CODING: Words stricken are deletions; words underlined are additions.House Bill 1967e1
HB 1967, First Engrossed
1 A bill to be entitled
2 An act relating to health insurance; amending
3 s. 627.6406, F.S., relating to coverage for
4 maternity care; prohibiting an insurer from
5 imposing certain limitations on benefits,
6 coverage, or reimbursement; amending s.
7 627.6425, F.S.; requiring an insurer that
8 provides individual coverage to renew or
9 continue coverage; providing certain
10 exceptions; requiring an insurer to provide
11 notice of discontinuation; authorizing an
12 insurer to modify coverage; revising
13 requirements for renewability of individual
14 coverage; creating s. 627.6475, F.S.; providing
15 for an individual reinsurance pool; providing
16 purpose; providing definitions; providing
17 applicability and scope; providing requirements
18 for availability of coverage; requiring
19 maintenance of records; providing an election
20 for carriers; providing an election process;
21 requiring operations of the program to be
22 subject to the board of the Florida Small
23 Employer Reinsurance Program; requiring the
24 establishment of a separate account; providing
25 for standards to assure fair marketing;
26 authorizing the Department of Insurance to
27 adopt rules; creating s. 627.6487, F.S.;
28 providing for guaranteed availability of health
29 insurance coverage to eligible individuals;
30 prohibiting an insurer or health maintenance
31 organization from declining coverage for
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HB 1967, First Engrossed
1 eligible individuals or imposing preexisting
2 conditions; providing definitions; providing
3 certain exceptions; creating s. 627.64871,
4 F.S.; providing for application of requirements
5 for certification of coverage; providing
6 exceptions; creating s. 627.6489, F.S.;
7 authorizing the Florida Comprehensive Health
8 Association to contract with insurers to
9 provide disease management services; creating
10 s. 627.6512, F.S.; exempting certain group
11 health insurance policies from specified
12 requirements with respect to excepted benefits;
13 amending s. 627.6561, F.S., relating to
14 exclusions for preexisting conditions;
15 providing definitions; specifying circumstances
16 under which an insurer may impose an exclusion
17 for a preexisting condition; providing
18 exceptions; providing requirements for
19 creditable coverage; providing for an election
20 of methods for calculating creditable coverage;
21 requiring disclosure of certain elections;
22 providing for establishing creditable coverage;
23 providing exceptions; requiring an issuer to
24 provide certification pursuant to rules adopted
25 by the department; creating s. 627.65615, F.S.;
26 providing for special enrollment periods for
27 employees and dependents; specifying conditions
28 for special enrollment periods; creating s.
29 627.65625, F.S.; prohibiting an insurer from
30 discriminating against individual participants
31 and beneficiaries based on health status;
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HB 1967, First Engrossed
1 creating s. 627.6571, F.S.; specifying
2 circumstances under which an insurer that
3 issues group health insurance policies must
4 renew or continue coverage; providing for
5 notice of discontinuation; providing a process
6 for notification; authorizing an insurer to
7 modify coverage; amending s. 627.6574, F.S.,
8 relating to coverage for maternity care;
9 prohibiting a group, blanket, or franchise
10 policy from imposing certain limitations on
11 enrolling or renewing coverage; prohibiting an
12 insurer from imposing certain limitations on
13 benefits, coverage, or reimbursement;
14 prohibiting an insurer from providing monetary
15 payments or rebates; amending s. 627.6675,
16 F.S.; revising time limitations for application
17 for and payment of a converted policy;
18 requiring an insurer to offer a standard health
19 benefit plan; amending s. 627.6699, F.S.,
20 relating to the Employee Health Care Access
21 Act; revising definitions; providing
22 requirements for policies with respect to
23 preexisting conditions; providing exceptions;
24 requiring special enrollment periods;
25 authorizing a small carrier to deny coverage
26 under certain circumstances; revising
27 requirements for renewing coverage; increasing
28 membership of the board of the Small Employer
29 Health Reinsurance Program; requiring a small
30 employer to disclose certain information with
31 respect to a health benefit plan; amending s.
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HB 1967, First Engrossed
1 627.9404, F.S.; providing additional
2 definitions; amending s. 627.9407, F.S.;
3 specifying additional information required to
4 be disclosed for purposes of long-term care
5 insurance; requiring a disclosure statement;
6 amending s. 627.94071, F.S.; specifying
7 additional minimum standards for home health
8 care benefits; amending s. 627.94072, F.S.;
9 deleting a requirement to provide cash
10 surrender values in offering long-term care
11 insurance policies; amending s. 627.94073,
12 F.S.; revising notice of cancellation
13 provisions; amending s. 627.94074, F.S.;
14 revising standards for benefit triggers;
15 creating s. 641.2018, F.S.; authorizing a
16 health maintenance organization to offer high
17 deductible contracts to certain employers;
18 amending s. 641.31, F.S.; revising requirements
19 for a health maintenance contract that provides
20 coverage for maternity care; prohibiting a
21 health maintenance organization from denying
22 eligibility to enroll or to renew coverage;
23 prohibiting such an organization from imposing
24 certain limitations on benefits, coverage, or
25 reimbursement; prohibiting such an organization
26 from providing monetary payments or rebates;
27 amending s. 641.3102, F.S.; prohibiting health
28 maintenance organizations from declining to
29 offer coverage to an eligible individual under
30 s. 627.6487, F.S.; creating s. 641.31071, F.S.,
31 relating to exclusions for preexisting
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HB 1967, First Engrossed
1 conditions; providing definitions; specifying
2 circumstances under which a health maintenance
3 organization may impose an exclusion for a
4 preexisting condition; providing exceptions;
5 providing requirements for creditable coverage;
6 providing for an election of methods for
7 calculating creditable coverage; requiring
8 disclosure of certain elections; providing for
9 establishing creditable coverage; providing
10 exceptions; requiring a health maintenance
11 organization to provide certification pursuant
12 to rules adopted by the department; creating s.
13 641.31072, F.S.; requiring a health maintenance
14 organization to provide for special enrollment
15 periods under a contract for employees and
16 dependents; providing conditions for special
17 enrollment periods; creating s. 641.31073,
18 F.S.; prohibiting a health maintenance
19 organization from discriminating against
20 individual participants and beneficiaries based
21 on health status; creating s. 641.31074, F.S.;
22 requiring a health maintenance organization to
23 renew or continue coverage of certain group
24 health insurance contracts; requiring notice of
25 discontinuation; prescribing a process for
26 notification; authorizing a health maintenance
27 organization to modify coverage; amending s.
28 641.3921, F.S.; clarifying circumstances under
29 which a health maintenance organization may
30 issue a converted contract; amending s.
31 641.3922, F.S.; revising the time limitation
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HB 1967, First Engrossed
1 for applying for a converted contract; revising
2 the maximum premium rate for a converted
3 contract; requiring a health maintenance
4 organization to offer a standard health benefit
5 plan; providing that the act fulfills an
6 important state interest; repealing s.
7 627.6576, F.S., relating to a prohibition
8 against discriminating against handicapped
9 persons under policies of group, blanket, or
10 franchise health insurance; providing for
11 application of the act; requiring certain
12 legislative committees to conduct a study for
13 certain purposes and make recommendations to
14 the Legislature; requiring the Department of
15 Insurance to provide assistance; providing for
16 application of the act with respect to a plan
17 or contract maintained pursuant to a collective
18 bargaining agreement; providing an effective
19 date.
20
21 Be It Enacted by the Legislature of the State of Florida:
22
23 Section 1. Section 627.6406, Florida Statutes, 1996
24 Supplement, is amended to read:
25 627.6406 Maternity care.--
26 (1) Any policy of health insurance that provides
27 coverage for maternity care must shall also cover the services
28 of certified nurse-midwives and midwives licensed pursuant to
29 chapter 467, and the services of birth centers licensed under
30 ss. 383.30-383.335.
31
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HB 1967, First Engrossed
1 (2) An insurer issuing a health insurance policy that
2 which provides maternity and newborn coverage may not limit
3 coverage for the length of a maternity and newborn stay in a
4 hospital or for followup care outside of a hospital to any
5 time period that is less than that determined to be medically
6 necessary, in accordance with prevailing medical standards and
7 consistent with proposed 1996 guidelines for perinatal care of
8 the American Academy of Pediatrics or the American College of
9 Obstetricians and Gynecologists as proposed on May 1, 1996, by
10 the treating obstetrical care provider or the pediatric care
11 provider.
12 (3) Nothing in This section does not affect affects
13 any agreement between an insurer and a hospital or other
14 health care provider with respect to reimbursement for health
15 care services provided, rate negotiations with providers, or
16 capitation of providers, and this section does not prohibit or
17 prohibits appropriate utilization review or case management by
18 an insurer.
19 (4) Any policy of health insurance that provides
20 coverage, benefits, or services for maternity or newborn care
21 must provide coverage for postdelivery care for a mother and
22 her newborn infant. The postdelivery care must include a
23 postpartum assessment and newborn assessment and may be
24 provided at the hospital, at the attending physician's office,
25 at an outpatient maternity center, or in the home by a
26 qualified licensed health care professional trained in mother
27 and baby care. The services must include physical assessment
28 of the newborn and mother, and the performance of any
29 medically necessary clinical tests and immunizations in
30 keeping with prevailing medical standards.
31
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1 (5) An insurer subject to subsection (1) shall
2 communicate active case questions and concerns regarding
3 postdelivery care directly to the treating physician or
4 hospital in written form, in addition to other forms of
5 communication. Such insurers shall also use a process that
6 which includes a written protocol for utilization review and
7 quality assurance.
8 (6) An insurer subject to subsection (1) may not:
9 (a) Deny to a mother or her newborn infant
10 eligibility, or continued eligibility, to enroll or to renew
11 coverage under the terms of the policy for the purpose of
12 avoiding the requirements of this section.
13 (b) Provide monetary payments or rebates to a mother
14 to encourage the mother to accept less than the minimum
15 protections available under this section.
16 (c) Penalize or otherwise reduce or limit the
17 reimbursement of an attending provider solely because the
18 attending provider provided care to an individual participant
19 or beneficiary in accordance with this section.
20 (d) Provide incentives, monetary or otherwise, to an
21 attending provider solely to induce the provider to provide
22 care to an individual participant or beneficiary in a manner
23 inconsistent with this section.
24 (e) Subject to paragraph (7)(c), restrict benefits for
25 any portion of a period within a hospital length of stay
26 required under subsection (2) in a manner that is less
27 favorable than the benefits provided for any preceding portion
28 of such stay.
29 (7)(a) This section does not require a mother who is a
30 participant or beneficiary to:
31 1. Give birth in a hospital.
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HB 1967, First Engrossed
1 2. Stay in the hospital for a fixed period of time
2 following the birth of her infant.
3 (b) This section does not apply with respect to any
4 health insurance coverage that does not provide benefits for
5 hospital lengths of stay in connection with childbirth for a
6 mother or her newborn infant.
7 (c) This section does not prevent a policy from
8 imposing deductibles, coinsurance, or other cost-sharing in
9 relation to benefits for hospital lengths of stay in
10 connection with childbirth for a mother or her newborn infant,
11 except that such coinsurance or other cost-sharing for any
12 portion of a period within a hospital length of stay required
13 under subsection (2) may not be greater than such coinsurance
14 or cost-sharing for any preceding portion of such stay.
15 Section 2. Section 627.6425, Florida Statutes, 1996
16 Supplement, is amended to read:
17 (Substantial rewording of section. See
18 s. 627.6425, F.S., 1996 Supp., for present text.)
