Senate Bill 1800e2
CODING: Words stricken are deletions; words underlined are additions.
CS for CS for SB 1800 Second Engrossed
(ntc)
1
A bill to be entitled
2
An act relating to health insurance; amending
3
s. 222.21, F.S.; exempting moneys paid into a
4
Roth individual retirement account from
5
creditors' claims; amending s. 222.22, F.S.;
6
exempting moneys paid into a Medical Savings
7
Account from attachment, garnishment, or legal
8
process; amending s. 627.410, F.S.; exempting
9
certain policies from rating requirements;
10
amending s. 627.6425, F.S.; specifying
11
exceptions to guaranteed renewability of
12
individual health insurance policies; amending
13
s. 627.6487, F.S.; redefining the term
14
"eligible individual" for purposes of
15
guaranteed-issuance of an individual health
16
insurance policy; amending s. 627.6498, F.S.;
17
requiring the Department of Insurance to
18
annually establish standard risk rates for
19
purposes of determining premium rates of
20
coverage issued by the Florida Comprehensive
21
Health Association; amending s. 627.6571, F.S.;
22
specifying exceptions to guaranteed
23
renewability of group health insurance
24
policies; amending s. 627.6575, F.S.; providing
25
that coverage may not be denied if specified
26
notice is given; amending s. 627.6415, F.S.;
27
providing that coverage may not be denied if
28
specified notice is given; amending s.
29
627.6578, F.S.; providing that coverage may not
30
be denied if specified notice is given;
31
amending s. 627.6675, F.S.; requiring the
1
CODING: Words stricken are deletions; words underlined are additions.
CS for CS for SB 1800 Second Engrossed
(ntc)
1
Department of Insurance to annually establish
2
standard risk rates for purposes of determining
3
maximum premiums for conversion policies;
4
revising standards for renewal of converted
5
insurance policies; requiring the insurer to
6
mail certain information to a person eligible
7
for a converted policy, upon request; creating
8
s. 627.6685, F.S.; requiring health insurers
9
and health maintenance organizations to include
10
in their plans that offer mental health
11
coverage certain mental health benefits that
12
are not less favorable than those for medical
13
or surgical benefits covered by the plan;
14
defining terms; providing exemptions; limiting
15
applicability of this section; amending s.
16
627.6699, F.S.; redefining the term "health
17
benefit plan" as used in the Employee Health
18
Care Access Act; amending s. 627.674, F.S.;
19
revising the minimum standards for Medicare
20
Supplement policies; amending s. 627.6741,
21
F.S.; revising requirements for insurers to
22
issue, cancel, nonrenew, and replace Medicare
23
supplement policies; restricting
24
preexisting-condition exclusions; authorizing
25
the Department of Insurance to adopt rules
26
governing guaranteed issue of Medicare
27
supplement coverage for continuously covered
28
individuals; amending s. 627.9403, F.S.;
29
specifying the provisions of the Long-term Care
30
Insurance Act that apply to limited benefit
31
policies; amending s. 627.9404, F.S.; defining
2
CODING: Words stricken are deletions; words underlined are additions.
CS for CS for SB 1800 Second Engrossed
(ntc)
1
the terms "limited benefit policy" and
2
"qualified long-term care limited benefit
3
insurance policy"; amending s. 627.9407, F.S.;
4
revising the requirements for exclusion of
5
coverage for preexisting conditions for
6
long-term care policies; requiring
7
limited-benefit policies to contain a
8
disclosure statement regarding their
9
qualification for favorable tax treatment;
10
amending s. 627.94073, F.S.; revising the
11
notice requirement for long-term care policies
12
regarding the right to designate a secondary
13
person to receive notice of lapse of coverage;
14
amending s. 641.225, F.S.; increasing surplus
15
requirements for health maintenance
16
organizations; amending s. 641.285, F.S.;
17
increasing deposit requirements for health
18
maintenance organizations; revising exceptions;
19
amending s. 641.26, F.S.; requiring health
20
maintenance organizations to file certain
21
reports with the Department of Insurance;
22
requiring that health maintenance organizations
23
provide additional information upon the request
24
of the department; amending s. 641.31, F.S.;
25
providing that coverage may not be denied if
26
specified notice is given; amending s.
27
641.31074, F.S.; revising requirements for
28
guaranteed renewability of a health maintenance
29
organization contract; amending s. 641.3111,
30
F.S.; requiring health maintenance organization
31
contracts to provide for an extension of
3
CODING: Words stricken are deletions; words underlined are additions.
CS for CS for SB 1800 Second Engrossed
(ntc)
1
benefits upon termination of the contract;
2
amending s. 641.316, F.S.; revising the amount
3
of the bond that a fiscal intermediary services
4
organization is required to maintain;
5
specifying certain additional requirements and
6
conditions for the bond and the intermediary;
7
amending s. 641.3922, F.S.; revising the method
8
for establishing the maximum premium for
9
converted contracts issued by health
10
maintenance organizations; revising the
11
exceptions to guaranteed renewability of
12
converted health maintenance organization
13
contracts; requiring a health maintenance
14
organization to mail certain information to a
15
person eligible for a converted contract;
16
amending s. 641.495, F.S.; exempting from
17
licensure under part I of ch. 395, F.S.,
18
certain beds of a health maintenance
19
organization; providing an effective date.
20
21
Be It Enacted by the Legislature of the State of Florida:
22
23
Section 1. Paragraph (a) of subsection (2) of section
24
222.21, Florida Statutes, is amended to read:
25
222.21 Exemption of pension money and retirement or
26
profit-sharing benefits from legal processes.--
27
(2)(a) Except as provided in paragraph (b), any money
28
or other assets payable to a participant or beneficiary from,
29
or any interest of any participant or beneficiary in, a
30
retirement or profit-sharing plan that is qualified under s.
31
401(a), s. 403(a), s. 403(b), s. 408, s. 408A, or s. 409 of
4
CODING: Words stricken are deletions; words underlined are additions.
CS for CS for SB 1800 Second Engrossed
(ntc)
1
the Internal Revenue Code of 1986, as amended, is exempt from
2
all claims of creditors of the beneficiary or participant.
3
Section 2. Section 222.22, Florida Statutes, is
4
amended to read:
5
222.22 Exemption of moneys in the Prepaid
6
Postsecondary Education Expense Trust Fund and in a Medical
7
Savings Account from legal process.--
8
(1) Moneys paid into or out of the Prepaid
9
Postsecondary Education Expense Trust Fund by or on behalf of
10
a purchaser or qualified beneficiary pursuant to an advance
11
payment contract made under s. 240.551, which contract has not
12
been terminated, are not liable to attachment, garnishment, or
13
legal process in the state in favor of any creditor of the
14
purchaser or beneficiary of such advance payment contract.
15
(2) Moneys paid into or out of a Medical Savings
16
Account by or on behalf of a person depositing money into such
17
account or a qualified beneficiary are not liable to
18
attachment, garnishment, or legal process in the state in
19
favor of any creditor of such person or beneficiary of such
20
Medical Savings Account.
21
Section 3. Subsection (6) of section 627.410, Florida
22
Statutes, is amended to read:
23
627.410 Filing, approval of forms.--
24
(6)(a) An insurer shall not deliver or issue for
25
delivery or renew in this state any health insurance policy
26
form until it has filed with the department a copy of every
27
applicable rating manual, rating schedule, change in rating
28
manual, and change in rating schedule; if rating manuals and
29
rating schedules are not applicable, the insurer must file
30
with the department applicable premium rates and any change in
31
applicable premium rates.
5
CODING: Words stricken are deletions; words underlined are additions.
CS for CS for SB 1800 Second Engrossed
(ntc)
1
(b) The department may establish by rule, for each
2
type of health insurance form, procedures to be used in
3
ascertaining the reasonableness of benefits in relation to
4
premium rates and may, by rule, exempt from any requirement of
5
paragraph (a) any health insurance policy form or type thereof
6
(as specified in such rule) to which form or type such
7
requirements may not be practically applied or to which form
8
or type the application of such requirements is not desirable
9
or necessary for the protection of the public. With respect to
10
any health insurance policy form or type thereof which is
11
exempted by rule from any requirement of paragraph (a),
12
premium rates filed pursuant to ss. 627.640 and 627.662 shall
13
be for informational purposes.
14
(c) Every filing made pursuant to this subsection
15
shall be made within the same time period provided in, and
16
shall be deemed to be approved under the same conditions as
17
those provided in, subsection (2).
18
(d) Every filing made pursuant to this subsection,
19
except disability income policies and accidental death
20
policies, shall be prohibited from applying the following
21
rating practices:
22
1. Select and ultimate premium schedules.
23
2. Premium class definitions which classify insured
24
based on year of issue or duration since issue.
25
3. Attained age premium structures on policy forms
26
under which more than 50 percent of the policies are issued to
27
persons age 65 or over.
28
(e) Except as provided in subparagraph 1., an insurer
29
shall continue to make available for purchase any individual
30
policy form issued on or after October 1, 1993. A policy form
31
shall not be considered to be available for purchase unless
6
CODING: Words stricken are deletions; words underlined are additions.
CS for CS for SB 1800 Second Engrossed
(ntc)
1
the insurer has actively offered it for sale in the previous
2
12 months.
3
1. An insurer may discontinue the availability of a
4
policy form if the insurer provides to the department in
5
writing its decision at least 30 days prior to discontinuing
6
the availability of the form of the policy or certificate.
7
After receipt of the notice by the department, the insurer
8
shall no longer offer for sale the policy form or certificate
9
form in this state.
10
2. An insurer that discontinues the availability of a
11
policy form pursuant to subparagraph 1. shall not file for
12
approval a new policy form providing similar benefits as the
13
discontinued form for a period of 5 years after the insurer
14
provides notice to the department of the discontinuance. The
15
period of discontinuance may be reduced if the department
16
determines that a shorter period is appropriate.
17
3. The experience of all policy forms providing
18
similar benefits shall be combined for all rating purposes.
