer to any small employer, upon request,
20 a standard health benefit plan and a basic health benefit plan
21 that meets the criteria set forth in this section.
22 2. For purposes of this subsection, the terms
23 "standard health benefit plan" and "basic health benefit plan"
24 mean policies or contracts that a small employer carrier
25 offers to eligible small employers that contain:
26 a. An exclusion for services that are not medically
27 necessary or that are not covered preventive health services;
28 and
29 b. A procedure for preauthorization by the small
30 employer carrier, or its designees.
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1 3. A small employer carrier may include the following
2 managed care provisions in the policy or contract to control
3 costs:
4 a. A preferred provider arrangement or exclusive
5 provider organization or any combination thereof, in which a
6 small employer carrier enters into a written agreement with
7 the provider to provide services at specified levels of
8 reimbursement or to provide reimbursement to specified
9 providers. Any such written agreement between a provider and a
10 small employer carrier must contain a provision under which
11 the parties agree that the insured individual or covered
12 member has no obligation to make payment for any medical
13 service rendered by the provider which is determined not to be
14 medically necessary. A carrier may use preferred provider
15 arrangements or exclusive provider arrangements to the same
16 extent as allowed in group products that are not issued to
17 small employers.
18 b. A procedure for utilization review by the small
19 employer carrier or its designees.
20
21 This subparagraph does not prohibit a small employer carrier
22 from including in its policy or contract additional managed
23 care and cost containment provisions, subject to the approval
24 of the department, which have potential for controlling costs
25 in a manner that does not result in inequitable treatment of
26 insureds or subscribers. The carrier may use such provisions
27 to the same extent as authorized for group products that are
28 not issued to small employers.
29 4. The standard health benefit plan shall include:
30 a. Coverage for inpatient hospitalization, except
31 coverage for inpatient hospital care for induced abortions and
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1 related procedures is required only when performed to save the
2 life of the mother;
3 b. Coverage for outpatient services, but such coverage
4 is required for induced abortions and related procedures only
5 when such services are necessary to save the life of the
6 mother;
7 c. Coverage for newborn children pursuant to s.
8 627.6575;
9 d. Coverage for child care supervision services
10 pursuant to s. 627.6579;
11 e. Coverage for adopted children upon placement in the
12 residence pursuant to s. 627.6578;
13 f. Coverage for mammograms pursuant to s. 627.6613;
14 g. Coverage for handicapped children pursuant to s.
15 627.6615;
16 h. Emergency or urgent care out of the geographic
17 service area; and
18 i. Coverage for services provided by a hospice
19 licensed under s. 400.602 in cases where such coverage would
20 be the most appropriate and the most cost-effective method for
21 treating a covered illness.
22 5. The standard health benefit plan and the basic
23 health benefit plan may include a schedule of benefit
24 limitations for specified services and procedures. If the
25 committee develops such a schedule of benefits limitation for
26 the standard health benefit plan or the basic health benefit
27 plan, a small employer carrier offering the plan must offer
28 the employer an option for increasing the benefit schedule
29 amounts by 4 percent annually.
30 6. The basic health benefit plan shall include all of
31 the benefits specified in subparagraph 4.; however, the basic
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1 health benefit plan shall place additional restrictions on the
2 benefits and utilization and may also impose additional cost
3 containment measures.
4 7. Sections 627.419(2), (3), and (4), 627.6574,
5 627.6616, 627.6618, and 627.668 apply to the standard health
6 benefit plan and to the basic health benefit plan. However,
7 notwithstanding said provisions, the plans may specify limits
8 on the number of authorized treatments, if such limits are
9 reasonable and do not discriminate against any type of
10 provider.
11 8. Each small employer carrier that provides for
12 inpatient and outpatient services by allopathic hospitals may
13 provide as an option of the insured similar inpatient and
14 outpatient services by hospitals accredited by the American
15 Osteopathic Association when such services are available and
16 the osteopathic hospital agrees to provide the service.
17 Section 2. This act shall take effect October 1, 1997.
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20 HOUSE SUMMARY
21
Defines "medically necessary" to be procedures and
22 services necessary to save a mother's life and limits
coverage for induced abortions and related procedures to
23 those which are medically necessary. Requires physicians
to bill and accept payment for induced abortions only
24 when the abortion is medically necessary.
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