19 627.6425 Renewability of individual coverage.--
20 (1) Except as otherwise provided in this section, an
21 insurer that provides individual health insurance coverage to
22 an individual shall renew or continue in force such coverage
23 at the option of the individual. For the purpose of this
24 section, the term "individual health insurance" means health
25 insurance coverage, as described in s. 627.6561(5)(a)2.,
26 offered to an individual in this state, including certificates
27 of coverage offered to individuals in this state as part of a
28 group policy issued to an association outside this state, but
29 the term does not include short-term limited duration
30 insurance or excepted benefits specified in subsection (6) or
31 subsection (7).
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HB 1967, First Engrossed
1 (2) An insurer may nonrenew or discontinue health
2 insurance coverage of an individual in the individual market
3 based only on one or more of the following:
4 (a) The individual has failed to pay premiums or
5 contributions in accordance with the terms of the health
6 insurance coverage or the insurer has not received timely
7 premium payments.
8 (b) The individual has performed an act or practice
9 that constitutes fraud or made an intentional
10 misrepresentation of material fact under the terms of the
11 coverage.
12 (c) The insurer is ceasing to offer coverage in the
13 individual market in accordance with subsection (3) and
14 applicable state law.
15 (d) In the case of a health insurer that offers health
16 insurance coverage in the market through a network plan, the
17 individual no longer resides, lives, or works in the service
18 area, or in an area for which the insurer is authorized to do
19 business, but only if such coverage is terminated under this
20 paragraph uniformly without regard to any
21 health-status-related factor of covered individuals.
22 (e) In the case of health insurance coverage that is
23 made available in the individual market only through one or
24 more bona fide associations, as defined in s. 627.6571(5), the
25 membership of the individual in the association, on the basis
26 of which the coverage is provided, ceases, but only if such
27 coverage is terminated under this paragraph uniformly without
28 regard to any health-status-related factor of covered
29 individuals.
30 (3)(a) In any case in which an insurer decides to
31 discontinue offering a particular policy form for health
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HB 1967, First Engrossed
1 insurance coverage offered in the individual market, coverage
2 under such form may be discontinued by the insurer only if:
3 1. The insurer provides notice to each covered
4 individual provided coverage under this policy form in the
5 individual market of such discontinuation at least 90 days
6 prior to the date of the discontinuation of such coverage;
7 2. The insurer offers to each individual in the
8 individual market provided coverage under this policy form the
9 option to purchase any other individual health insurance
10 coverage currently being offered by the insurer for
11 individuals in such market in the state; and
12 3. In exercising the option to discontinue coverage of
13 this policy form and in offering the option of coverage under
14 subparagraph 2., the insurer acts uniformly without regard to
15 any health-status-related factor of enrolled individuals or
16 individuals who may become eligible for such coverage.
17 (b)1. Subject to subparagraph (a)3., in any case in
18 which an insurer elects to discontinue offering all health
19 insurance coverage in the individual market in this state,
20 health insurance coverage may be discontinued by the insurer
21 only if:
22 a. The insurer provides notice to the department and
23 to each individual of such discontinuation at least 180 days
24 prior to the date of the expiration of such coverage; and
25 b. All health insurance issued or delivered for
26 issuance in the state in the individual market is discontinued
27 and coverage under such health insurance coverage in such
28 market is not renewed.
29 2. In the case of a discontinuation under subparagraph
30 1. in the individual market, the insurer may not provide for
31 the issuance of any individual health insurance coverage in
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HB 1967, First Engrossed
1 this state during the 5-year period beginning on the date of
2 the discontinuation of the last health insurance coverage not
3 so renewed.
4 (4) At the time of coverage renewal, an insurer may
5 modify the health insurance coverage for a policy form offered
6 to individuals in the individual market so long as such
7 modification is consistent with the laws of this state and
8 effective on a uniform basis among all individuals with that
9 policy form.
10 (5) In applying this section in the case of health
11 insurance coverage that is made available by an insurer in the
12 individual market to individuals only through one or more
13 associations, a reference to an "individual" includes a
14 reference to such an association of which the individual is a
15 member.
16 (6) The requirements of this section do not apply to
17 any health insurance coverage in relation to its provision of
18 excepted benefits described in s. 627.6561(5)(b).
19 (7) The requirements of this section do not apply to
20 any health insurance coverage in relation to its provision of
21 excepted benefits described in s. 627.6561(5)(c), (d), or (e),
22 if the benefits are provided under a separate policy,
23 certificate, or contract of insurance.
24 (8) This section applies to health insurance coverage
25 offered, sold, issued, or renewed in the individual market on
26 or after July 1, 1997.
27 Section 3. Section 627.6475, Florida Statutes, is
28 created to read:
29 627.6475 Individual reinsurance pool.--
30 (1) PURPOSE.--The purpose of this section is to
31 provide for the establishment of a reinsurance program for
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HB 1967, First Engrossed
1 coverage of individuals who are eligible for issuance of
2 individual health insurance from a health insurance issuer
3 pursuant to s. 627.6487.
4 (2) DEFINITIONS.--As used in this section:
5 (a) "Board," "carrier," and "health benefit plan" have
6 the same meaning ascribed in s. 627.6699(3).
7 (b) "Health insurance issuer," "issuer," and
8 "individual health insurance" have the same meaning ascribed
9 in s. 627.6487(2).
10 (c) "Reinsuring carrier" means a health insurance
11 issuer that elects to comply with the requirements set forth
12 in subsection (7).
13 (d) "Risk-assuming carrier" means a health insurance
14 issuer that elects to comply with the requirements set forth
15 in subsection (6).
16 (e) "Eligible individual" has the same meaning
17 ascribed in s. 627.6487(3).
18 (3) APPLICABILITY AND SCOPE.--This section applies to
19 individual health insurance offered by a health insurance
20 issuer to an eligible individual.
21 (4) MAINTENANCE OF RECORDS.--Each health insurance
22 issuer that offers individual health insurance must maintain
23 at its principal place of business a complete and detailed
24 description of its rating practices and renewal practices, as
25 required for small employer carriers pursuant to s.
26 627.6699(8).
27 (5) ISSUER'S ELECTION TO BECOME A RISK-ASSUMING
28 CARRIER.--
29 (a) Each health insurance issuer that offers
30 individual health insurance must elect to become a
31 risk-assuming carrier or a reinsuring carrier for purposes of
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HB 1967, First Engrossed
1 this section. Each such issuer must make an initial election,
2 binding through December 31, 1999. The issuer's initial
3 election must be made no later than October 31, 1997. By
4 October 31, 1997, all issuers must file a final election,
5 which is binding for 2 years, from January 1, 1998, through
6 December 31, 1999, after which an election shall be binding
7 for a period of 5 years. The department may permit an issuer
8 to modify its election at any time for good cause shown, after
9 a hearing.
10 (b) The department shall establish an application
11 process for issuers seeking to change their status under this
12 subsection.
13 (c) An election to become a risk-assuming carrier is
14 subject to approval under this subsection.
15 (d) An issuer that elects to cease participating as a
16 reinsuring carrier and to become a risk-assuming carrier may
17 not reinsure or continue to reinsure any individual health
18 benefits plan under subsection (7) once the issuer becomes a
19 risk-assuming carrier, and the issuer must pay a prorated
20 assessment based upon business issued as a reinsuring carrier
21 for any portion of the year that the business was reinsured.
22 An issuer that elects to cease participating as a
23 risk-assuming carrier and to become a reinsuring carrier may
24 reinsure individual health insurance under the terms set forth
25 in subsection (7) and must pay a prorated assessment based
26 upon business issued as a reinsuring carrier for any portion
27 of the year that the business was reinsured.
28 (6) ELECTION PROCESS TO BECOME A RISK-ASSUMING
29 CARRIER.--
30 (a)1. A health insurance issuer that offers individual
31 health insurance may become a risk-assuming carrier by filing
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HB 1967, First Engrossed
1 with the department a designation of election under this
2 subsection in a format and manner prescribed by the
3 department. The department shall approve the election of a
4 health insurance issuer to become a risk-assuming carrier if
5 the department finds that the issuer is capable of assuming
6 that status pursuant to the criteria set forth in paragraph
7 (b).
8 2. The department must approve or disapprove any
9 designation as a risk-assuming carrier within 60 days after a
10 filing.
11 (b) In determining whether to approve an application
12 by an issuer to become a risk-assuming carrier, the department
13 shall consider:
14 1. The issuer's financial ability to support the
15 assumption of the risk of individuals.
16 2. The issuer's history of rating and underwriting
17 individuals.
18 3. The issuer's commitment to market fairly to all
19 individuals in the state or its service area, as applicable.
20 4. The issuer's ability to assume and manage the risk
21 of enrolling individuals without the protection of the
22 reinsurance program provided in subsection (7).
23 (c) The department shall provide public notice of an
24 issuer's designation of election under this subsection to
25 become a risk-assuming carrier and shall provide at least a
26 21-day period for public comment prior to making a decision on
27 the election. The department shall hold a hearing on the
28 election at the request of the issuer.
29 (d) The department may rescind the approval granted to
30 a risk-assuming carrier under this subsection if the
31
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HB 1967, First Engrossed
1 department finds that the carrier no longer meets the criteria
2 of paragraph (b).
3 (7) INDIVIDUAL HEALTH REINSURANCE PROGRAM.--
4 (a) The individual health reinsurance program shall
5 operate subject to the supervision and control of the board of
6 the small employer health reinsurance program established
7 pursuant to s. 627.6699(11). The board shall establish a
8 separate, segregated account for eligible individuals
9 reinsured pursuant to this section, which account may not be
10 commingled with the small employer health reinsurance account.
11 (b) A reinsuring carrier may reinsure with the program
12 coverage of an eligible individual, subject to each of the
13 following provisions:
14 1. A reinsuring carrier may reinsure an eligible
15 individual within 60 days after commencement of the coverage
16 of the eligible individual.
17 2. The program may not reimburse a participating
18 carrier with respect to the claims of a reinsured eligible
19 individual until the carrier has paid incurred claims of at
20 least $5,000 in a calendar year for benefits covered by the
21 program. In addition, the reinsuring carrier is responsible
22 for 10 percent of the next $50,000 and 5 percent of the next
23 $100,000 of incurred claims during a calendar year, and the
24 program shall reinsure the remainder.
25 3. The board shall annually adjust the initial level
26 of claims and the maximum limit to be retained by the carrier
27 to reflect increases in costs and utilization within the
28 standard market for health benefit plans within the state. The
29 adjustment may not be less than the annual change in the
30 medical component of the "Commerce Price Index for All Urban
31 Consumers" of the Bureau of Labor Statistics of the United
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HB 1967, First Engrossed
1 States Department of Labor, unless the board proposes and the
2 department approves a lower adjustment factor.
3 4. A reinsuring carrier may terminate reinsurance for
4 all reinsured eligible individuals on any plan anniversary.
5 5. The premium rate charged for reinsurance by the
6 program to a health maintenance organization that is approved
7 by the Secretary of Health and Human Services as a federally
8 qualified health maintenance organization pursuant to 42
9 U.S.C. s. 300e(c)(2)(A) and that, as such, is subject to
10 requirements that limit the amount of risk that may be ceded
11 to the program, which requirements are more restrictive than
12 subparagraph 2., shall be reduced by an amount equal to that
13 portion of the risk, if any, which exceeds the amount set
14 forth in subparagraph 2., which may not be ceded to the
15 program.
16 6. The board may consider adjustments to the premium
17 rates charged for reinsurance by the program or carriers that
18 use effective cost-containment measures, including high-cost
19 case management, as defined by the board.