19
Section 4. Subsection (3) of section 627.6425, Florida
20
Statutes, is amended to read:
21
627.6425 Renewability of individual coverage.--
22
(3)(a) In any case in which an insurer decides to
23
discontinue offering a particular policy form for health
24
insurance coverage offered in the individual market, coverage
25
under such form may be discontinued by the insurer only if:
26
1. The insurer provides notice to each covered
27
individual provided coverage under this policy form in the
28
individual market of such discontinuation at least 90 days
29
prior to the date of the nonrenewal discontinuation of such
30
coverage;
31
7
CODING: Words stricken are deletions; words underlined are additions.
CS for CS for SB 1800 Second Engrossed
(ntc)
1
2. The insurer offers to each individual in the
2
individual market provided coverage under this policy form the
3
option to purchase any other individual health insurance
4
coverage currently being offered by the insurer for
5
individuals in such market in the state; and
6
3. In exercising the option to discontinue coverage of
7
this policy form and in offering the option of coverage under
8
subparagraph 2., the insurer acts uniformly without regard to
9
any health-status-related factor of enrolled individuals or
10
individuals who may become eligible for such coverage.
11
(b)1. Subject to subparagraph (a)3., in any case in
12
which an insurer elects to discontinue offering all health
13
insurance coverage in the individual market in this state,
14
health insurance coverage may be discontinued by the insurer
15
only if:
16
a. The insurer provides notice to the department and
17
to each individual of such discontinuation at least 180 days
18
prior to the date of the nonrenewal expiration of such
19
coverage; and
20
b. All health insurance issued or delivered for
21
issuance in the state in the individual market is discontinued
22
and coverage under such health insurance coverage in such
23
market is not renewed.
24
2. In the case of a discontinuation under subparagraph
25
1. in the individual market, the insurer may not provide for
26
the issuance of any individual health insurance coverage in
27
this state during the 5-year period beginning on the date of
28
the discontinuation of the last health insurance coverage not
29
so renewed.
30
Section 5. Subsection (3) of section 627.6487, Florida
31
Statutes, is amended to read:
8
CODING: Words stricken are deletions; words underlined are additions.
CS for CS for SB 1800 Second Engrossed
(ntc)
1
627.6487 Guaranteed availability of individual health
2
insurance coverage to eligible individuals.--
3
(3) For the purposes of this section, the term
4
"eligible individual" means an individual:
5
(a)1. For whom, as of the date on which the individual
6
seeks coverage under this section, the aggregate of the
7
periods of creditable coverage, as defined in s. 627.6561(5)
8
and (6), is 18 or more months; and
9
2.a. Whose most recent prior creditable coverage was
10
under a group health plan, governmental plan, or church plan,
11
or health insurance coverage offered in connection with any
12
such plan; or
13
b. Whose most recent prior creditable coverage was
14
under an individual plan issued by a health insurer or health
15
maintenance organization, which coverage is terminated due to
16
the insurer or health maintenance organization becoming
17
insolvent or discontinuing the offering of all individual
18
coverage in the state, or due to the insured no longer living
19
in the service area of the insurer or health maintenance
20
organization that provides coverage through a network plan;
21
(b) Who is not eligible for coverage under:
22
1. A group health plan, as defined in s. 2791 of the
23
Public Health Service Act;
24
2. A conversion policy or contract issued by an
25
authorized insurer or health maintenance organization under s.
26
627.6675 or s. 641.3921, respectively, offered to an
27
individual who is no longer eligible for coverage under either
28
an insured or self-insured employer plan;
29
3. Part A or part B of Title XVIII of the Social
30
Security Act; or
31
9
CODING: Words stricken are deletions; words underlined are additions.
CS for CS for SB 1800 Second Engrossed
(ntc)
1
4. A state plan under Title XIX of such act, or any
2
successor program, and does not have other health insurance
3
coverage;
4
(c) With respect to whom the most recent coverage
5
within the coverage period described in paragraph (1)(a) was
6
not terminated based on a factor described in s.
7
627.6571(2)(a) or (b), relating to nonpayment of premiums or
8
fraud, unless such nonpayment of premiums or fraud was due to
9
acts of an employer or person other than the individual;
10
(d) Who, having been offered the option of
11
continuation coverage under a COBRA continuation provision or
12
under s. 627.6692, elected such coverage; and
13
(e) Who, if the individual elected such continuation
14
provision, has exhausted such continuation coverage under such
15
provision or program.
16
Section 6. Paragraph (a) of subsection (4) of section
17
627.6498, Florida Statutes, is amended to read:
18
627.6498 Minimum benefits coverage; exclusions;
19
premiums; deductibles.--
20
(4) PREMIUMS, DEDUCTIBLES, AND COINSURANCE.--
21
(a) The plan shall provide for annual deductibles for
22
major medical expense coverage in the amount of $1,000 or any
23
higher amounts proposed by the board and approved by the
24
department, plus the benefits payable under any other type of
25
insurance coverage or workers' compensation. The schedule of
26
premiums and deductibles shall be established by the
27
association. With regard to any preferred provider arrangement
28
utilized by the association, the deductibles provided in this
29
paragraph shall be the minimum deductibles applicable to the
30
preferred providers and higher deductibles, as approved by the
31
10
CODING: Words stricken are deletions; words underlined are additions.
CS for CS for SB 1800 Second Engrossed
(ntc)
1
department, may be applied to providers who are not preferred
2
providers.
3
1. Separate schedules of premium rates based on age
4
may apply for individual risks.
5
2. Rates are subject to approval by the department.
6
3. Standard risk rates for coverages issued by the
7
association shall be established by the department, pursuant
8
to s. 627.6675(3) association, subject to approval by the
9
department, using reasonable actuarial techniques, and shall
10
reflect anticipated experience and expenses of such coverages
11
for standard risks.
12
4. The board shall establish separate premium
13
schedules for low-risk individuals, medium-risk individuals,
14
and high-risk individuals and shall revise premium schedules
15
annually pursuant to this section for each 6-month policy
16
period beginning January 1999 1992. For the calendar year 1991
17
and thereafter, No rate shall exceed 200 percent of the
18
standard risk rate for low-risk individuals, 225 percent of
19
the standard risk rate for medium-risk individuals, or 250
20
percent of the standard risk rate for high-risk individuals.
21
For the purpose of determining what constitutes a low-risk
22
individual, medium-risk individual, or high-risk individual,
23
the board shall consider the anticipated claims payment for
24
individuals based upon an individual's health condition.
25
Section 7. Paragraphs (a) and (b) of subsection (3) of
26
section 627.6571, Florida Statutes, are amended to read:
27
627.6571 Guaranteed renewability of coverage.--
28
(3)(a) An insurer may discontinue offering a
29
particular policy form of group health insurance coverage
30
offered in the small-group market or large-group market only
31
if:
11
CODING: Words stricken are deletions; words underlined are additions.
CS for CS for SB 1800 Second Engrossed
(ntc)
1
1. The insurer provides notice to each policyholder
2
provided coverage of this form in such market, and to
3
participants and beneficiaries covered under such coverage, of
4
such discontinuation at least 90 days prior to the date of the
5
nonrenewal discontinuation of such coverage;
6
2. The insurer offers to each policyholder provided
7
coverage of this form in such market the option to purchase
8
all, or in the case of the large-group market, any other
9
health insurance coverage currently being offered by the
10
insurer in such market; and
11
3. In exercising the option to discontinue coverage of
12
this form and in offering the option of coverage under
13
subparagraph 2., the insurer acts uniformly without regard to
14
the claims experience of those policyholders or any
15
health-status-related factor that relates to any participants
16
or beneficiaries covered or new participants or beneficiaries
17
who may become eligible for such coverage.
18
(b)1. In any case in which an insurer elects to
19
discontinue offering all health insurance coverage in the
20
small-group market or the large-group market, or both, in this
21
state, health insurance coverage may be discontinued by the
22
insurer only if:
23
a. The insurer provides notice to the department and
24
to each policyholder, and participants and beneficiaries
25
covered under such coverage, of such discontinuation at least
26
180 days prior to the date of the nonrenewal discontinuation
27
of such coverage; and
28
b. All health insurance issued or delivered for
29
issuance in this state in such market markets is discontinued
30
and coverage under such health insurance coverage in such
31
market is not renewed.
12
CODING: Words stricken are deletions; words underlined are additions.
CS for CS for SB 1800 Second Engrossed
(ntc)
1
2. In the case of a discontinuation under subparagraph
2
1. in a market, the insurer may not provide for the issuance
3
of any health insurance coverage in the market in this state
4
during the 5-year period beginning on the date of the
5
discontinuation of the last insurance coverage not renewed.
6
Section 8. Subsection (4) of section 627.6575, Florida
7
Statutes, is amended to read:
8
627.6575 Coverage for newborn children.--
9
(4) A policy or contract may require the insured to
10
notify the insurer of the birth of a child within a time
11
period, as specified in the policy, of not less than 30 days
12
after the birth. If timely notice is given, the insurer may
13
not charge an additional premium for coverage of the newborn
14
child for the duration of the notice period. If timely notice
15
is not given, the insurer may charge an additional premium
16
from the date of birth. If notice is given within 60 days of
17
the birth of the child, the insurer may not deny coverage for
18
a child due to the failure of the insured to timely notify the
19
insurer of the birth of the child.
20
Section 9. Subsection (2) of section 627.6415, Florida
21
Statutes, is amended to read:
22
627.6415 Coverage for natural-born, adopted, and
23
foster children; children in insured's custodial care.--
24
(2) A policy may require the insured to notify the
25
insurer of the birth or placement of an adopted child within a
26
specified time period of not less than 30 days after the birth
27
or placement in the residence of a child adopted by the
28
insured. If timely notice is given, the insurer may not
29
charge an additional premium for coverage of the child for the
30
notice period. If timely notice is not given, the insurer may
31
charge an additional premium from the date of birth or
13
CODING: Words stricken are deletions; words underlined are additions.