20 7. A reinsuring carrier shall apply its
21 case-management and claims-handling techniques, including, but
22 not limited to, utilization review, individual case
23 management, preferred provider provisions, other managed-care
24 provisions, or methods of operation consistently with both
25 reinsured business and nonreinsured business.
26 (c)1. The board, as part of the plan of operation,
27 shall establish a methodology for determining premium rates to
28 be charged by the program for reinsuring eligible individuals
29 pursuant to this section. The methodology must include a
30 system for classifying individuals which reflects the types of
31 case characteristics commonly used by carriers in this state.
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1 The methodology must provide for the development of basic
2 reinsurance premium rates, which shall be multiplied by the
3 factors set for them in this paragraph to determine the
4 premium rates for the program. The basic reinsurance premium
5 rates shall be established by the board, subject to the
6 approval of the department, and shall be set at levels that
7 reasonably approximate gross premiums charged to eligible
8 individuals for individual health insurance by health
9 insurance issuers. The premium rates set by the board may vary
10 by geographical area, as determined under this section, to
11 reflect differences in cost. An eligible individual may be
12 reinsured for a rate that is five times the rate established
13 by the board.
14 2. The board shall periodically review the methodology
15 established, including the system of classification and any
16 rating factors, to ensure that it reasonably reflects the
17 claims experience of the program. The board may propose
18 changes to the rates that are subject to the approval of the
19 department.
20 (d) If individual health insurance for an eligible
21 individual is entirely or partially reinsured with the program
22 pursuant to this section, the premium charged to the eligible
23 individual for any rating period for the coverage issued must
24 be the same premium that would have been charged to that
25 individual if the health insurance issuer elected not to
26 reinsure coverage for that individual.
27 (e)1. Before March 1 of each calendar year, the board
28 shall determine and report to the department the program net
29 loss in the individual account for the previous year,
30 including administrative expenses for that year and the
31
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1 incurred losses for that year, taking into account investment
2 income and other appropriate gains and losses.
3 2. Any net loss in the individual account for the year
4 shall be recouped by assessing the carriers as follows:
5 a. The operating losses of the program shall be
6 assessed in the following order subject to the specified
7 limitations. The first tier of assessments shall be made
8 against reinsuring carriers in an amount that may not exceed 5
9 percent of each reinsuring carrier's premiums for individual
10 health insurance. If such assessments have been collected and
11 additional moneys are needed, the board shall make a second
12 tier of assessments in an amount that may not exceed 0.5
13 percent of each carrier's health benefit plan premiums.
14 b. Except as provided in paragraph (f), risk-assuming
15 carriers are exempt from all assessments authorized pursuant
16 to this section. The amount paid by a reinsuring carrier for
17 the first tier of assessments shall be credited against any
18 additional assessments made.
19 c. The board shall equitably assess reinsuring
20 carriers for operating losses of the individual account based
21 on market share. The board shall annually assess each carrier
22 a portion of the operating losses of the individual account.
23 The first tier of assessments shall be determined by
24 multiplying the operating losses by a fraction, the numerator
25 of which equals the reinsuring carrier's earned premium
26 pertaining to direct writings of individual health insurance
27 in the state during the calendar year for which the assessment
28 is levied, and the denominator of which equals the total of
29 all such premiums earned by reinsuring carriers in the state
30 during that calendar year. The second tier of assessments
31 shall be based on the premiums that all carriers, except
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HB 1967, First Engrossed
1 risk-assuming carriers, earned on all health benefit plans
2 written in this state. The board may levy interim assessments
3 against reinsuring carriers to ensure the financial ability of
4 the plan to cover claims expenses and administrative expenses
5 paid or estimated to be paid in the operation of the plan for
6 the calendar year prior to the association's anticipated
7 receipt of annual assessments for that calendar year. Any
8 interim assessment is due and payable within 30 days after
9 receipt by a carrier of the interim assessment notice. Interim
10 assessment payments shall be credited against the carrier's
11 annual assessment. Health benefit plan premiums and benefits
12 paid by a carrier that are less than an amount determined by
13 the board to justify the cost of collection may not be
14 considered for purposes of determining assessments.
15 d. Subject to the approval of the department, the
16 board shall adjust the assessment formula for reinsuring
17 carriers that are approved as federally qualified health
18 maintenance organizations by the Secretary of Health and Human
19 Services pursuant to 42 U.S.C. s. 300e(c)(2)(A) to the extent,
20 if any, that restrictions are placed on them which are not
21 imposed on other carriers.
22 3. Before March 1 of each year, the board shall
23 determine and file with the department an estimate of the
24 assessments needed to fund the losses incurred by the program
25 in the individual account for the previous calendar year.
26 4. If the board determines that the assessments needed
27 to fund the losses incurred by the program in the individual
28 account for the previous calendar year will exceed the amount
29 specified in subparagraph 2., the board shall evaluate the
30 operation of the program and report its findings and
31 recommendations to the department in the format established in
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1 s. 627.6699(11) for the comparable report for the small
2 employer reinsurance program.
3 (f) Notwithstanding paragraph (e), the administrative
4 expenses of the program shall be recouped by assessing
5 risk-assuming carriers and reinsuring carriers, and such
6 amounts may not be considered part of the operating losses of
7 the plan for the purposes of this paragraph. Each carrier's
8 portion of such administrative expenses shall be determined by
9 multiplying the total of such administrative expenses by a
10 fraction, the numerator of which equals the carrier's earned
11 premium pertaining to direct writing of individual health
12 benefit plans in the state during the calendar year for which
13 the assessment is levied, and the denominator of which equals
14 the total of such premiums earned by all carriers in the state
15 during such calendar year.
16 (g) Except as otherwise provided in this section, the
17 board and the department shall have all powers, duties, and
18 responsibilities with respect to carriers that issue and
19 reinsure individual health insurance, as specified for the
20 board and the department in s. 627.6699(11) with respect to
21 small employer carriers, including, but not limited to, the
22 provisions of s. 627.6699(11) relating to:
23 1. Use of assessments that exceed the amount of actual
24 losses and expenses.
25 2. The annual determination of each carrier's
26 proportion of the assessment.
27 3. Interest for late payment of assessments.
28 4. Authority for the department to approve deferment
29 of an assessment against a carrier.
30 5. Limited immunity from legal actions or carriers.
31
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HB 1967, First Engrossed
1 6. Development of standards for compensation to be
2 paid to agents. Such standards shall be limited to those
3 specifically enumerated in s. 627.6699(13)(d).
4 7. Monitoring compliance by carriers with this
5 section.
6 (8) STANDARDS TO ASSURE FAIR MARKETING.--
7 (a) Each health insurance issuer that offers
8 individual health insurance shall actively market coverage to
9 eligible individuals in the state. The provisions of s.
10 627.6699(13) that apply to small employer carriers that market
11 policies to small employers shall also apply to health
12 insurance issuers that offer individual health insurance with
13 respect to marketing policies to individuals.
14 (b) A violation of this section by a health insurance
15 issuer or an agent is an unfair trade practice under s.
16 626.9541 or ss. 641.3903 and 641.3907.
17 (9) RULEMAKING AUTHORITY.--The department may adopt
18 rules to administer this section, including rules governing
19 compliance by carriers.
20 Section 4. Section 627.6487, Florida Statutes, is
21 created to read:
22 627.6487 Guaranteed availability of individual health
23 insurance coverage to eligible individuals.--
24 (1) Subject to the requirements of this section, each
25 health insurance issuer that offers individual health
26 insurance coverage in this state may not, with respect to an
27 eligible individual who desires to enroll in individual health
28 insurance coverage:
29 (a) Decline to offer such coverage to, or deny
30 enrollment of, such individual; or
31
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HB 1967, First Engrossed
1 (b) Impose any preexisting condition exclusion with
2 respect to such coverage. For purposes of this section, the
3 term "preexisting condition" means, with respect to coverage,
4 a limitation of benefits relating to a condition based on the
5 fact that the condition was present before the date of
6 enrollment for such coverage, whether or not any medical
7 advice, diagnosis, care, or treatment was recommended or
8 received before such date.
9 (2) For the purposes of this section:
10 (a) "Health insurance issuer" and "issuer" mean an
11 authorized insurer or a health maintenance organization.
12 (b) "Individual health insurance" means health
13 insurance, as defined in s. 627.6561(5)(a)2., which is offered
14 to an individual, including certificates of coverage offered
15 to individuals in this state as part of a group policy issued
16 to an association outside this state, but the term does not
17 include short-term limited duration insurance or excepted
18 benefits specified in s. 624.6561(5)(b) or, if the benefits
19 are provided under a separate policy, certificate, or
20 contract, the term does not include excepted benefits
21 specified in s. 627.6561(5)(c), (d), or (e).
22 (3) For the purposes of this section, the term
23 "eligible individual" means an individual:
24 (a)1. For whom, as of the date on which the individual
25 seeks coverage under this section, the aggregate of the
26 periods of creditable coverage, as defined in s. 627.6561(5)
27 and (6), is 18 or more months; and
28 2. Whose most recent prior creditable coverage was
29 under a group health plan, governmental plan, or church plan,
30 or health insurance coverage offered in connection with any
31 such plan;
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HB 1967, First Engrossed
1 (b) Who is not eligible for coverage under:
2 1. A group health plan, as defined in section 2791, of
3 the Public Health Service Act;
4 2. A conversion policy under s. 627.6675 or s.
5 641.3921;
6 3. Medicare, part A or part B of Title XVIII of the
7 Social Security Act as amended; or
8 4. A state plan under Medicaid, Title XIX of the
9 Social Security Act, as amended, or any successor program,
10
11 and does not have other health insurance coverage;
12 (c) With respect to whom the most recent coverage
13 within the coverage period described in paragraph (1)(a) was
14 not terminated based on a factor described in s.
15 627.6571(2)(a) or (b), relating to nonpayment of premiums or
16 fraud, unless such nonpayment of premiums or fraud was due to
17 acts of an employer or person other than the individual;
18 (d) Who, having been offered the option of
19 continuation coverage under a COBRA continuation provision or
20 under s. 627.6692, elected such coverage; and
21 (e) Who, if the individual elected such continuation
22 provision, has exhausted such continuation coverage under such
23 provision or program.
24 (4)(a) The health insurance issuer may elect to limit
25 the coverage offered under subsection (1) if the issuer offers
26 at least two different policy forms of health insurance
27 coverage, both of which:
28 1. Are designed for, made generally available to,
29 actively marketed to, and enroll both eligible and other
30 individuals by the issuer; and
31 2. Meet the requirement of paragraph (b).
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HB 1967, First Engrossed
1
2 For purposes of this subsection, policy forms that have
3 different cost-sharing arrangements or different riders are
4 considered to be different policy forms.
5 (b) The requirement of this subsection is met for
6 health insurance coverage policy forms offered by an issuer in
7 the individual market if the issuer offers the policy forms
8 for individual health insurance coverage with the largest, and
9 next to largest, premium volume of all such policy forms
10 offered by the issuer in this state or applicable marketing or
11 service area, as prescribed in rules adopted by the
12 department, in the individual market in the period involved.