CS for CS for SB 1800 Second Engrossed
(ntc)
1
placement. If notice is given within 60 days of the birth or
2
placement of the child, the insurer may not deny coverage for
3
the child due to the failure of the insured to timely notify
4
the insurer of the birth or placement of the child.
5
Section 10. Subsection (2) of section 627.6578,
6
Florida Statutes, is amended to read:
7
627.6578 Coverage for natural-born, adopted, and
8
foster children; children in insured's custodial care.--
9
(2) A policy or contract may require the insured to
10
notify the insurer of the birth or placement of an adopted
11
child within a specified time period of not less than 30 days
12
after the birth or placement in the residence of a child
13
adopted by the insured. If timely notice is given, the
14
insurer may not charge an additional premium for coverage of
15
the child for the duration of the notice period. If timely
16
notice is not given, the insurer may charge an additional
17
premium from the date of birth or placement. If notice is
18
given within 60 days of the birth or placement of the child,
19
the insurer may not deny coverage for the child due to the
20
failure of the insured to timely notify the insurer of the
21
birth or placement of the child.
22
Section 11. Subsection (3), paragraph (b) of
23
subsection (7), and subsection (17) of section 627.6675,
24
Florida Statutes, are amended to read:
25
627.6675 Conversion on termination of
26
eligibility.--Subject to all of the provisions of this
27
section, a group policy delivered or issued for delivery in
28
this state by an insurer or nonprofit health care services
29
plan that provides, on an expense-incurred basis, hospital,
30
surgical, or major medical expense insurance, or any
31
combination of these coverages, shall provide that an employee
14
CODING: Words stricken are deletions; words underlined are additions.
CS for CS for SB 1800 Second Engrossed
(ntc)
1
or member whose insurance under the group policy has been
2
terminated for any reason, including discontinuance of the
3
group policy in its entirety or with respect to an insured
4
class, and who has been continuously insured under the group
5
policy, and under any group policy providing similar benefits
6
that the terminated group policy replaced, for at least 3
7
months immediately prior to termination, shall be entitled to
8
have issued to him or her by the insurer a policy or
9
certificate of health insurance, referred to in this section
10
as a "converted policy." An employee or member shall not be
11
entitled to a converted policy if termination of his or her
12
insurance under the group policy occurred because he or she
13
failed to pay any required contribution, or because any
14
discontinued group coverage was replaced by similar group
15
coverage within 31 days after discontinuance.
16
(3) CONVERSION PREMIUM; EFFECT ON PREMIUM RATES FOR
17
GROUP COVERAGE.--
18
(a) The premium for the converted policy shall be
19
determined in accordance with premium rates applicable to the
20
age and class of risk of each person to be covered under the
21
converted policy and to the type and amount of insurance
22
provided. However, the premium for the converted policy may
23
not exceed 200 percent of the standard risk rate as
24
established by the department, pursuant to this subsection
25
Florida Comprehensive Health Association, adjusted for
26
differences in benefit levels and structure between the
27
converted policy and the policy offered by the Florida
28
Comprehensive Health Association.
29
(b) Actual or expected experience under converted
30
policies may be combined with such experience under group
31
policies for the purposes of determining premium and loss
15
CODING: Words stricken are deletions; words underlined are additions.
CS for CS for SB 1800 Second Engrossed
(ntc)
1
experience and establishing premium rate levels for group
2
coverage.
3
(c) The department shall annually determine standard
4
risk rates, using reasonable actuarial techniques and
5
standards adopted by the department by rule. The standard risk
6
rates must be determined as follows:
7
1. Standard risk rates for individual coverage must be
8
determined separately for indemnity policies, preferred
9
provider/exclusive provider policies, and health maintenance
10
organization contracts.
11
2. The department shall survey insurers and health
12
maintenance organizations representing at least an 80 percent
13
market share, based on premiums earned in the state for the
14
most recent calendar year, for each of the categories
15
specified in subparagraph 1.
16
3. Standard risk rate schedules must be determined,
17
computed as the average rates charged by the carriers
18
surveyed, giving appropriate weight to each carrier's
19
statewide market share of earned premiums.
20
4. The rate schedule shall be determined from analysis
21
of the one county with the largest market share in the state
22
of all such carriers.
23
5. The rate for other counties must be determined by
24
using the weighted average of each carrier's county factor
25
relationship to the county determined in subparagraph 4.
26
6. The rate schedule must be determined for different
27
age brackets and family-size brackets.
28
(7) INFORMATION REQUESTED BY INSURER.--
29
(b) The converted policy may provide that the insurer
30
may refuse to renew the policy or the coverage of any person
31
only for one or more of the following reasons:
16
CODING: Words stricken are deletions; words underlined are additions.
CS for CS for SB 1800 Second Engrossed
(ntc)
1
1. Either the benefits provided under the sources
2
referred to in subparagraphs (a)1. and 2. for the person or
3
the benefits provided or available under the sources referred
4
to in subparagraph (a)3. for the person, together with the
5
benefits provided by the converted policy, would result in
6
overinsurance according to the insurer's standards on file
7
with the department.
8
2. The converted policyholder fails to provide the
9
information requested pursuant to paragraph (a).
10
3. Fraud or intentional material misrepresentation in
11
applying for any benefits under the converted policy.
12
4. Eligibility of the insured person for coverage
13
under Medicare or under any other state or federal law
14
providing for benefits similar to those provided by the
15
converted policy.
16
4.5. Other reasons approved by the department.
17
(17) NOTIFICATION.--A notification of the conversion
18
privilege shall be included in each certificate of coverage.
19
The insurer shall mail an election and premium notice form,
20
including an outline of coverage, on a form approved by the
21
department, within 14 days after an individual who is eligible
22
for a converted policy gives notice to the insurer that the
23
individual is considering applying for the converted policy or
24
otherwise requests such information. The outline of coverage
25
must contain a description of the principal benefits and
26
coverage provided by the policy and its principal exclusions
27
and limitations, including, but not limited to, deductibles
28
and coinsurance.
29
Section 12. Section 627.6685, Florida Statutes, is
30
created to read:
31
627.6685 Mental health coverage.--
17
CODING: Words stricken are deletions; words underlined are additions.
CS for CS for SB 1800 Second Engrossed
(ntc)
1
(1) DEFINITIONS.--As used in this section, the term:
2
(a) "Aggregate lifetime limit" means, with respect to
3
benefits under a group health plan or health insurance
4
coverage, a dollar limitation on the total amount that may be
5
paid with respect to such benefits under the plan or health
6
insurance coverage with respect to an individual or other
7
coverage unit.
8
(b) "Annual limit" means, with respect to benefits
9
under a group health plan or health insurance coverage, a
10
dollar limitation on the total amount of benefits that may be
11
paid with respect to such benefits in a 12-month period under
12
the plan or health insurance coverage with respect to an
13
individual or other coverage unit.
14
(c) "Medical or surgical benefits" means benefits with
15
respect to medical or surgical services, as defined under the
16
terms of the plan or coverage, but does not include mental
17
health benefits.
18
(d) "Mental health benefits" means benefits with
19
respect to mental health services, as defined under the terms
20
of the plan or coverage, but does not include benefits with
21
respect to treatment of substance abuse or chemical
22
dependency.
23
(e) "Health insurance coverage" means coverage
24
provided by an authorized insurer or by a health maintenance
25
organization.
26
(2) BENEFITS.--
27
(a)1. In the case of a group health plan, or health
28
insurance coverage offered in connection with such a plan,
29
which provides both medical and surgical benefits and mental
30
health benefits:
31
18
CODING: Words stricken are deletions; words underlined are additions.
CS for CS for SB 1800 Second Engrossed
(ntc)
1
a. If the plan or coverage does not include an
2
aggregate lifetime limit on substantially all medical and
3
surgical benefits, the plan or coverage may not impose any
4
aggregate lifetime limit on mental health benefits.
5
b. If the plan or coverage includes an aggregate
6
lifetime limit on substantially all medical and surgical
7
benefits, the plan or coverage must:
8
(I) Apply that applicable lifetime limit both to the
9
medical and surgical benefits to which it otherwise would
10
apply and to mental health benefits and not distinguish in the
11
application of such limit between such medical and surgical
12
benefits and mental health benefits; or
13
(II) Not include any aggregate lifetime limit on
14
mental health benefits which is less than that applicable
15
lifetime limit.
16
c. For any plan or coverage that is not described in
17
sub-subparagraph a. or sub-subparagraph b. and that includes
18
no or different aggregate lifetime limits on different
19
categories of medical and surgical benefits, the department
20
shall establish rules under which sub-subparagraph b. is
21
applied to such plan or coverage with respect to mental health
22
benefits by substituting for the applicable lifetime limit an
23
average aggregate lifetime limit that is computed taking into
24
account the weighted average of the aggregate lifetime limits
25
applicable to such categories.
26
2. In the case of a group health plan, or health
27
insurance coverage offered in connection with such a plan,
28
which provides both medical and surgical benefits and mental
29
health benefits:
30
a. If the plan or coverage does not include an annual
31
limit on substantially all medical and surgical benefits, the
19
CODING: Words stricken are deletions; words underlined are additions.
CS for CS for SB 1800 Second Engrossed
(ntc)
1
plan or coverage may not impose any annual limit on mental
2
health benefits.
3
b. If the plan or coverage includes an annual limit on
4
substantially all medical and surgical benefits, the plan or
5
coverage must:
6
(I) Apply that applicable annual limit both to medical
7
and surgical benefits to which it otherwise would apply and to
8
mental health benefits and not distinguish in the application
9
of such limit between such medical and surgical benefits and
10
mental health benefits; or
11
(II) Not include any annual limit on mental health
12
benefits which is less than the applicable annual limit.