13 To the greatest extent possible, such rules must be consistent
14 with regulations adopted by the United States Department of
15 Health and Human Services.
16 (5)(a) In the case of a health insurance issuer that
17 offers individual health insurance coverage through a network
18 plan, the issuer may:
19 1. Limit the individuals who may be enrolled under
20 such coverage to those who live, reside, or work within the
21 service area for such network plan; and
22 2. Within the service area of such plan, deny such
23 coverage to such individuals if the issuer has demonstrated to
24 the department that:
25 a. It will not have the capacity to deliver services
26 adequately to additional individual enrollees because of its
27 obligations to existing group contract holders and enrollees
28 and individual enrollees; and
29 b. It is applying this paragraph uniformly to
30 individuals without regard to any health-status-related factor
31
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HB 1967, First Engrossed
1 of such individuals and without regard to whether the
2 individuals are eligible individuals.
3 (b) An issuer, upon denying individual health
4 insurance coverage in any service area in accordance with
5 subparagraph (a)2., may not offer coverage in the individual
6 market within such service area for a period of 180 days after
7 such coverage is denied.
8 (6)(a) A health insurance issuer may deny individual
9 health insurance coverage to an eligible individual if the
10 issuer has demonstrated to the department that:
11 1. It does not have the financial reserves necessary
12 to underwrite additional coverage; and
13 2. It is applying this paragraph uniformly to all
14 individuals in the individual market in this state consistent
15 with the laws of this state and without regard to any
16 health-status-related factor of such individuals and without
17 regard to whether the individuals are eligible individuals.
18 (b) An issuer, upon denying individual health
19 insurance coverage in any service area in accordance with
20 paragraph (a), may not offer such coverage in the individual
21 market within such service area for a period of 180 days after
22 the date such coverage is denied or until the issuer has
23 demonstrated to the department that the issuer has sufficient
24 financial reserves to underwrite additional coverage,
25 whichever occurs later.
26 (7)(a) Subsection (1) does not require that a health
27 insurance issuer that offers health insurance coverage only in
28 connection with group health plans or through one or more bona
29 fide associations, as defined in s. 627.6571(5), or both,
30 offer such health insurance coverage in the individual market.
31
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1 (b) A health insurance issuer that offers health
2 insurance coverage in connection with group health plans is
3 not deemed to be a health insurance issuer offering individual
4 health insurance coverage solely because such issuer offers a
5 conversion policy.
6 (8) This section does not:
7 (a) Restrict the amount of the premium rates that an
8 issuer may charge an individual for individual health
9 insurance coverage; or
10 (b) Prevent a health insurance issuer that offers
11 individual health insurance coverage from establishing premium
12 discounts or rebates or modifying otherwise applicable
13 copayments or deductibles in return for adherence to programs
14 of health promotion and disease prevention.
15 (9) Each health insurance issuer that offers
16 individual health insurance coverage to an eligible individual
17 shall elect to become a risk-assuming carrier or a reinsuring
18 carrier, as provided by s. 627.6475.
19 (10) This section applies to individual health
20 insurance coverage offered on or after January 1, 1998. An
21 individual who would have been eligible for coverage on July
22 1, 1997, shall be eligible for coverage on January 1, 1998,
23 and shall remain eligible for the same period of time after
24 January 1, 1998, that the individual would have remained
25 eligible for coverage after July 1, 1997.
26 Section 5. Section 627.64871, Florida Statutes, is
27 created to read:
28 627.64871 Certification of coverage.--
29 (1) Section 627.6561(8), applies to health insurance
30 coverage offered by an insurer in the individual market in the
31 same manner as it applies to health insurance coverage offered
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HB 1967, First Engrossed
1 by an insurer in connection with a group health plan in the
2 small-group market or large-group market.
3 (2) This section does not apply to any health
4 insurance coverage in relation to its provision of excepted
5 benefits described in s. 627.6561(5)(b).
6 (3) This section does not apply to any health
7 insurance coverage in relation to its provision of excepted
8 benefits described in s. 627.6561(5)(c), (d), or (e), if the
9 benefits are provided under a separate policy, certificate, or
10 contract of insurance.
11 (4) This section applies to health insurance coverage
12 offered, sold, issued, renewed, or in effect on or after July
13 1, 1997.
14 Section 6. Section 627.6489, Florida Statutes, is
15 created to read:
16 627.6489 Disease Management Program.--
17 (1) The association may contract with insurers to
18 provide disease management services for insurers that elect to
19 participate in the association disease management program.
20 (2) An insurer that elects to contract for such
21 services shall provide the association with all medical
22 records and claims information necessary for the association
23 to effectively manage the services.
24 (3) Monies collected by the association for providing
25 disease management services shall be used by the association
26 to pay administrative expenses associated with the disease
27 management program and to reduce any deficits incurred by the
28 association. No funds received at any time by the association
29 as a result of assessments against insurers may be used in
30 connection with the disease management program. No costs
31
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HB 1967, First Engrossed
1 related to the disease management program provided to an
2 insurer shall be assessed against any other insurer.
3 Section 7. Section 627.6512, Florida Statutes, is
4 created to read:
5 627.6512 Exemption of certain group health insurance
6 policies.--Sections 627.6561, 627.65615, 627.65625, and
7 627.6571, do not apply to:
8 (1) Any group insurance policy in relation to its
9 provision of excepted benefits described in s. 627.6561(5)(b).
10 (2) Any group health insurance policy in relation to
11 its provision of excepted benefits described in s.
12 627.6561(5)(c), if the benefits:
13 (a) Are provided under a separate policy, certificate,
14 or contract of insurance; or
15 (b) Are otherwise not an integral part of the policy.
16 (3) Any group health insurance policy in relation to
17 its provision of excepted benefits described in s.
18 627.6561(5)(d), if all of the following conditions are met:
19 (a) The benefits are provided under a separate policy,
20 certificate, or contract of insurance;
21 (b) There is no coordination between the provision of
22 such benefits and any exclusion of benefits under any group
23 policy maintained by the same policyholder; and
24 (c) Such benefits are paid with respect to an event
25 without regard to whether benefits are provided with respect
26 to such an event under any group health policy maintained by
27 the same policyholder.
28 (4) Any group health policy in relation to its
29 provision of excepted benefits described in s. 627.6561(5)(e),
30 if the benefits are provided under a separate policy,
31 certificate, or contract of insurance.
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HB 1967, First Engrossed
1 Section 8. Section 627.6561, Florida Statutes, is
2 amended to read:
3 (Substantial rewording of section. See
4 s. 627.6561, F.S., for present text.)
5 627.6561 Preexisting conditions.--
6 (1) As used in this section, the term:
7 (a) "Enrollment date" means, with respect to an
8 individual covered under a group health policy, the date of
9 enrollment of the individual in the plan or coverage or, if
10 earlier, the first day of the waiting period of such
11 enrollment.
12 (b) "Late enrollee" means, with respect to coverage
13 under a group health policy, a participant or beneficiary who
14 enrolls under the policy other than during:
15 1. The first period in which the individual is
16 eligible to enroll under the policy.
17 2. A special enrollment period, as provided under s.
18 627.65615.
19 (c) "Waiting period" means, with respect to a group
20 health policy and an individual who is a potential participant
21 or beneficiary of the policy, the period that must pass with
22 respect to the individual before the individual is eligible to
23 be covered for benefits under the terms of the policy.
24 (2) Subject to the exceptions specified in subsection
25 (4), an insurer that offers group health insurance coverage
26 may, with respect to a participant or beneficiary, impose a
27 preexisting condition exclusion only if:
28 (a) Such exclusion relates to a physical or mental
29 condition, regardless of the cause of the condition, for which
30 medical advice, diagnosis, care, or treatment was recommended
31
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HB 1967, First Engrossed
1 or received within the 6-month period ending on the enrollment
2 date;
3 (b) Such exclusion extends for a period of not more
4 than 12 months, or 18 months in the case of a late enrollee,
5 after the enrollment date; and
6 (c) The period of any such preexisting condition
7 exclusion is reduced by the aggregate of the periods of
8 creditable coverage, as defined in subsection (5), applicable
9 to the participant or beneficiary as of the enrollment date.
10 (3) Genetic information may not be treated as a
11 condition described in paragraph (2)(a) in the absence of a
12 diagnosis of the condition related to such information.
13 (4)(a) Subject to paragraph (b), an insurer that
14 offers group health insurance coverage, may not impose any
15 preexisting condition exclusion in the case of:
16 1. An individual who, as of the last day of the 30-day
17 period beginning with the date of birth, is covered under
18 creditable coverage.
19 2. A child who is adopted or placed for adoption
20 before attaining 18 years of age and who, as of the last day
21 of the 30-day period beginning on the date of the adoption or
22 placement for adoption, is covered under creditable coverage.
23 This provision does not apply to coverage before the date of
24 such adoption or placement for adoption.
25 3. Pregnancy.
26 (b) Subparagraphs (a)1. and 2. do not apply to an
27 individual after the end of the first 63-day period during all
28 of which the individual was not covered under any creditable
29 coverage.
30
31
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HB 1967, First Engrossed
1 (5)(a) The term, "creditable coverage," means, with
2 respect to an individual, coverage of the individual under any
3 of the following:
4 1. A group health plan, as defined in s. 2791 of the
5 Public Health Service Act.
6 2. Health insurance coverage consisting of medical
7 care, provided directly, through insurance or reimbursement,
8 or otherwise and including terms and services paid for as
9 medical care, under any hospital or medical service policy or
10 certificate, hospital or medical service plan contract, or
11 health maintenance contract offered by a health insurance
12 issuer.
13 3. Medicare, part A or part B of Title XVIII of the
14 Social Security Act, as amended.
15 4. Medicaid, Title XIX of the Social Security Act, as
16 amended, other than children eligible solely for the federal
17 program for the distribution of pediatric vaccines.
18 5. Chapter 55 of Title 10, United States Code.
19 6. A medical care program of the Indian Health Service
20 or of a tribal organization.
21 7. The Florida Comprehensive Health Association or
22 another state health benefit risk pool.
23 8. A health plan offered under chapter 89 of Title 5,
24 United States Code.
25 9. A public health plan as defined by rules adopted by
26 the department. To the greatest extent possible, such rules
27 must be consistent with regulations adopted by the United
28 States Department of Health and Human Services.
29 10. A health benefit plan under s. 5(e) of the Peace
30 Corps Act (22 United States Code, 2504(e)).
31
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1 (b) Creditable coverage does not include coverage that
2 consists solely of one or more or any combination thereof of
3 the following excepted benefits:
4 1. Coverage only for accident, or disability income
5 insurance, or any combination thereof.
6 2. Coverage issued as a supplement to liability
7 insurance.
8 3. Liability insurance, including general liability
9 insurance and automobile liability insurance.
10 4. Workers' compensation or similar insurance.
11 5. Automobile medical payment insurance.
12 6. Credit-only insurance.
13 7. Coverage for onsite medical clinics, including
14 prepaid health clinics under part II of chapter 641.
15 8. Other similar insurance coverage, specified in
16 rules adopted by the department, under which benefits for
17 medical care are secondary or incidental to other insurance
18 benefits. To the extent possible, such rules must be
19 consistent with regulations adopted by the United States
20 Department of Health and Human Services.
21 (c) The following benefits do not constitute
22 creditable coverage, if offered separately:
23 1. Limited scope dental or vision benefits.
24 2. Benefits for long-term care, nursing home care,
25 home health care, community-based care, or any combination
26 thereof.
27 3. Such other similar, limited benefits as are
28 specified in rules adopted by the department.
29 (d) The following benefits do not constitute
30 creditable coverage if offered as independent, noncoordinated
31 benefits:
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HB 1967, First Engrossed
1 1. Coverage only for a specified disease or illness.
2 2. Hospital indemnity or other fixed indemnity
3 insurance.
4 (e) Benefits provided through a Medicare supplemental
5 health insurance, as defined under s. 1882(g)(1) of the Social
6 Security Act, coverage supplemental to the coverage provided
7 under chapter 55 of Title 10, United States Code, and similar
8 supplemental coverage provided to coverage under a group
9 health plan are not considered creditable coverage if offered
10 as a separate insurance policy.
11 (6)(a) A period of creditable coverage may not be
12 counted, with respect to enrollment of an individual under a
13 group health plan, if, after such period and before the
14 enrollment date, there was a 63-day period during all of which
15 the individual was not covered under any creditable coverage.
16 (b) Any period during which an individual is in a
17 waiting period for any coverage under a group health plan or
18 for group health insurance coverage may not be taken into
19 account in determining the 63-day period under paragraph (a)
20 or paragraph (4)(b).
21 (7)(a) Except as otherwise provided under paragraph
22 (b), an insurer shall count a period of creditable coverage
23 without regard to the specific benefits covered under the
24 period.
25 (b) An insurer may elect to count, as creditable
26 coverage, coverage of benefits within each of several classes
27 or categories of benefits specified in rules adopted by the
28 department rather than as provided under paragraph (a). To the
29 extent possible, such rules must be consistent with
30 regulations adopted by the United States Department of Health
31 and Human Services. Such election shall be made on a uniform
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HB 1967, First Engrossed
1 basis for all participants and beneficiaries. Under such
2 election, an insurer shall count a period of creditable
3 coverage with respect to any class or category of benefits if
4 any level of benefits is covered within such class or
5 category.
6 (c) In the case of an election with respect to an
7 insurer under paragraph (b), the insurer shall:
8 1. Prominently state in 10-point type or larger in any
9 disclosure statements concerning the policy, and state to each
10 certificateholder at the time of enrollment under the policy,
11 that the insurer has made such election; and
12 2. Include in such statements a description of the
13 effect of this election.
14 (8)(a) Periods of creditable coverage with respect to
15 an individual shall be established through presentation of
16 certifications described in this subsection or in such other
17 manner as is specified in rules adopted by the department. To
18 the extent possible, such rules must be consistent with
19 regulations adopted by the United States Department of Health
20 and Human Services.
21 (b) An insurer that offers group health insurance
22 coverage shall provide the certification described in
23 paragraph (a):
24 1. At the time an individual ceases to be covered
25 under the plan or otherwise becomes covered under a COBRA
26 continuation provision or continuation pursuant to s.
27 627.6692.
28 2. In the case of an individual becoming covered under
29 a COBRA continuation provision or pursuant to s. 627.6692, at
30 the time the individual ceases to be covered under such a
31 provision.
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HB 1967, First Engrossed
1 3. Upon the request on behalf of an individual made
2 not later than 24 months after the date of cessation of the
3 coverage described in this paragraph.
4
5 The certification under subparagraph 1. may be provided, to
6 the extent practicable, at a time consistent with notices
7 required under any applicable COBRA continuation provision or
8 continuation pursuant to s. 627.6692.
9 (c) The certification described in this section is a
10 written certification that must include:
11 1. The period of creditable coverage of the individual
12 under the policy and the coverage, if any, under such COBRA
13 continuation provision or continuation pursuant to s.
14 627.6692; and
15 2. The waiting period, if any, imposed with respect to
16 the individual for any coverage under such policy.
17 (d) In the case of an election described in subsection
18 (7) by an insurer, if the insurer enrolls an individual for
19 coverage under the plan and the individual provides a
20 certification of coverage of the individual, as provided in
21 this subsection:
22 1. Upon request of such insurer, the insurer that
23 issued the certification provided by the individual shall
24 promptly disclose to such requesting plan or insurer
25 information on coverage of classes and categories of health
26 benefits available under such insurer's plan or coverage.
27 2. Such insurer may charge the requesting insurer for
28 the reasonable cost of disclosing such information.
29 (e) The department shall adopt rules to prevent an
30 insurer's failure to provide information under this subsection
31 with respect to previous coverage of an individual from
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HB 1967, First Engrossed
1 adversely affecting any subsequent coverage of the individual
2 under another group health plan or health insurance coverage.
3 To the greatest extent possible, such rules must be consistent
4 with regulations adopted by the United States Department of
5 Health and Human Services.
6 (9)(a) Except as provided in paragraph (b), no period
7 before July 1, 1996, shall be taken into account in
8 determining creditable coverage.
9 (b) The department shall adopt rules that provide a
10 process whereby individuals who need to establish creditable
11 coverage for periods before July 1, 1996, and who would have
12 such coverage credited but for paragraph (a), may be given
13 credit for creditable coverage for such periods through the
14 presentation of documents or other means. To the greatest
15 extent possible, such rules must be consistent with
16 regulations adopted by the United States Department of Health
17 and Human Services.
18 (10) Except as otherwise provided in this subsection,
19 paragraph (8)(b) applies to events that occur on or after July
20 1, 1996.
21 (a) In no case is a certification required to be
22 provided under paragraph (8)(b) prior to June 1, 1997.
23 (b) In the case of an event that occurs on or after
24 July 1, 1996, and before October 1, 1996, a certification is
25 not required to be provided under paragraph (8)(b), unless an
26 individual, with respect to whom the certification is required
27 to be made, requests such certification in writing.
28 (11) In the case of an individual who seeks to
29 establish creditable coverage for any period for which
30 certification is not required because it relates to an event
31 that occurred before July 1, 1996:
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HB 1967, First Engrossed
1 (a) The individual may present evidence of other
2 creditable coverage in order to establish the period of
3 creditable coverage.
4 (b) An insurer is not subject to any penalty or
5 enforcement action with respect to the insurer's crediting, or
6 not crediting, such coverage if the insurer has sought to
7 comply in good faith with applicable provisions of this
8 section.
9 (12) For purposes of subsection (9), any plan
10 amendment made pursuant to a collective bargaining agreement
11 relating to the plan which amends the plan solely to conform
12 to any requirement of this section may not be treated as a
13 termination of such collective bargaining agreement.
14 (13) This section does not apply to any health
15 insurance coverage in relation to its provision of excepted
16 benefits described in paragraph (5)(b).
17 (14) This section does not apply to any health
18 insurance coverage in relation to its provision of excepted
19 benefits described in paragraphs (5)(c), (d), or (e), if the
20 benefits are provided under a separate policy, certificate, or
21 contract of insurance.
22 (15) This section applies to health insurance coverage
23 offered, sold, issued, renewed, or in effect on or after July
24 1, 1997.
25 Section 9. Section 627.65615, Florida Statutes, is
26 created to read:
27 627.65615 Special enrollment periods.--
28 (1) An insurer that issues a group health insurance
29 policy shall permit an employee who is eligible, but not
30 enrolled, for coverage under the terms of the policy, or a
31 dependent of such an employee if the dependent is eligible but
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1 not enrolled for coverage under such terms, to enroll for
2 coverage under the terms of the policy if each of the
3 following conditions is met:
4 (a) The employee or dependent was covered under a
5 group health plan or had health insurance coverage at the time
6 coverage was previously offered to the employee or dependent.
7 For the purpose of this section, the terms "group health plan"
8 and "health insurance coverage" have the same meaning ascribed
9 in s. 2791 of the Public Health Service Act.
10 (b) The employee stated in writing at such time that
11 coverage under a group health plan or health insurance
12 coverage was the reason for declining enrollment, but only if
13 the plan sponsor or insurer, if applicable, required such a
14 statement at such time and provided the employee with notice
15 of such requirement and the consequences of such requirement
16 at such time.
17 (c) The employee's or dependent's coverage described
18 in paragraph (a):
19 1. Was under a COBRA continuation provision or
20 continuation pursuant to s. 627.6692, and the coverage under
21 such provision was exhausted; or
22 2. Was not under such a provision and the coverage was
23 terminated as a result of loss of eligibility for the
24 coverage, including legal separation, divorce, death,
25 termination of employment, or reduction in the number of hours
26 of employment, or the coverage was terminated as a result of
27 the termination of employer contributions toward such
28 coverage.
29 (d) Under the terms of the plan, the employee requests
30 such enrollment not later than 30 days after the date of
31 exhaustion of coverage described in subparagraph (c)1., or
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1 termination or employer contribution described in subparagraph
2 (c)2.
3 (2) For dependent beneficiaries, if:
4 (a) A group health insurance policy makes coverage
5 available with respect to a dependent of an individual;
6 (b) The individual is a participant under the policy,
7 or has met any waiting period applicable to becoming a
8 participant under the policy, and is eligible to be enrolled
9 under the policy but for a failure to enroll during a previous
10 enrollment period; and
11 (c) A person becomes such a dependent of the
12 individual through marriage, birth, or adoption or placement
13 for adoption,
14
15 the insurer shall provide for a dependent special enrollment
16 period described in subsection (3) during which the person,
17 or, if not otherwise enrolled, the individual, may be enrolled
18 under the policy as a dependent of the individual, and in the
19 case of the birth or adoption of a child, the spouse of the
20 individual may be enrolled as a dependent of the individual if
21 such spouse is otherwise eligible for coverage.
22 (3) A dependent special enrollment period under
23 subsection (2) shall be a period of not less than 30 days and
24 shall begin on the later of:
25 (a) The date that dependent coverage is made
26 available; or
27 (b) The date of the marriage, birth, or adoption or
28 placement for adoption described in subsection (2)(c).
29 (4) If an individual seeks to enroll a dependent
30 during the first 30 days of such a dependent special
31
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1 enrollment period, the coverage of the dependent shall become
2 effective:
3 (a) In the case of marriage, not later than the first
4 day of the first month beginning after the date the completed
5 request for enrollment is received.
6 (b) In the case of a dependent's birth, as of the date
7 of such birth.
8 (c) In the case of dependent's adoption or placement
9 for adoption, the date of such adoption or placement for
10 adoption.
11 Section 10. Section 627.65625, Florida Statutes, is
12 created to read:
13 627.65625 Prohibiting discrimination against
14 individual participants and beneficiaries based on health
15 status.--
16 (1) Subject to subsection (2), an insurer that offers
17 a group health insurance policy may not establish rules for
18 eligibility, including continued eligibility, of an individual
19 to enroll under the terms of the policy based on any of the
20 following health-status-related factors in relation to the
21 individual or a dependent of the individual:
22 (a) Health status.
23 (b) Medical condition, including physical and mental
24 illnesses.
25 (c) Claims experience.
26 (d) Receipt of health care.
27 (e) Medical history.
28 (f) Genetic information.
29 (g) Evidence of insurability, including conditions
30 arising out of acts of domestic violence.
31 (h) Disability.
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1 (2) Subsection (1) does not:
2 (a) Require an insurer to provide particular benefits
3 other than those provided under the terms of such plan or
4 coverage.
5 (b) Prevent such a plan or coverage from establishing
6 limitations or restrictions on the amount, level, extent, or
7 nature of the benefits or coverage for similarly situated
8 individuals enrolled in the plan or coverage.
9 (3) For purposes of subsection (1), rules for
10 eligibility to enroll under a policy include rules for
11 defining any applicable waiting periods of enrollment.
12 (4)(a) An insurer that offers health insurance
13 coverage may not require any individual, as a condition of
14 enrollment or continued enrollment under the policy, to pay a
15 premium or contribution that is greater than such premium or
16 contribution for a similarly situated individual enrolled
17 under the policy on the basis of any health-status-related
18 factor in relation to the individual or to an individual
19 enrolled under the policy as a dependent of the individual.