13
c. For any plan or coverage that is not described in
14
sub-subparagraph a. or sub-subparagraph b. and that includes
15
no or different annual limits on different categories of
16
medical and surgical benefits, the department shall establish
17
rules under which sub-subparagraph b. is applied to such plan
18
or coverage with respect to mental health benefits by
19
substituting for the applicable annual limit an average annual
20
limit that is computed taking into account the weighted
21
average of the annual limits applicable to such categories.
22
(b) This section may not be construed:
23
1. As requiring a group health plan, or health
24
insurance coverage offered in connection with such a plan, to
25
provide any mental health benefits; or
26
2. In the case of a group health plan, or health
27
insurance coverage offered in connection with such a plan,
28
which provides mental health benefits, as affecting the terms
29
and conditions, including cost-sharing, limits on numbers of
30
visits or days of coverage, and requirements relating to
31
medical necessity, relating to the amount, duration, or scope
20
CODING: Words stricken are deletions; words underlined are additions.
CS for CS for SB 1800 Second Engrossed
(ntc)
1
of mental health benefits under the plan or coverage, except
2
as specifically provided in paragraph (a) with respect to
3
parity in the imposition of aggregate lifetime limits and
4
annual limits for mental health benefits.
5
(3) EXEMPTIONS.--
6
(a) This section does not apply to any group health
7
plan, or group health insurance coverage offered in connection
8
with a group health plan, for any plan year of a small
9
employer as defined in s. 627.6699.
10
(b) This section does not apply with respect to a
11
group health plan, or health insurance coverage offered in
12
connection with a group health plan, if the application of
13
this section to such plan or coverage results in an increase
14
in the cost under the plan or for such coverage of at least 1
15
percent.
16
(4) SEPARATE APPLICATION TO EACH OPTION OFFERED.--For
17
any group health plan that offers a participant or beneficiary
18
two or more benefit-package options under the plan, the
19
requirements of this section apply separately with respect to
20
each such option.
21
(5) DURATION.--This section does not apply to benefits
22
for services furnished on or after September 30, 2001.
23
(6) CONFLICTING PROVISIONS.--The provisions of this
24
section prevail over any conflicting provision of s. 627.668.
25
Section 13. Paragraph (k) of subsection (3) of section
26
627.6699, Florida Statutes, is amended to read:
27
627.6699 Employee Health Care Access Act.--
28
(3) DEFINITIONS.--As used in this section, the term:
29
(k) "Health benefit plan" means any hospital or
30
medical policy or certificate, hospital or medical service
31
plan contract, or health maintenance organization subscriber
21
CODING: Words stricken are deletions; words underlined are additions.
CS for CS for SB 1800 Second Engrossed
(ntc)
1
contract. The term does not include accident-only, specified
2
disease, individual hospital indemnity, credit, dental-only,
3
vision-only, Medicare supplement, long-term care, or
4
disability income insurance; similar supplemental plans
5
provided under a separate policy, certificate, or contract of
6
insurance, which cannot duplicate coverage under an underlying
7
health plan and are specifically designed to fill gaps in the
8
underlying health plan, coinsurance, or deductibles; coverage
9
issued as a supplement to liability insurance; workers'
10
compensation or similar insurance; or automobile
11
medical-payment insurance.
12
Section 14. Paragraphs (a) and (d) of subsection (2)
13
and subsection (3) of section 627.674, Florida Statutes, are
14
amended to read:
15
627.674 Minimum standards; filing requirements.--
16
(2)(a) The department must adopt rules establishing
17
minimum standards for Medicare supplement policies that, taken
18
together with the requirements of this part, are no less
19
comprehensive or beneficial to persons insured or covered
20
under Medicare supplement policies issued, delivered, or
21
issued for delivery in this state, including certificates
22
under group or blanket policies issued, delivered, or issued
23
for delivery in this state, than the standards provided in 42
24
U.S.C. Section 1395ss, or the most recent version of the NAIC
25
Model Regulation To Implement the NAIC Medicare Supplement
26
Insurance Minimum Standards Model Act adopted by the National
27
Association of Insurance Commissioners on July 31, 1991, or
28
the Omnibus Budget Reconciliation Act of 1990 (Pub. L. No.
29
101-508).
30
(d) For policies issued on or after January 1, 1991,
31
the department may adopt rules to establish minimum policy
22
CODING: Words stricken are deletions; words underlined are additions.
CS for CS for SB 1800 Second Engrossed
(ntc)
1
standards to authorize the types of policies specified by 42
2
U.S.C. Section 1395ss(p)(2)(C) and any optional benefits to
3
facilitate policy comparisons.
4
(3) A policy may not be filed with the department as a
5
Medicare supplement policy unless the policy meets or exceeds,
6
either in a single policy or, in the case of nonprofit health
7
care services plans, in one or more policies issued in
8
conjunction with one another, the requirements of 42 U.S.C.
9
Section 1395ss, or the most recent version of the NAIC
10
Medicare Supplement Insurance Minimum Standards Model Act,
11
adopted by the National Association of Insurance Commissioners
12
on July 31, 1991, and the Omnibus Budget Reconciliation Act of
13
1990 (Pub. L. No. 101-508).
14
Section 15. Section 627.6741, Florida Statutes, is
15
amended to read:
16
627.6741 Issuance, cancellation, nonrenewal, and
17
replacement.--
18
(1) An insurer issuing Medicare supplement policies in
19
this state shall offer the opportunity of enrolling in a
20
Medicare supplement policy, without conditioning the issuance
21
or effectiveness of the policy on, and without discriminating
22
in the price of the policy based on, the medical or health
23
status or receipt of health care by the individual:
24
(a) To any individual who is 65 years of age or older
25
and who resides in this state, upon the request of the
26
individual during the 6-month period beginning with the first
27
month in which the individual has attained 65 years of age and
28
is enrolled in Medicare part B; or
29
(b) To any individual who is 65 years of age or older
30
and is enrolled in Medicare part B, who resides in this state,
31
upon the request of the individual during the 2-month period
23
CODING: Words stricken are deletions; words underlined are additions.
CS for CS for SB 1800 Second Engrossed
(ntc)
1
following termination of coverage under a group health
2
insurance policy.;
3
4
A Medicare supplement policy issued to an individual under
5
paragraph (a) or paragraph (b) may not exclude benefits based
6
on a pre-existing condition if the individual has a continuous
7
period of creditable coverage, as defined in s. 627.6561(5),
8
of at least 6 months as of the date of application for
9
coverage.
10
11
the opportunity of enrolling in a Medicare supplement policy,
12
without conditioning the issuance or effectiveness of the
13
policy on, and without discriminating in the price of the
14
policy based on, the medical or health status or receipt of
15
health care by the individual.
16
(2) For both individual and group Medicare supplement
17
policies:
18
(a) An insurer shall neither cancel nor nonrenew a
19
Medicare supplement policy or certificate for any reason other
20
than nonpayment of premium or material misrepresentation.
21
(b) If it is not replacing an existing policy, a
22
Medicare supplement policy shall not limit or preclude
23
liability under the policy for a period longer than 6 months
24
because of a health condition existing before the policy is
25
effective. The policy may not define a preexisting condition
26
more restrictively than a condition for which medical advice
27
was given or treatment was recommended by or received from a
28
physician within 6 months before the effective date of
29
coverage.
30
(c) If a Medicare supplement policy or certificate
31
replaces another Medicare supplement policy or certificate or
24
CODING: Words stricken are deletions; words underlined are additions.
CS for CS for SB 1800 Second Engrossed
(ntc)
1
creditable coverage as defined in s. 627.6561(5) a group
2
health insurance policy or certificate, the replacing insurer
3
shall waive any time periods applicable to preexisting
4
conditions, waiting periods, elimination periods, and
5
probationary periods in the new Medicare supplement policy for
6
similar benefits to the extent such time was spent under the
7
original policy, subject to the requirements of s.
8
627.6561(6)-(11).
9
(3) For group Medicare supplement policies:
10
(a) If a group Medicare supplement insurance policy is
11
terminated by the group policyholder and not replaced as
12
provided in paragraph (c), the insurer shall offer
13
certificateholders an individual Medicare supplement policy.
14
The insurer shall offer the certificateholder at least the
15
following choices:
16
1. An individual Medicare supplement policy that
17
provides for continuation of the benefits contained in the
18
group policy.
19
2. An individual Medicare supplement policy that
20
provides only the benefits required to meet the minimum
21
standards.
22
(b) If membership in a group is terminated, the
23
insurer shall:
24
1. Offer the certificateholder conversion
25
opportunities specified in paragraph (a); or
26
2. At the option of the group policyholder, offer the
27
certificateholder continuation of coverage under the group
28
policy.
29
(c) If a group Medicare supplement policy is replaced
30
by another group Medicare supplement policy purchased by the
31
same policyholder, the succeeding insurer shall offer coverage
25
CODING: Words stricken are deletions; words underlined are additions.
CS for CS for SB 1800 Second Engrossed
(ntc)
1
to all persons covered under the old group policy on its date
2
of termination. Coverage under the new group policy may not
3
result in any exclusion for preexisting conditions that would
4
have been covered under the group policy being replaced.
5
(4) If a policy is canceled, the insurer must return
6
promptly the unearned portion of any premium paid. If the
7
insured cancels the policy, the earned premium shall be
8
computed by the use of the short-rate table last filed with
9
the state official having supervision of insurance in the
10
state where the insured resided when the policy was issued.
11
If the insurer cancels, the earned premium shall be computed
12
pro rata. Cancellation shall be without prejudice to any
13
claim originating prior to the effective date of the
14
cancellation.
15
(5) The department shall by rule prescribe standards
16
relating to the guaranteed issue of coverage, without
17
exclusions for preexisting conditions, for continuously
18
covered individuals consistent with the provisions of 42
19
U.S.C. Section 1395ss(s)(3).
20
Section 16. Section 627.9403, Florida Statutes, is
21
amended to read:
22
627.9403 Scope.--The provisions of this part shall
23
apply to long-term care insurance policies delivered or issued
24
for delivery in this state, and to policies delivered or
25
issued for delivery outside this state to the extent provided
26
in s. 627.9406, by an insurer, a fraternal benefit society as
27
defined in s. 632.601, a health care services plan as defined
28
in s. 641.01, a health maintenance organization as defined in
29
s. 641.19, a prepaid health clinic as defined in s. 641.402,
30
or a multiple-employer welfare arrangement as defined in s.
31
624.437. A policy which is advertised, marketed, or offered as
26
CODING: Words stricken are deletions; words underlined are additions.
CS for CS for SB 1800 Second Engrossed
(ntc)
1
a long-term care policy and as a Medicare supplement policy
2
shall meet the requirements of this part and the requirements
3
of ss. 627.671-627.675 and, to the extent of a conflict, be
4
subject to the requirement that is more favorable to the
5
policyholder or certificateholder. The provisions of this
6
part shall not apply to a continuing care contract issued
7
pursuant to chapter 651 and shall not apply to guaranteed
8
renewable policies issued prior to October 1, 1988. Any
9
limited benefit policy that limits coverage to care in a
10
nursing home or to one or more lower levels of care required
11
or authorized to be provided by this part or by department
12
rule must meet all requirements of this part that apply to
13
long-term care insurance policies, except s. 627.9407(3)(c),
14
(9), (10)(f), and (12), and s. 627.94073(2) s. 627.9407(3)(c)
15
and (9). If the limited benefit policy does not provide
16
coverage for care in a nursing home, but does provide coverage
17
for one or more lower levels of care, the policy shall also be
18
exempt from the requirements of s. 627.9407(3)(d).
19
Section 17. Section 627.9404, Florida Statutes, is
20
amended to read:
21
627.9404 Definitions.--For the purposes of this part:
22
(1) "Long-term care insurance policy" means any
23
insurance policy or rider advertised, marketed, offered, or
24
designed to provide coverage on an expense-incurred,
25
indemnity, prepaid, or other basis for one or more necessary
26
or medically necessary diagnostic, preventive, therapeutic,
27
curing, treating, mitigating, rehabilitative, maintenance, or
28
personal care services provided in a setting other than an
29
acute care unit of a hospital. Long-term care insurance shall
30
not include any insurance policy which is offered primarily to
31
provide basic Medicare supplement coverage, basic hospital
27
CODING: Words stricken are deletions; words underlined are additions.
CS for CS for SB 1800 Second Engrossed
(ntc)
1
expense coverage, basic medical-surgical expense coverage,
2
hospital confinement indemnity coverage, major medical expense
3
coverage, disability income protection coverage, accident only
4
coverage, specified disease or specified accident coverage, or
5
limited benefit health coverage.
6
(2) "Applicant" means:
7
(a) In the case of an individual long-term care
8
insurance policy, the person who seeks to contract for
9
benefits.
10
(b) In the case of a group long-term care insurance
11
policy, the proposed certificateholder.
12
(3) "Certificate" means any certificate issued under a
13
group long-term care insurance policy, which policy has been
14
delivered or issued for delivery in this state.
15
(4) "Chronically ill" means certified by a licensed
16
health care practitioner as:
17
(a) Being unable to perform, without substantial
18
assistance from another individual, at least two activities of
19
daily living for a period of at least 90 days due to a loss of
20
functional capacity; or
21
(b) Requiring substantial supervision for protection
22
from threats to health and safety due to severe cognitive
23
impairment.
24
(5) "Cognitive impairment" means a deficiency in a
25
person's short-term or long-term memory, orientation as to
26
person, place, and time, deductive or abstract reasoning, or
27
judgment as it relates to safety awareness.
28
(6) "Licensed health care practitioner" means any
29
physician, nurse licensed under chapter 464, or
30
psychotherapist licensed under chapter 490 or chapter 491, or
31
28
CODING: Words stricken are deletions; words underlined are additions.
CS for CS for SB 1800 Second Engrossed
(ntc)
1
any individual who meets any requirements prescribed by rule
2
by the department.
3
(7) "Limited benefit policy" means any policy that
4
limits coverage to care in a nursing home or to one or more
5
lower levels of care required or authorized to be provided by
6
this part or by department rule.
7
(8)(7) "Maintenance or personal care services" means
8
any care the primary purpose of which is the provision of
9
needed assistance with any of the disabilities as a result of
10
which the individual is a chronically ill individual,
11
including the protection from threats to health and safety due
12
to severe cognitive impairment.
13
(9)(8) "Policy" means any policy, contract, subscriber
14
agreement, rider, or endorsement delivered or issued for
15
delivery in this state by any of the entities specified in s.
16
627.9403.
17
(10) "Qualified limited benefit insurance policy"
18
means an accident and health insurance contract as defined in
19
s. 7702B of the Internal Revenue Code and all applicable
20
sections of this part.
21
(11)(9) "Qualified long-term care services" means
22
necessary diagnostic, preventive, curing, treating,
23
mitigating, and rehabilitative services, and maintenance or
24
personal care services which are required by a chronically ill
25
individual and are provided pursuant to a plan of care
26
prescribed by a licensed health care practitioner.
27
(12)(10) "Qualified long-term care insurance policy"
28
means an accident and health insurance contract as defined in
29
s. 7702B of the Internal Revenue Code and all applicable
30
sections of this part.
31
29
CODING: Words stricken are deletions; words underlined are additions.
CS for CS for SB 1800 Second Engrossed
(ntc)
1
Section 18. Paragraph (a) of subsection (4) of section
2
627.9407, Florida Statutes, is amended, and subsection (13) is
3
added to that section, to read:
4
627.9407 Disclosure, advertising, and performance
5
standards for long-term care insurance.--
6
(4) PREEXISTING CONDITION.--
7
(a) A long-term care insurance policy or certificate,
8
other than a policy or certificate issued to a group referred
9
to in s. 627.9405(1)(a), may not use a definition of
10
"preexisting condition" which is more restrictive than the
11
following: "Preexisting condition" means the existence of
12
symptoms which would cause an ordinarily prudent person to
13
seek diagnosis, care, or treatment, or a condition for which
14
medical advice or treatment was recommended by or received
15
from a provider of health care services within 6 months
16
preceding the effective date of coverage of an insured person.
17
(13) ADDITIONAL DISCLOSURE.--A limited benefit policy
18
qualified under s. 7702B of the Internal Revenue Code must
19
include a disclosure statement within the policy and within
20
the outline of coverage that the policy is intended to be a
21
qualified limited benefit insurance contract. A limited
22
benefit policy that is not intended to be a qualified limited
23
benefit insurance contract must include a disclosure statement
24
within the policy and within the outline of coverage that the
25
policy is not intended to be a qualified limited benefit
26
insurance contract. The disclosure must be prominently
27
displayed and must read as follows: "This limited benefit
28
insurance policy is not intended to be a qualified limited
29
benefit insurance contract. You need to be aware that benefits
30
received under this policy may create unintended, adverse
31
income tax consequences to you. You may want to consult with a
30
CODING: Words stricken are deletions; words underlined are additions.
CS for CS for SB 1800 Second Engrossed
(ntc)
1
knowledgeable individual about such potential income tax
2
consequences."
3
Section 19. Subsection (2) of section 627.94073,
4
Florida Statutes, is amended to read:
5
627.94073 Notice of cancellation; grace period.--
6
(2) A long-term care policy may not be canceled for
7
nonpayment of premium unless, after expiration of the grace
8
period in subsection (1), and at least 30 days prior to the
9
effective date of such cancellation, the insurer has mailed a
10
notification of possible lapse in coverage to the policyholder
11
and to a specified secondary addressee if such addressee has
12
been designated in writing by name and address by the
13
policyholder. For policies issued or renewed on or after
14
October 1, 1996, the insurer shall notify the policyholder, at
15
least once every 2 years, of the right to designate a
16
secondary addressee. The applicant has the right to designate
17
at least one person who is to receive the notice of
18
termination, in addition to the insured. Designation shall not
19
constitute acceptance of any liability on the third party for
20
services provided to the insured. The form used for the
21
written designation must provide space clearly designated for
22
listing at least one person. The designation shall include
23
each person's full name and home address. In the case of an
24
applicant who elects not to designate an additional person,
25
the waiver shall state: "Protection against unintended
26
lapse.--I understand that I have the right to designate at
27
least one person other than myself to receive notice of lapse
28
or termination of this long-term care or limited benefit
29
long-term care insurance policy for nonpayment of premium. I
30
understand that notice will not be given until 30 days after a
31
premium is due and unpaid. I elect NOT to designate any person
31
CODING: Words stricken are deletions; words underlined are additions.
CS for CS for SB 1800 Second Engrossed
(ntc)
1
to receive such notice." Notice shall be given by first class
2
United States mail, postage prepaid, and notice may not be
3
given until 30 days after a premium is due and unpaid. Notice
4
shall be deemed to have been given as of 5 days after the date
5
of mailing.
6
Section 20. Subsections (1) and (2) of section
7
641.225, Florida Statutes, are amended to read:
8
641.225 Surplus requirements.--
9
(1) Each health maintenance organization shall at all
10
times maintain a minimum surplus in an amount that which is
11
the greater of $1,500,000, $500,000 or 10 percent of total
12
liabilities, or 2 percent of total annualized premium. All
13
health maintenance organizations that which have a valid
14
certificate of authority before October 1, 1998 1988, or an
15
entity described in subsection (3), and that which do not meet
16
the minimum surplus requirement, shall increase their surplus
17
as follows:
18
19
Date Amount
20
21
September 30, 1998 1989 $800,000, $200,000 or 10 6 percent
22
of total liabilities, or 1 percent
23
of annualized premium, whichever is
24
greater
25
26
September 30, 1999 1990 $1,150,000, $350,000 or 10 8
27
percent of total liabilities, or
28
1.25 percent of annualized premium,
29
whichever is greater
30
31
32
CODING: Words stricken are deletions; words underlined are additions.