20 (b) This subsection does not:
21 1. Restrict the amount that an employer may be charged
22 for coverage under a group health insurance policy; or
23 2. Prevent an insurer that offers group health
24 insurance coverage from establishing premium discounts or
25 rebates or modifying otherwise applicable copayments or
26 deductibles in return for adherence to programs of health
27 promotion and disease prevention.
28 Section 11. Section 627.6571, Florida Statutes, is
29 created to read:
30 627.6571 Guaranteed renewability of coverage.--
31
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1 (1) Except as otherwise provided in this section, an
2 insurer that issues a group health insurance policy must renew
3 or continue in force such coverage at the option of the
4 policyholder.
5 (2) An insurer may nonrenew or discontinue a group
6 health insurance policy based only on one or more of the
7 following conditions:
8 (a) The policyholder has failed to pay premiums or
9 contributions in accordance with the terms of the policy or
10 the insurer has not received timely premium payments.
11 (b) The policyholder has performed an act or practice
12 that constitutes fraud or made an intentional
13 misrepresentation of material fact under the terms of the
14 policy.
15 (c) The policyholder has failed to comply with a
16 material provision of the plan which relates to rules for
17 employer contributions or group participation.
18 (d) The insurer is ceasing to offer a particular type
19 of coverage in a market in accordance with subsection (3).
20 (e) In the case of an insurer that offers health
21 insurance coverage through a network plan, there is no longer
22 any enrollee in connection with such plan who lives, resides,
23 or works in the service area of the insurer or in the area in
24 which the insurer is authorized to do business and, in the
25 case of the small-group market, the insurer would deny
26 enrollment with respect to such plan under s. 627.6699(5)(i).
27 (f) In the case of health insurance coverage that is
28 made available only through one or more bona fide associations
29 as defined in subsection (5), the membership of an employer in
30 the association, on the basis of which the coverage is
31 provided, ceases, but only if such coverage is terminated
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1 under this paragraph uniformly without regard to any
2 health-status-related factor that relates to any covered
3 individuals.
4 (3)(a) An insurer may discontinue offering a
5 particular policy form of group health insurance coverage
6 offered in the small-group market or large-group market only
7 if:
8 1. The insurer provides notice to each policyholder
9 provided coverage of this form in such market, and to
10 participants and beneficiaries covered under such coverage, of
11 such discontinuation at least 90 days prior to the date of the
12 discontinuation of such coverage;
13 2. The insurer offers to each policyholder provided
14 coverage of this form in such market the option to purchase
15 all, or in the case of the large-group market, any other
16 health insurance coverage currently being offered by the
17 insurer in such market; and
18 3. In exercising the option to discontinue coverage of
19 this form and in offering the option of coverage under
20 subparagraph 2., the insurer acts uniformly without regard to
21 the claims experience of those policyholders or any
22 health-status-related factor that relates to any participants
23 or beneficiaries covered or new participants or beneficiaries
24 who may become eligible for such coverage.
25 (b)1. In any case in which an insurer elects to
26 discontinue offering all health insurance coverage in the
27 small-group market or the large-group market, or both, in this
28 state, health insurance coverage may be discontinued by the
29 insurer only if:
30 a. The insurer provides notice to the department and
31 to each policyholder, and participants and beneficiaries
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1 covered under such coverage, of such discontinuation at least
2 180 days prior to the date of the discontinuation of such
3 coverage; and
4 b. All health insurance issued or delivered for
5 issuance in this state in such markets is discontinued and
6 coverage under such health insurance coverage in such market
7 is not renewed.
8 2. In the case of a discontinuation under subparagraph
9 1. in a market, the insurer may not provide for the issuance
10 of any health insurance coverage in the market in this state
11 during the 5-year period beginning on the date of the
12 discontinuation of the last insurance coverage not renewed.
13 (c) A mailing to one household constitutes a mailing
14 to all covered persons residing in that household. A separate
15 mailing is required for each separate household.
16 (4) At the time of coverage renewal, an insurer may
17 modify the health insurance coverage for a product offered:
18 (a) In the large-group market; or
19 (b) In the small-group market if, for coverage that is
20 available in such market other than only through one or more
21 bona fide associations as defined in subsection (5), such
22 modification is consistent with s. 627.6699 and effective on a
23 uniform basis among group health plans with that product.
24 (5) As used in this section, the term "bona fide
25 association" means an association that:
26 (a) Has been actively in existence for at least 5
27 years;
28 (b) Has been formed and maintained in good faith for
29 purposes other than obtaining insurance;
30 (c) Does not condition membership in the association
31 on any health-status-related factor that relates to an
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1 individual, including an employee of an employer or a
2 dependent of an employee;
3 (d) Makes health insurance coverage offered through
4 the association available to all members regardless of any
5 health-status-related factor that relates to such members or
6 individuals eligible for coverage through a member; and
7 (e) Does not make health insurance coverage offered
8 through the association available other than in connection
9 with a member of the association.
10 (6) In applying this section in the case of health
11 insurance coverage that is made available by an insurer in the
12 small-group market or large-group market to employers only
13 through one or more associations, a reference to
14 "policyholder" is deemed, with respect to coverage provided to
15 an employer member of the association, to include a reference
16 to such employer.
17 Section 12. Section 627.6574, Florida Statutes, 1996
18 Supplement, is amended to read:
19 627.6574 Maternity care.--
20 (1) Any group, blanket, or franchise policy of health
21 insurance that provides coverage for maternity care must shall
22 also cover the services of certified nurse-midwives and
23 midwives licensed pursuant to chapter 467, and the services of
24 birth centers licensed under ss. 383.30-383.335.
25 (2) Any group, blanket, or franchise policy of health
26 insurance that provides maternity and newborn coverage may not
27 limit coverage for the length of a maternity and newborn stay
28 in a hospital or for followup care outside of a hospital to
29 any time period that is less than that determined to be
30 medically necessary, in accordance with prevailing medical
31 standards and consistent with proposed 1996 guidelines for
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1 perinatal care of the American Academy of Pediatrics or the
2 American College of Obstetricians and Gynecologists as
3 proposed on May 1, 1996, by the treating obstetrical care
4 provider or the pediatric care provider.
5 (3) Nothing in This section does not affect affects
6 any agreement between an insurer and a hospital or other
7 health care provider with respect to reimbursement for health
8 care services provided, rate negotiations with providers, or
9 capitation of providers, and this section does not prohibit or
10 prohibits appropriate utilization review or case management by
11 an insurer.
12 (4) Any group, blanket, or franchise policy of health
13 insurance that provides coverage, benefits, or services for
14 maternity or newborn care must provide coverage for
15 postdelivery care for a mother and her newborn infant. The
16 postdelivery care must include a postpartum assessment and
17 newborn assessment and may be provided at the hospital, at the
18 attending physician's office, at an outpatient maternity
19 center, or in the home by a qualified licensed health care
20 professional trained in mother and baby care. The services
21 must include physical assessment of the newborn and mother,
22 and the performance of any medically necessary clinical tests
23 and immunizations in keeping with prevailing medical
24 standards.
25 (5) An insurer subject to subsection (1) shall
26 communicate active case questions and concerns regarding
27 postdelivery care directly to the treating physician or
28 hospital in written form, in addition to other forms of
29 communication. Such insurers shall also use a process that
30 which includes a written protocol for utilization review and
31 quality assurance.
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1 (6) An insurer subject to subsection (1) may not:
2 (a) Deny to a mother or her newborn infant
3 eligibility, or continued eligibility, to enroll or to renew
4 coverage under the terms of the policy for the purpose of
5 avoiding the requirements of this section.
6 (b) Provide monetary payments or rebates to a mother
7 to encourage the mother to accept less than the minimum
8 protections available under this section.
9 (c) Penalize or otherwise reduce or limit the
10 reimbursement of an attending provider solely because the
11 attending provider provided care to an individual participant
12 or beneficiary in accordance with this section.
13 (d) Provide incentives, monetary or otherwise, to an
14 attending provider solely to induce the provider to provide
15 care to an individual participant or beneficiary in a manner
16 inconsistent with this section.
17 (e) Subject to paragraph (7)(c), restrict benefits for
18 any portion of a period within a hospital length of stay
19 required under subsection (2) in a manner that is less
20 favorable than the benefits provided for any preceding portion
21 of such stay.
22 (7)(a) This section does not require a mother who is a
23 participant or beneficiary to:
24 1. Give birth in a hospital.
25 2. Stay in the hospital for a fixed period of time
26 following the birth of her infant.
27 (b) This section does not apply with respect to any
28 health insurance coverage that does not provide benefits for
29 hospital lengths of stay in connection with childbirth for a
30 mother or her newborn infant.
31
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1 (c) This section does not prevent a policy from
2 imposing deductibles, coinsurance, or other cost-sharing in
3 relation to benefits for hospital lengths of stay in
4 connection with childbirth for a mother or her newborn infant,
5 except that such coinsurance or other cost-sharing for any
6 portion of a period within a hospital length of stay required
7 under subsection (2) may not be greater than such coinsurance
8 or cost-sharing for any preceding portion of such stay.
9 Section 13. Subsection (1), paragraph (a) of
10 subsection (3), and subsection (11) of section 627.6675,
11 Florida Statutes, are amended, to read:
12 627.6675 Conversion on termination of
13 eligibility.--Subject to all of the provisions of this
14 section, a group policy delivered or issued for delivery in
15 this state by an insurer or nonprofit health care services
16 plan that provides, on an expense-incurred basis, hospital,
17 surgical, or major medical expense insurance, or any
18 combination of these coverages, shall provide that an employee
19 or member whose insurance under the group policy has been
20 terminated for any reason, including discontinuance of the
21 group policy in its entirety or with respect to an insured
22 class, and who has been continuously insured under the group
23 policy, and under any group policy providing similar benefits
24 that the terminated group policy replaced, for at least 3
25 months immediately prior to termination, shall be entitled to
26 have issued to him by the insurer a policy or certificate of
27 health insurance, referred to in this section as a "converted
28 policy." An employee or member shall not be entitled to a
29 converted policy if termination of his insurance under the
30 group policy occurred because he failed to pay any required
31 contribution, or because any discontinued group coverage was
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1 replaced by similar group coverage within 31 days after
2 discontinuance.
3 (1) TIME LIMIT.--Written application for the converted
4 policy shall be made and the first premium must be paid to the
5 insurer, not later than 63 31 days after termination of the
6 group policy.
7 (3) CONVERSION PREMIUM; EFFECT ON PREMIUM RATES FOR
8 GROUP COVERAGE.--
9 (a) The premium for the converted policy shall be
10 determined in accordance with premium rates applicable to the
11 age and class of risk of each person to be covered under the
12 converted policy and to the type and amount of insurance
13 provided. However, the premium for the converted policy may
14 not exceed 200 percent of the standard risk rate as
15 established by the Florida Comprehensive Health Association,
16 adjusted for differences in benefit levels and structure
17 between the converted policy and the policy offered by the
18 Florida Comprehensive Health Association.
19 (11) ALTERNATIVE PLANS.--The insurer shall, in
20 addition to the option required by subsection (10), offer the
21 standard health benefit plan, as established pursuant to s.
22 627.6699(12). The insurer may, at its option, also offer
23 alternative plans for group health conversion in addition to
24 the plans one required by this section.
25 Section 14. (1) The changes made by this act to
26 section 627.6675, Florida Statutes, apply to conversion
27 policies offered, sold, issued, or renewed on or after January
28 1, 1998.