CS for CS for SB 1800 Second Engrossed
(ntc)
1
September 30, 2000 1991 $1,500,000, $500,000 or 10 percent
2
of total liabilities, or 2 percent
3
of annualized premium, whichever is
4
greater
5
6
(2) The department shall not issue a certificate of
7
authority, except as provided in subsection (3), unless the
8
health maintenance organization has a minimum surplus in an
9
amount which is the greater of:
10
(a) $1,500,000;
11
(a)(b) Ten percent of their total liabilities based on
12
their startup actuarial projection as set forth in this part;
13
or
14
(b) Two percent of their total projected premiums
15
based on their startup projection as set forth in this part;
16
or
17
(c) $1,500,000, $500,000 plus all startup losses,
18
excluding profits, projected to be incurred on their startup
19
actuarial projection until the projection reflects statutory
20
net profits for 12 consecutive months.
21
Section 21. Section 641.285, Florida Statutes, is
22
amended to read:
23
641.285 Insolvency protection.--
24
(1) Unless otherwise provided in this section, Each
25
health maintenance organization shall deposit with the
26
department cash or securities of the type eligible under s.
27
625.52, which shall have at all times a market value in the
28
amount set forth in this subsection. The amount of the
29
deposit shall be reviewed annually, or more often, as the
30
department deems necessary. The market value of the deposit
31
shall be a minimum of $300,000. the greater of:
33
CODING: Words stricken are deletions; words underlined are additions.
CS for CS for SB 1800 Second Engrossed
(ntc)
1
(a) Twice its reasonably estimated average monthly
2
uncovered expenditures; or
3
(b) $100,000.
4
(2) If securities or assets deposited by a health
5
maintenance organization under this part are subject to
6
material fluctuations in market value, the department may, in
7
its discretion, require the organization to deposit and
8
maintain on deposit additional securities or assets in an
9
amount as may be reasonably necessary to assure that the
10
deposit will at all times have a market value of not less than
11
the amount specified under this section.
12
(a) If for any reason the market value of assets and
13
securities of a health maintenance organization held on
14
deposit in this state under this code falls below the amount
15
required, the organization shall promptly deposit other or
16
additional assets or securities eligible for deposit
17
sufficient to cure the deficiency. If the health maintenance
18
organization has failed to cure the deficiency within 30 days
19
after receipt of notice thereof by registered or certified
20
mail from the department, the department may revoke the
21
certificate of authority of the health maintenance
22
organization.
23
(b) A health maintenance organization may, at its
24
option, deposit assets or securities in an amount exceeding
25
its deposit required or otherwise permitted under this code by
26
not more than 20 percent of the required or permitted deposit,
27
or $20,000, whichever is the larger amount, for the purpose of
28
absorbing fluctuations in the value of securities and assets
29
deposited and to facilitate the exchange and substitution of
30
securities and assets. During the solvency of the health
31
maintenance organization, any excess shall be released to the
34
CODING: Words stricken are deletions; words underlined are additions.
CS for CS for SB 1800 Second Engrossed
(ntc)
1
organization upon its request. During the insolvency of the
2
health maintenance organization, any excess deposit shall be
3
released only as provided in s. 625.62.
4
(3) Whenever the department determines that the
5
financial condition of a health maintenance organization has
6
deteriorated to the point that the policyholders' or
7
subscribers' best interests are not being preserved by the
8
activities of a health maintenance organization, the
9
department may require such health maintenance organization to
10
deposit and maintain deposited in trust with the department
11
for the protection of the health maintenance organization's
12
policyholders, subscribers, and creditors, for such time as
13
the department deems necessary, securities eligible for such
14
deposit under s. 625.52 having a market value of not less than
15
the amount that the department determines is necessary, which
16
amount must not be less than $100,000 or greater than $2
17
million. The deposit required under this subsection is in
18
addition to any other deposits required of a health
19
maintenance organization pursuant to subsections (1) and (2).
20
The department shall waive the deposit requirements set forth
21
in subsection (1) whenever it is satisfied that:
22
(a) The health maintenance organization has sufficient
23
surplus and an adequate history of generating net income to
24
assure its financial viability for the next year;
25
(b) The performance and obligations of the health
26
maintenance organization are guaranteed by a guaranteeing
27
organization of the type and subject to the same provisions as
28
outlined in s. 641.225; or
29
(c) The assets of the health maintenance organization
30
or its contracts with any insurer, health care provider,
31
governmental entity, or other person are reasonably sufficient
35
CODING: Words stricken are deletions; words underlined are additions.
CS for CS for SB 1800 Second Engrossed
(ntc)
1
to assure the performance of the obligations of the
2
organization.
3
(4) All income from deposits shall belong to the
4
depositing health maintenance organization and shall be paid
5
to it as it becomes available. A health maintenance
6
organization that has made a securities deposit may withdraw
7
that deposit, or any part thereof, after making a substitute
8
deposit of cash or eligible securities or any combination of
9
these or other acceptable measures of equal amount and value.
10
(5)(a) The requirements of this section do not apply
11
to an applying or licensed health maintenance organization
12
which has a plan, approved by the department, for handling
13
insolvency which provides for continuation of benefits and
14
payments to unaffiliated providers for services rendered both
15
prior to and after insolvency for the duration of the contract
16
period for which payment has been made, except that benefits
17
to members who are confined on the date of insolvency in an
18
inpatient facility shall be continued until their discharge.
19
This plan shall include at least one of the following:
20
1. Contracts of insurance or reinsurance on file with
21
the department that will protect subscribers in the event the
22
health maintenance organization is unable to meet its
23
obligations. Each agreement between the organization and an
24
insurer shall be subject to the laws of this state regarding
25
reinsurance. Each agreement and any modification thereto
26
shall be filed with and approved by the department. Each
27
agreement shall remain in full force and in effect until
28
replaced or for at least 90 days following written
29
notification to the department by registered mail of
30
cancellation or termination by either party. The department
31
36
CODING: Words stricken are deletions; words underlined are additions.
CS for CS for SB 1800 Second Engrossed
(ntc)
1
shall be endorsed on the agreement as an additional insured
2
party;
3
2. Contractual arrangements with health care providers
4
that include a guarantee by the provider to continue providing
5
health care services to any subscriber of the health
6
maintenance organization, upon insolvency of the organization,
7
until the end of the contract period for which payment by or
8
on behalf of the subscriber has been made or the discharge of
9
the subscriber from an inpatient facility, whichever occurs
10
later; or
11
3. Other measures acceptable to the department.
12
(b) The department shall reduce the deposit
13
requirements specified in subsection (1) whenever the
14
department has determined that the health maintenance
15
organization has a plan for handling insolvency which
16
partially meets the requirements of this section. The amount
17
of the deposit reduction shall be based on the extent to which
18
the organization meets the requirements of this section.
19
Section 22. Section 641.26, Florida Statutes, is
20
amended to read:
21
641.26 Annual report.--
22
(1) Every health maintenance organization shall,
23
annually within 3 months after the end of its fiscal year, or
24
within an extension of time therefor as the department, for
25
good cause, may grant, in a form prescribed by the department,
26
file a report with the department, verified by the oath of two
27
officers of the organization or, if not a corporation, of two
28
persons who are principal managing directors of the affairs of
29
the organization, properly notarized, showing its condition on
30
the last day of the immediately preceding reporting period.
31
Such report shall include:
37
CODING: Words stricken are deletions; words underlined are additions.
CS for CS for SB 1800 Second Engrossed
(ntc)
1
(a) A financial statement of the health maintenance
2
organization filed on a computer diskette using a format
3
acceptable to the department.;
4
(b) A financial statement of the health maintenance
5
organization filed on forms acceptable to the department.;
6
(c) An audited financial statement of the health
7
maintenance organization, including its balance sheet and a
8
statement of operations for the preceding year certified by an
9
independent certified public accountant, prepared in
10
accordance with statutory accounting principles.;
11
(d) The number of health maintenance contracts issued
12
and outstanding and the number of health maintenance contracts
13
terminated.;
14
(e) The number and amount of damage claims for medical
15
injury initiated against the health maintenance organization
16
and any of the providers engaged by it during the reporting
17
year, broken down into claims with and without formal legal
18
process, and the disposition, if any, of each such claim.;
19
(f) An actuarial certification that:
20
1. The health maintenance organization is actuarially
21
sound, which certification shall consider the rates, benefits,
22
and expenses of, and any other funds available for the payment
23
of obligations of, the organization.;
24
2. The rates being charged or to be charged are
25
actuarially adequate to the end of the period for which rates
26
have been guaranteed.;
27
3. Incurred but not reported claims and claims
28
reported but not fully paid have been adequately provided
29
for.; and
30
(g) A report prepared by the Certified Public
31
Accountant and filed with the department describing material
38
CODING: Words stricken are deletions; words underlined are additions.
CS for CS for SB 1800 Second Engrossed
(ntc)
1
weaknesses in the health maintenance organization's internal
2
control structure as noted by the Certified Public Accountant
3
during the audit. The report must be filed with the annual
4
audited financial report as required in paragraph (c). The
5
health maintenance organization shall provide a description of
6
remedial actions taken or proposed to correct material
7
weaknesses, if the actions are not described in the
8
independent certified public accountant's report.
9
(h)(g) Such other information relating to the
10
performance of health maintenance organizations as is required
11
by the department.
12
(2) The department may require updates of the
13
actuarial certification as to a particular health maintenance
14
organization if the department has reasonable cause to believe
15
that such reserves are understated to the extent of materially
16
misstating the financial position of the health maintenance
17
organization. Workpapers in support of the statement of the
18
updated actuarial certification must be provided to the
19
department upon request.
20
(3)(2) Every health maintenance organization shall
21
file quarterly, within 45 days after each of its quarterly
22
reporting periods, an unaudited financial statement of the
23
organization as described in paragraphs (1)(a) and (b). The
24
quarterly report shall be verified by the oath of two officers
25
of the organization, properly notarized.