29 (2) An individual who was entitled on July 1, 1997, to
30 a conversion policy under section 627.6675, Florida Statutes,
31 shall be entitled on January 1, 1998, to a conversion policy
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1 meeting the requirements of section 627.6675, Florida
2 Statutes, as amended by this act. Such an individual shall
3 remain entitled to a conversion policy for the same period of
4 time after January 1, 1998, as the individual would have
5 remained eligible after July 1, 1997, including the condition
6 that application for coverage be made within 63 days of the
7 termination of the group coverage.
8 Section 15. Subsections (3), (5), and (7), and
9 paragraph (b) of subsection (11) of section 627.6699, Florida
10 Statutes, 1996 Supplement, are amended, and present
11 subsections (14) and (15) of that section are redesignated as
12 subsections (15) and (16), respectively, and a new subsection
13 (14) is added to that section, to read:
14 627.6699 Employee Health Care Access Act.--
15 (3) DEFINITIONS.--As used in this section, the term:
16 (a) "Actuarial certification" means a written
17 statement, by a member of the American Academy of Actuaries or
18 another person acceptable to the department, that a small
19 employer carrier is in compliance with subsection (6), based
20 upon the person's examination, including a review of the
21 appropriate records and of the actuarial assumptions and
22 methods used by the carrier in establishing premium rates for
23 applicable health benefit plans.
24 (b) "Basic health benefit plan" and "standard health
25 benefit plan" mean low-cost health care plans developed
26 pursuant to subsection (12).
27 (c) "Board" means the board of directors of the
28 program.
29 (d) "Carrier" means a person who provides health
30 benefit plans in this state, including an authorized insurer,
31 a health maintenance organization, a multiple-employer welfare
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1 arrangement, or any other person providing a health benefit
2 plan that is subject to insurance regulation in this state.
3 However, the term does not include a multiple-employer welfare
4 arrangement, which multiple-employer welfare arrangement
5 operates solely for the benefit of the members or the members
6 and the employees of such members, and was in existence on
7 January 1, 1992.
8 (e) "Case management program" means the specific
9 supervision and management of the medical care provided or
10 prescribed for a specific individual, which may include the
11 use of health care providers designated by the carrier.
12 (f) "Creditable coverage" has the same meaning
13 ascribed in s. 627.6561.
14 (g)(f) "Dependent" means the spouse or child of an
15 eligible employee, subject to the applicable terms of the
16 health benefit plan covering that employee.
17 (h)(g) "Eligible employee" means an employee who works
18 full time, having a normal workweek of 25 or more hours, and
19 who has met any applicable waiting-period requirements or
20 other requirements of this act. The term includes a
21 self-employed individual, a sole proprietor, a partner of a
22 partnership, or an independent contractor, if the sole
23 proprietor, partner, or independent contractor is included as
24 an employee under a health benefit plan of a small employer,
25 but does not include a part-time, temporary, or substitute
26 employee.
27 (i)(h) "Established geographic area" means the county
28 or counties, or any portion of a county or counties, within
29 which the carrier provides or arranges for health care
30 services to be available to its insureds, members, or
31 subscribers.
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1 (j)(i) "Guaranteed-issue basis" means an insurance
2 policy that must be offered to an employer, employee, or
3 dependent of the employee, regardless of health status,
4 preexisting conditions, or claims history.
5 (k)(j) "Health benefit plan" means any hospital or
6 medical policy or certificate, hospital or medical service
7 plan contract, or health maintenance organization subscriber
8 contract. The term does not include accident-only, specified
9 disease, individual hospital indemnity, credit, dental-only,
10 vision-only, Medicare supplement, long-term care, or
11 disability income insurance; coverage issued as a supplement
12 to liability insurance; workers' compensation or similar
13 insurance; or automobile medical-payment insurance.
14 (l)(k) "Late enrollee" means an eligible employee or
15 dependent as defined under s. 627.6561(1)(b). who requests
16 enrollment in a health benefit plan of a small employer after
17 the initial enrollment period provided under the terms of the
18 plan has ended. However, an eligible employee or dependent is
19 not considered a late enrollee if the enrollee:
20 1. Was covered under another employer health benefit
21 plan at the time the individual was eligible to enroll; lost
22 coverage under that plan as a result of termination of
23 employment, the termination of the other plan's coverage, the
24 death of a spouse, or divorce; and requests enrollment within
25 30 days after coverage under that plan was terminated;
26 2. The individual is employed by an employer that
27 offers multiple health benefit plans and the individual elects
28 a different plan during an open enrollment period; or
29 3. A court has ordered that coverage be provided for a
30 spouse or minor child under a covered employee's health
31
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HB 1967, First Engrossed
1 benefit plan and a request for enrollment is made within 30
2 days after issuance of the court order.
3 (m)(l) "Limited benefit policy or contract" means a
4 policy or contract that provides coverage for each person
5 insured under the policy for a specifically named disease or
6 diseases, a specifically named accident, or a specifically
7 named limited market that fulfills an experimental or
8 reasonable need, such as the small group market.
9 (n)(m) "Modified community rating" means a method used
10 to develop carrier premiums which spreads financial risk
11 across a large population and allows adjustments for age,
12 gender, family composition, tobacco usage, and geographic area
13 as determined under paragraph (5)(j)(k).
14 (o)(n) "Participating carrier" means any carrier that
15 issues health benefit plans in this state except a small
16 employer carrier that elects to be a risk-assuming carrier.
17 (p)(o) "Plan of operation" means the plan of operation
18 of the program, including articles, bylaws, and operating
19 rules, adopted by the board under subsection (11).
20 (p) "Preexisting condition provision" means a policy
21 provision that excludes coverage for charges or expenses
22 incurred during a specified period following the insured's
23 effective date of coverage, as to:
24 1. A condition that, during a specified period
25 immediately preceding the effective date of coverage, had
26 manifested itself in such a manner as would cause an
27 ordinarily prudent person to seek medical advice, diagnosis,
28 care, or treatment or for which medical advice, diagnosis,
29 care, or treatment was recommended or received as to that
30 condition; or
31
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1 2. Pregnancy existing on the effective date of
2 coverage.
3 (q) "Program" means the Florida Small Employer Carrier
4 Reinsurance Program created under subsection (11).
5 (r) "Qualifying previous coverage" and "qualifying
6 existing coverage" mean benefits or coverage provided under:
7 1. An employer-based health insurance or health
8 benefit arrangement that provides benefits similar to or
9 exceeding benefits provided under the basic health plan; or
10 2. An individual health insurance policy, including
11 coverage issued by a health maintenance organization, a
12 fraternal benefit society, or a multiple-employer welfare
13 arrangement, that provides benefits similar to or exceeding
14 the benefits provided under the basic health benefit plan,
15 provided that such policy has been in effect for a period of
16 at least 1 year.
17 (r)(s) "Rating period" means the calendar period for
18 which premium rates established by a small employer carrier
19 are assumed to be in effect.
20 (s)(t) "Reinsuring carrier" means a small employer
21 carrier that elects to comply with the requirements set forth
22 in subsection (11).
23 (t)(u) "Risk-assuming carrier" means a small employer
24 carrier that elects to comply with the requirements set forth
25 in subsection (10).
26 (u)(v) "Self-employed individual" means an individual
27 or sole proprietor who derives his or her income from a trade
28 or business carried on by the individual or sole proprietor
29 which results in taxable income as indicated on IRS Form 1040,
30 schedule C or F, and which generated taxable income in one of
31 the 2 previous years.
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1 (v)(w) "Small employer" means, in connection with a
2 health benefit plan with respect to a calendar year and a plan
3 year, any person, sole proprietor, self-employed individual,
4 independent contractor, firm, corporation, partnership, or
5 association that is actively engaged in business, has its
6 principal place of business in this state, and that, on at
7 least 50 percent of its working days during the preceding
8 calendar quarter, employed an average of at least one but not
9 more than 50 eligible employees on business days during the
10 preceding calendar year, and employed at least one employee on
11 the first day of the plan year, the majority of whom were
12 employed within this state. In determining the number of
13 eligible employees, companies that are affiliated companies,
14 or that are eligible to file a combined tax return for
15 purposes of state taxation, may be considered a single
16 employer. For purposes of this section, a sole proprietor, an
17 independent contractor, or a self-employed individual is
18 considered a small employer only if all of the conditions and
19 criteria established in this section are met.
20 (w)(x) "Small employer carrier" means a carrier that
21 offers health benefit plans covering eligible employees of one
22 or more small employers.
23 (5) AVAILABILITY OF COVERAGE.--
24 (a) Beginning January 1, 1993, every small employer
25 carrier issuing new health benefit plans to small employers in
26 this state must, as a condition of transacting business in
27 this state, offer to eligible small employers a standard
28 health benefit plan and a basic health benefit plan. Such a
29 small employer carrier shall issue a standard health benefit
30 plan or a basic health benefit plan to every eligible small
31 employer that elects to be covered under such plan, agrees to
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1 make the required premium payments under such plan, and to
2 satisfy the other provisions of the plan.
3 (b) In the case of a small employer carrier which does
4 not, on or after January 1, 1993, offer coverage but which
5 does, on or after January 1, 1993, renew or continue coverage
6 in force, such carrier shall be required to provide coverage
7 to newly eligible employees and dependents on the same basis
8 as small employer carriers which are offering coverage on or
9 after January 1, 1993.
10 (c) Every small employer carrier must, as a condition
11 of transacting business in this state:
12 1. Beginning January 1, 1994, offer and issue all
13 small employer health benefit plans on a guaranteed-issue
14 basis to every eligible small employer, with 3 to 50 eligible
15 employees, that elects to be covered under such plan, agrees
16 to make the required premium payments, and satisfies the other
17 provisions of the plan. A rider for additional or increased
18 benefits may be medically underwritten and may only be added
19 to the standard health benefit plan. The increased rate
20 charged for the additional or increased benefit must be rated
21 in accordance with this section.
22 2. Beginning April 15, 1994, offer and issue basic and
23 standard small employer health benefit plans on a
24 guaranteed-issue basis to every eligible small employer, with
25 one or two eligible employees, which elects to be covered
26 under such plan, agrees to make the required premium payments,
27 and satisfies the other provisions of the plan. A rider for
28 additional or increased benefits may be medically underwritten
29 and may only be added to the standard health benefit plan.
30 The increased rate charged for the additional or increased
31 benefit must be rated in accordance with this section.
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1 3. Offer to eligible small employers the standard and
2 basic health benefit plans. This subparagraph does not limit
3 a carrier's ability to offer other health benefit plans to
4 small employers if the standard and basic health benefit plans
5 are offered and rejected.
6 (d) A small employer carrier must file with the
7 department, in a format and manner prescribed by the
8 committee, a standard health care plan and a basic health care
9 plan to be used by the carrier.
10 (e) The department at any time may, after providing
11 notice and an opportunity for a hearing, disapprove the
12 continued use by the small employer carrier of the standard or
13 basic health benefit plan on the grounds that such plan does
14 not meet the requirements of this section.
15 (f) Except as provided in paragraph (g), a health
16 benefit plan covering small employers, issued or renewed on or
17 after October 1, 1992, must comply with preexisting condition
18 provisions specified in s. 627.6561 or, for health maintenance
19 contracts, in s. 641.31071. the following provisions:
20 1. Preexisting condition provisions must not exclude
21 coverage for a period beyond 12 months following the
22 individual's effective date of coverage; and
23 2. Preexisting condition provisions may relate only
24 to:
25 a. Conditions that, during the 6-month period
26 immediately preceding the effective date of coverage, had
27 manifested themselves in such a manner as would cause an
28 ordinarily prudent person to seek medical advice, diagnosis,
29 care, or treatment or for which medical advice, diagnosis,
30 care, or treatment was recommended or received; or
31
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1 b. A pregnancy existing on the effective date of
2 coverage.