26
(4)(3) Any health maintenance organization that which
27
neglects to file an annual report or quarterly report in the
28
form and within the time required by this section shall
29
forfeit up to $1,000 for each day for the first 10 days during
30
which the neglect continues and shall forfeit up to $2,000 for
31
each day after the first 10 days during which the neglect
39
CODING: Words stricken are deletions; words underlined are additions.
CS for CS for SB 1800 Second Engrossed
(ntc)
1
continues; and, upon notice by the department to that effect,
2
the organization's authority to enroll new subscribers or to
3
do business in this state shall cease while such default
4
continues. The department shall deposit all sums collected by
5
it under this section to the credit of the Insurance
6
Commissioner's Regulatory Trust Fund. The department shall not
7
collect more than $100,000 for each report.
8
(5)(4) Each authorized health maintenance organization
9
shall retain an independent certified public accountant,
10
hereinafter referred to in this section as "CPA," who agrees
11
by written contract with the health maintenance organization
12
to comply with the provisions of this part. The contract
13
shall state:
14
(a) The CPA shall provide to the HMO audited financial
15
statements consistent with this part.
16
(b) Any determination by the CPA that the health
17
maintenance organization does not meet minimum surplus
18
requirements as set forth in this part shall be stated by the
19
CPA, in writing, in the audited financial statement.
20
(c) The completed work papers and any written
21
communications between the CPA firm and the health maintenance
22
organization relating to the audit of the health maintenance
23
organization shall be made available for review on a
24
visual-inspection-only basis by the department at the offices
25
of the health maintenance organization, at the department, or
26
at any other reasonable place as mutually agreed between the
27
department and the health maintenance organization. The CPA
28
must retain for review the work papers and written
29
communications for a period of not less than 6 years.
30
(d) The CPA shall provide to the department a written
31
report describing material weaknesses in the health
40
CODING: Words stricken are deletions; words underlined are additions.
CS for CS for SB 1800 Second Engrossed
(ntc)
1
maintenance organizations's internal control structure as
2
noted during the audit.
3
(6)(5) To facilitate uniformity in financial
4
statements and to facilitate department analysis, the
5
department may by rule adopt the form for financial statements
6
of a health maintenance organization, including supplements as
7
approved by the National Association of Insurance
8
Commissioners in 1995, and may adopt subsequent amendments
9
thereto if the methodology remains substantially consistent,
10
and may by rule require each health maintenance organization
11
to submit to the department all or part of the information
12
contained in the annual statement in a computer-readable form
13
compatible with the electronic data processing system
14
specified by the department.
15
(7) In addition to information called for and
16
furnished in connection with its annual or quarterly
17
statements, the health maintenance organization shall furnish
18
to the department as soon as reasonably possible such
19
information as to its material transactions which, in the
20
department's opinion, may have a material adverse effect on
21
the health maintenance organizations financial condition, as
22
the department may request in writing. All such information
23
furnished pursuant to the department's request must be
24
verified by the oath of two executive officers of the health
25
maintenance organization.
26
(8) Each health maintenance organization shall file
27
one copy of its annual statement convention blank in
28
electronic form, along with such additional filings as
29
prescribed by the department for the preceding year, with the
30
National Association of Insurance Commissioners. Each health
31
maintenance organization shall pay to the department a
41
CODING: Words stricken are deletions; words underlined are additions.
CS for CS for SB 1800 Second Engrossed
(ntc)
1
reasonable fee to cover costs associated with the filing and
2
analysis of the documents by the National Association of
3
Insurance Commissioners.
4
Section 23. Paragraph (a) of subsection (9) of section
5
641.31, is amended to read:
6
641.31 Health maintenance contracts.--
7
(9) All health maintenance contracts that provide
8
coverage, benefits, or services for a member of the family of
9
the subscriber must, as to such family member's coverage,
10
benefits, or services, provide also that the coverage,
11
benefits, or services applicable for children must be provided
12
with respect to a newborn child of the subscriber, or covered
13
family member of the subscriber, from the moment of birth.
14
However, with respect to a newborn child of a covered family
15
member other than the spouse of the insured or subscriber, the
16
coverage for the newborn child terminates 18 months after the
17
birth of the newborn child. The coverage, benefits, or
18
services for newborn children must consist of coverage for
19
injury or sickness, including the necessary care or treatment
20
of medically diagnosed congenital defects, birth
21
abnormalities, or prematurity, and transportation costs of the
22
newborn to and from the nearest appropriate facility
23
appropriately staffed and equipped to treat the newborn's
24
condition, when such transportation is certified by the
25
attending physician as medically necessary to protect the
26
health and safety of the newborn child.
27
(a) A contract may require the subscriber to notify
28
the plan of the birth of a child within a time period, as
29
specified in the contract, of not less than 30 days after the
30
birth, or a contract may require the preenrollment of a
31
newborn prior to birth. However, if timely notice is given, a
42
CODING: Words stricken are deletions; words underlined are additions.
CS for CS for SB 1800 Second Engrossed
(ntc)
1
plan may not charge an additional premium for additional
2
coverage of the newborn child for not less than 30 days after
3
the birth of the child. If timely notice is not given, the
4
plan may charge an additional premium from the date of birth.
5
If notice is given within 60 days of the birth of the child,
6
the contract may not deny coverage of the child due to failure
7
of the subscriber to timely notify the plan of the birth of
8
the child or to preenroll the child.
9
Section 24. Paragraph (d) of subsection (2), and
10
paragraphs (a) and (b) of subsection (3) of section 641.31074,
11
Florida Statutes, are amended to read:
12
641.31074 Guaranteed renewability of coverage.--
13
(2) A health maintenance organization may nonrenew or
14
discontinue a contract based only on one or more of the
15
following conditions:
16
(d) The health maintenance organization is ceasing to
17
offer coverage in such a market in accordance with subsection
18
(3) and applicable state law.
19
(3)(a) A health maintenance organization may
20
discontinue offering a particular contract form for group
21
coverage offered in the small group market or large group
22
market only if:
23
1. The health maintenance organization provides notice
24
to each contract holder provided coverage of this form in such
25
market, and participants and beneficiaries covered under such
26
coverage, of such discontinuation at least 90 days prior to
27
the date of the nonrenewal discontinuation of such coverage;
28
2. The health maintenance organization offers to each
29
contract holder provided coverage of this form in such market
30
the option to purchase all, or in the case of the large-group
31
market, any other health insurance coverage currently being
43
CODING: Words stricken are deletions; words underlined are additions.
CS for CS for SB 1800 Second Engrossed
(ntc)
1
offered by the health maintenance organization in such market;
2
and
3
3. In exercising the option to discontinue coverage of
4
this form and in offering the option of coverage under
5
subparagraph 2., the health maintenance organization acts
6
uniformly without regard to the claims experience of those
7
contract holders or any health-status-related factor that
8
relates to any participants or beneficiaries covered or new
9
participants or beneficiaries who may become eligible for such
10
coverage.
11
(b)1. In any case in which a health maintenance
12
organization elects to discontinue offering all coverage in
13
the small group market or the large group market, or both, in
14
this state, coverage may be discontinued by the insurer only
15
if:
16
a. The health maintenance organization provides notice
17
to the department and to each contract holder, and
18
participants and beneficiaries covered under such coverage, of
19
such discontinuation at least 180 days prior to the date of
20
the nonrenewal discontinuation of such coverage; and
21
b. All health insurance issued or delivered for
22
issuance in this state in such market is markets are
23
discontinued and coverage under such health insurance coverage
24
in such market is not renewed.
25
2. In the case of a discontinuation under subparagraph
26
1. in a market, the health maintenance organization may not
27
provide for the issuance of any health maintenance
28
organization contract coverage in the market in this state
29
during the 5-year period beginning on the date of the
30
discontinuation of the last insurance contract not renewed.
31
44
CODING: Words stricken are deletions; words underlined are additions.
CS for CS for SB 1800 Second Engrossed
(ntc)
1
Section 25. Section 641.3111, Florida Statutes, is
2
amended to read:
3
641.3111 Extension of benefits.--
4
(1) Every group health maintenance contract shall
5
provide that termination of the contract by the health
6
maintenance organization shall be without prejudice to any
7
continuous loss which commenced while the contract was in
8
force, but any extension of benefits beyond the period the
9
contract was in force may be predicated upon the continuous
10
total disability of the subscriber and may be limited to
11
payment for the treatment of a specific accident or illness
12
incurred while the subscriber was a member. Such extension of
13
benefits may be limited to the occurrence of the earliest of
14
the following events:
15
(a) The expiration of 12 months.
16
(b) Such time as the member is no longer totally
17
disabled.
18
(c) A succeeding carrier elects to provide replacement
19
coverage without limitation as to the disability condition.
20
(d) The maximum benefits payable under the contract
21
have been paid.
22
(2) For the purposes of this section, an individual is
23
totally disabled if the individual has a condition resulting
24
from an illness or injury which prevents an individual from
25
engaging in any employment or occupation for which the
26
individual is or may become qualified by reason of education,
27
training, or experience, and the individual is under the
28
regular care of a physician.
29
(3) In the case of maternity coverage, when not
30
covered by the succeeding carrier, a reasonable extension of
31
benefits or accrued liability provision is required, which
45
CODING: Words stricken are deletions; words underlined are additions.
CS for CS for SB 1800 Second Engrossed
(ntc)
1
provision provides for continuation of the contract benefits
2
in connection with maternity expenses for a pregnancy that
3
commenced while the policy was in effect. The extension shall
4
be for the period of that pregnancy and shall not be based
5
upon total disability.
6
(4) Except as provided in subsection (1), no
7
subscriber is entitled to an extension of benefits if the
8
termination of the contract by the health maintenance
9
organization is based upon any event referred to in s.
10
641.3922(7)(a), (b), or (e)(a)-(g).
11
Section 26. Section 641.316, Florida Statutes, is
12
amended to read:
13
641.316 Fiscal intermediary services.--
14
(1) It is the intent of the Legislature, through the
15
adoption of this section, to ensure the financial soundness of
16
fiscal intermediary services organizations established to
17
develop, manage, and administer the business affairs of health
18
care professional providers such as medical doctors, doctors
19
of osteopathy, doctors of chiropractic, doctors of podiatric
20
medicine, doctors of dentistry, or other health professionals
21
regulated by the Department of Health.
22
(2)(a) The term "fiduciary" or "fiscal intermediary
23
services" means reimbursements received or collected on behalf
24
of health care professionals for services rendered, patient
25
and provider accounting, financial reporting and auditing,
26
receipts and collections management, compensation and
27
reimbursement disbursement services, or other related
28
fiduciary services pursuant to health care professional
29
contracts with health maintenance organizations.
30
(b) The term "fiscal intermediary services
31
organization" means a person or entity which performs
46
CODING: Words stricken are deletions; words underlined are additions.
CS for CS for SB 1800 Second Engrossed
(ntc)
1
fiduciary or fiscal intermediary services to health care
2
professionals who contract with health maintenance
3
organizations other than a fiscal intermediary services
4
organization owned, operated, or controlled by a hospital
5
licensed under chapter 395, an insurer licensed under chapter
6
624, a third-party administrator licensed under chapter 626, a
7
prepaid limited health service organization licensed under
8
chapter 636, a health maintenance organization licensed under
9
this chapter, or physician group practices as defined in s.
10
455.654(3)(f) s. 455.236(3)(f).
11
(3) A fiscal intermediary services organization that
12
which is operated for the purpose of acquiring and
13
administering provider contracts with managed care plans for
14
professional health care services, including, but not limited
15
to, medical, surgical, chiropractic, dental, and podiatric
16
care, and which performs fiduciary or fiscal intermediary
17
services shall be required to secure and maintain a fidelity
18
bond in the minimum amount of 10 percent of the funds handled
19
by the intermediary in connection with its fiscal and
20
fiduciary services during the prior year or $1 million,
21
whichever is less. The minimum bond amount shall be $50,000.
22
The fidelity bond shall protect the fiscal intermediary from
23
loss caused by the dishonesty of its employees and must remain
24
unimpaired for as long as the intermediary continues in
25
business in the state. $10 million. This requirement shall
26
apply to all persons or entities engaged in the business of
27
providing fiduciary or fiscal intermediary services to any
28
contracted provider or provider panel. The fidelity bond shall
29
provide coverage against misappropriation of funds by the
30
fiscal intermediary or its officers, agents, or employees;
31
must be posted with the department for the benefit of managed
47
CODING: Words stricken are deletions; words underlined are additions.
CS for CS for SB 1800 Second Engrossed
(ntc)
1
care plans, subscribers, and providers; and must be on a form
2
approved by the department. The fidelity bond must be
3
maintained and remain unimpaired as long as the fiscal
4
intermediary services organization continues in business in
5
this state and until the termination of its registration.
6
(4) A fiscal intermediary services organization, as
7
described in subsection (3), shall secure and maintain a
8
surety bond on file with the department, naming the
9
intermediary as principal. The bond must be obtained from a
10
company authorized to write surety insurance in the state, and
11
the department shall be obligee on behalf of itself and third
12
parties. The penal sum of the bond may not be less than 5
13
percent of the funds handled by the intermediary in connection
14
with its fiscal and fiduciary services during the prior year
15
or $250,000, whichever is less. The minimum bond amount must
16
be $10,000. The condition of the bond must be that the
17
intermediary shall register with the department and shall not
18
misappropriate funds within its control or custody as a fiscal
19
intermediary or fiduciary. The aggregate liability of the
20
surety for any and all breaches of the conditions of the bond
21
may not exceed the penal sum of the bond. The bond must be
22
continuous in form, must be renewed annually by a continuation
23
certificate, and may be terminated by the surety upon its
24
giving 30 days' written notice of termination to the
25
department.
26
(5)(4) A fiscal intermediary services organization may
27
not collect from the subscriber any payment other than the
28
copayment or deductible specified in the subscriber agreement.
29
(6)(5) Any fiscal intermediary services organization,
30
other than a fiscal intermediary services organization owned,
31
operated, or controlled by a hospital licensed under chapter
48
CODING: Words stricken are deletions; words underlined are additions.
CS for CS for SB 1800 Second Engrossed
(ntc)
1
395, an insurer licensed under chapter 624, a third-party
2
administrator licensed under chapter 626, a prepaid limited
3
health service organization licensed under chapter 636, a
4
health maintenance organization licensed under this chapter,
5
or physician group practices as defined in s. 455.654(3)(f) s.
6
455.236(3)(f), must register with the department and meet the
7
requirements of this section. In order to register as a fiscal
8
intermediary services organization, the organization must
9
comply with ss. 641.21(1)(c) and (d) and 641.22(6). Should the
10
department determine that the fiscal intermediary services
11
organization does not meet the requirements of this section,
12
the registration shall be denied. In the event that the
13
registrant fails to maintain compliance with the provisions of
14
this section, the department may revoke or suspend the
15
registration. In lieu of revocation or suspension of the
16
registration, the department may levy an administrative
17
penalty in accordance with s. 641.25.
18
(7)(6) The department shall adopt promulgate rules
19
necessary to administer implement the provisions of this
20
section.
21
Section 27. Subsections (3), (7), and (14) of section
22
641.3922, Florida Statutes, are amended to read:
23
641.3922 Conversion contracts; conditions.--Issuance
24
of a converted contract shall be subject to the following
25
conditions:
26
(3) CONVERSION PREMIUM.--The premium for the converted
27
contract shall be determined in accordance with premium rates
28
applicable to the age and class of risk of each person to be
29
covered under the converted contract and to the type and
30
amount of coverage provided. However, the premium for the
31
converted contract may not exceed 200 percent of the standard
49
CODING: Words stricken are deletions; words underlined are additions.
CS for CS for SB 1800 Second Engrossed
(ntc)
1
risk rate, as established by the department under s.
2
627.6675(3) Florida Comprehensive Health Association and
3
adjusted for differences in benefit levels and structure
4
between the converted policy and the policy offered by the
5
Florida Comprehensive Health Association. The mode of payment
6
for the converted contract shall be quarterly or more
7
frequently at the option of the organization, unless otherwise
8
mutually agreed upon between the subscriber and the
9
organization.
10
(7) REASONS FOR CANCELLATION; TERMINATION.--The
11
converted health maintenance contract must contain a
12
cancellation or nonrenewability clause providing that the
13
health maintenance organization may refuse to renew the
14
contract of any person covered thereunder, but cancellation or
15
nonrenewal must be limited to one or more of the following
16
reasons:
17
(a) Fraud or intentional material misrepresentation,
18
subject to the limitations of s. 641.31(23), in applying for
19
any benefits under the converted health maintenance contract;
20
(b) Eligibility of the covered person for coverage
21
under Medicare, Title XVIII of the Social Security Act, as
22
added by the Social Security Amendments of 1965, or as later
23
amended or superseded, or under any other state or federal law
24
providing for benefits similar to those provided by the
25
converted health maintenance contract, except for Medicaid,
26
Title XIX of the Social Security Act, as amended by the Social
27
Security Amendments of 1965, or as later amended or
28
superseded.
29
(b)(c) Disenrollment for cause, after following the
30
procedures outlined in s. 641.3921(4).
31
50
CODING: Words stricken are deletions; words underlined are additions.
CS for CS for SB 1800 Second Engrossed
(ntc)
1
(c)(d) Willful and knowing misuse of the health
2
maintenance organization identification membership card by the
3
subscriber or the willful and knowing furnishing to the
4
organization by the subscriber of incorrect or incomplete
5
information for the purpose of fraudulently obtaining coverage
6
or benefits from the organization.
7
(d)(e) Failure, after notice, to pay required
8
premiums.
9
(e)(f) The subscriber has left the geographic area of
10
the health maintenance organization with the intent to
11
relocate or establish a new residence outside the
12
organization's geographic area.
13
(f)(g) A dependent of the subscriber has reached the
14
limiting age under the converted contract, subject to
15
subsection (12); but the refusal to renew coverage shall apply
16
only to coverage of the dependent, except in the case of
17
handicapped children.
18
(g)(h) A change in marital status that makes a person
19
ineligible under the original terms of the converted contract,
20
subject to subsection (12).
21
(14) NOTIFICATION.--A notification of the conversion
22
privilege shall be included in each health maintenance
23
contract and in any certificate or member's handbook. The
24
organization shall mail an election and premium notice form,
25
including an outline of coverage, on a form approved by the
26
department, within 14 days after any individual who is
27
eligible for a converted health maintenance contract gives
28
notice to the organization that the individual is considering
29
applying for the converted contract or otherwise requests such
30
information. The outline of coverage must contain a
31
description of the principal benefits and coverage provided by
51
CODING: Words stricken are deletions; words underlined are additions.
CS for CS for SB 1800 Second Engrossed
(ntc)
1
the contract and its principal exclusions and limitations,
2
including, but not limited to, deductibles and coinsurance.
3
Section 28. Subsection (12) is added to section
4
641.495, Florida Statutes, to read:
5
641.495 Requirements for issuance and maintenance of
6
certificate.--
7
(12) The provisions of part I of chapter 395 do not
8
apply to a health maintenance organization that, on or before
9
January 1, 1991, provides not more than 10 outpatient holding
10
beds for short-term and hospice-type patients in an ambulatory
11
care facility for its members, provided that such health
12
maintenance organization maintains current accreditation by
13
the Joint Commission on Accreditation of Health Care
14
Organizations, the Accreditation Association for Ambulatory
15
Health Care, or the National Committee for Quality Assurance.
16
Section 29. This act shall take effect January 1,
17
1999.
18
19
20
21
22
23
24
25
26
27
28
29
30
31
52