3 (g) A health benefit plan covering small employers,
4 issued or renewed on or after January 1, 1994, must comply
5 with the following conditions:
6 1. All health benefit plans must be offered and issued
7 on a guaranteed-issue basis, except that benefits purchased
8 through riders as provided in paragraph (c) may be medically
9 underwritten for the group, but may not be individually
10 underwritten as to the employees or the dependents of such
11 employees. Additional or increased benefits may only be
12 offered by riders.
13 2. The provisions of paragraph (f) apply to health
14 benefit plans issued to a small employer who has two three or
15 more eligible employees, and to health benefit plans that are
16 issued to a small employer who has fewer than two three
17 eligible employees and that cover an employee who has had
18 creditable qualifying previous coverage continually to a date
19 not more than 63 30 days before the effective date of the new
20 coverage.
21 3. With respect to any employee or dependent excluded
22 from coverage due to disease or medical condition or whose
23 coverage had been restricted for certain diseases or medical
24 conditions prior to January 1, 1993, and who has continued to
25 be an eligible employee or dependent as of April 1, 1993, an
26 open enrollment period shall be provided for a 90-day period
27 beginning within 60 days following the effective date of this
28 act, during which period any such employee or dependent shall
29 be entitled to be included within coverage and/or issued
30 coverage without restrictions for certain diseases or medical
31 conditions.
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1 3.4. For health benefit plans that are issued to a
2 small employer who has fewer than two three employees and that
3 cover an employee who has not been continually covered by
4 creditable qualifying previous coverage within 63 30 days
5 before the effective date of the new coverage, preexisting
6 condition provisions must not exclude coverage for a period
7 beyond 24 months following the employee's effective date of
8 coverage and may relate only to:
9 a. Conditions that, during the 24-month period
10 immediately preceding the effective date of coverage, had
11 manifested themselves in such a manner as would cause an
12 ordinarily prudent person to seek medical advice, diagnosis,
13 care, or treatment or for which medical advice, diagnosis,
14 care, or treatment was recommended or received; or
15 b. A pregnancy existing on the effective date of
16 coverage.
17 (h) All health benefit plans issued under this section
18 must comply with the following conditions:
19 1. In determining whether a preexisting condition
20 provision applies to an eligible employee or dependent, credit
21 must be given for the time the person was covered under
22 qualifying previous coverage if the previous coverage was
23 continuous to a date not more than 30 days prior to the
24 effective date of the new coverage, exclusive of any
25 applicable waiting period under the plan.
26 2. Late enrollees may be excluded from coverage only
27 for the greater of 18 months or the period of an 18-month
28 preexisting condition exclusion; however, if both a period of
29 exclusion from coverage and a preexisting condition exclusion
30 are applicable to a late enrollee, the combined period may not
31 exceed 18 months after the effective date of coverage. For
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1 employers who have fewer than two three employees, a late
2 enrollee may be excluded from coverage for no longer than 24
3 months if he was not covered by creditable qualifying previous
4 coverage continually to a date not more than 63 30 days before
5 the effective date of his new coverage.
6 2.3. Any requirement used by a small employer carrier
7 in determining whether to provide coverage to a small employer
8 group, including requirements for minimum participation of
9 eligible employees and minimum employer contributions, must be
10 applied uniformly among all small employer groups having the
11 same number of eligible employees applying for coverage or
12 receiving coverage from the small employer carrier. A small
13 employer carrier may vary application of minimum participation
14 requirements and minimum employer contribution requirements
15 only by the size of the small employer group.
16 3.4. In applying minimum participation requirements
17 with respect to a small employer, a small employer carrier
18 shall not consider as an eligible employee employees or
19 dependents who have qualifying existing coverage in an
20 employer-based group insurance plan or an ERISA qualified
21 self-insurance plan in determining whether the applicable
22 percentage of participation is met. However, a small employer
23 carrier may count eligible employees and dependents who have
24 coverage under another health plan that is sponsored by that
25 employer except if such plan is offered pursuant to s.
26 408.706.
27 4.5. A small employer carrier shall not increase any
28 requirement for minimum employee participation or any
29 requirement for minimum employer contribution applicable to a
30 small employer at any time after the small employer has been
31 accepted for coverage, unless the employer size has changed,
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1 in which case the small employer carrier may apply the
2 requirements that are applicable to the new group size.
3 5.6. If a small employer carrier offers coverage to a
4 small employer, it must offer coverage to all the small
5 employer's eligible employees and their dependents. A small
6 employer carrier may not offer coverage limited to certain
7 persons in a group or to part of a group, except with respect
8 to late enrollees.
9 6.7. A small employer carrier may not modify any
10 health benefit plan issued to a small employer with respect to
11 a small employer or any eligible employee or dependent through
12 riders, endorsements, or otherwise to restrict or exclude
13 coverage for certain diseases or medical conditions otherwise
14 covered by the health benefit plan.
15 7.8. An initial enrollment period of at least 30 days
16 must be provided. An annual 30-day open enrollment period
17 must be offered to each small employer's eligible employees
18 and their dependents. A small employer carrier must provide
19 special enrollment periods as required by s. 627.65615.
20 (i)1. A small employer carrier need not offer coverage
21 or accept applications pursuant to paragraph (a):
22 a. To a small employer if the small employer is not
23 physically located in an established geographic service area
24 of the small employer carrier, provided such geographic
25 service area shall not be less than a county;
26 b. To an employee if the employee does not work or
27 reside within an established geographic service area of the
28 small employer carrier; or
29 c. To a small employer group within an area in which
30 the small employer carrier reasonably anticipates, and
31 demonstrates to the satisfaction of the department, that it
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1 cannot, within its network of providers, deliver service
2 adequately to the members of such groups because of
3 obligations to existing group contract holders and enrollees.
4 2. A small employer carrier that cannot offer coverage
5 pursuant to sub-subparagraph 1.c. may not offer coverage in
6 the applicable area to new cases of employer groups having
7 more than 50 eligible employees or small employer groups until
8 the later of 180 days following each such refusal or the date
9 on which the carrier notifies the department that it has
10 regained its ability to deliver services to small employer
11 groups.
12 3.a. A small employer carrier may deny health
13 insurance coverage in the small-group market if the carrier
14 has demonstrated to the department that:
15 (I) It does not have the financial reserves necessary
16 to underwrite additional coverage; and
17 (II) It is applying this sub-subparagraph uniformly to
18 all employers in the small-group market in this state
19 consistent with this section and without regard to the claims
20 experience of those employers and their employees and their
21 dependents or any health-status-related factor that relates to
22 such employees and dependents.
23 b. A small employer carrier, upon denying health
24 insurance coverage in connection with health benefit plans in
25 accordance with sub-subparagraph a., may not offer coverage in
26 connection with group health benefit plans in the small-group
27 market in this state for a period of 180 days after the date
28 such coverage is denied or until the insurer has demonstrated
29 to the department that the insurer has sufficient financial
30 reserves to underwrite additional coverage, whichever is
31 later. The department may provide for the application of this
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1 sub-subparagraph on a service-area-specific basis. The
2 department shall, by rule, require each small employer carrier
3 to report, along with its annual statement for calendar year
4 1992, its gross annual premiums for health benefit plans
5 issued to small employers during calendar year 1992, including
6 both new and renewal business. No later than May 1, 1993, the
7 department shall calculate each carrier's percentage of all
8 small employer carrier premiums for calendar year 1992.
9 b. During calendar year 1993, a small employer carrier
10 may elect to not offer coverage or accept applications
11 pursuant to paragraph (a):
12 (I) After its gross annual premiums for all small
13 employer group health benefit plans written or renewed for
14 that year, excluding blocks of business assumed from other
15 carriers, exceeds 25 percent of the total of all small
16 employer carrier premiums for calendar year 1992; or
17 (II) After its gross annual premiums for small
18 employer group health benefit plans written or renewed for
19 that year, excluding blocks of business assumed from other
20 carriers, exceeds three times that carrier's gross annual
21 premiums for small employer group health benefit plans written
22 or renewed during calendar year 1992, if its share of small
23 employer carrier business for calendar year 1992 calculated
24 under sub-subparagraph a. exceeds 2 percent.
25 c. The election under sub-subparagraph b. is effective
26 upon filing of a notice of election with the department. The
27 department may, within 30 days after the filing of the notice,
28 disapprove the election if it finds that the carrier does not
29 meet the criteria of sub-subparagraph b. If the department
30 disapproves the election, the carrier is subject to paragraph
31 (a), effective on the date of such disapproval.
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1 d. An election under sub-subparagraph b. expires on
2 December 31, 1993, or upon revocation, whichever occurs
3 earlier.
4 e. A carrier may file with the department a notice
5 revoking its election under sub-subparagraph b. after the
6 election has been in effect for at least 3 months. Such
7 revocation of an election takes effect on the first day of the
8 calendar quarter following the filing of such notice with the
9 department and subjects the carrier to all requirements of
10 paragraph (a).
11 f. While a carrier's election under sub-subparagraph
12 b. is in effect, the carrier may not write any further small
13 employer group health benefit plans.
14 g. A carrier may not make an election under
15 sub-subparagraph b. more than once.
16 4.a. Beginning in 1994, the department shall, by rule,
17 require each small employer carrier to report, on or before
18 March 1 of each year, its gross annual premiums for all health
19 benefit plans issued to small employers during the previous
20 calendar year, and also to report its gross annual premiums
21 for new, but not renewal, standard and basic health benefit
22 plans subject to this section issued during the previous
23 calendar year. No later than May 1 of each year, the
24 department shall calculate each carrier's percentage of all
25 small employer group health premiums for the previous calendar
26 year and shall calculate the aggregate gross annual premiums
27 for new, but not renewal, standard and basic health benefit
28 plans for the previous calendar year.
29 b. Beginning with calendar year 1994, a small employer
30 carrier may elect to not offer coverage or accept applications
31 pursuant to paragraph (a):
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1 (I) After its gross annual premiums for new, but not
2 renewal, health benefit plans subject to this section for that
3 year, excluding blocks of business assumed from other
4 carriers, exceeds 25 percent of the aggregate gross annual
5 premiums for new, but not renewal, health benefit plans
6 subject to this section for the previous calendar year as
7 determined under sub-subparagraph a.; or
8 (II) After its gross annual premiums for new, but not
9 renewal, health benefit plans subject to this section,
10 excluding blocks of business assumed from other carriers,
11 exceeds three times the carrier's percentage of all small
12 employer group premiums for the previous calendar year as
13 determined under sub-subparagraph a., multiplied by the
14 aggregate gross annual premiums for new health benefit plans
15 for the previous year as determined under sub-subparagraph a.
16 A carrier may not exercise this option unless its percentage
17 of all small employer group premiums for the previous calendar
18 year as determined under sub-subparagraph a. exceeds 2
19 percent.
20 c. The election under sub-subparagraph b. is effective
21 upon filing of a notice of election with the department. The
22 department may, within 30 days after the filing of the notice,
23 disapprove the election if it finds that the carrier does not
24 meet the criteria of sub-subparagraph b. If the department
25 disapproves the election, the carrier is subject to paragraph
26 (a), effective on the date of such disapproval.
27 d. An election under sub-subparagraph b. expires on
28 December 31 of the year in which the election was made or upon
29 revocation, whichever occurs earlier.
30 e. A carrier may file with the department a notice
31 revoking its election under sub-subparagraph b. after the
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1 election has been in effect for at least 3 months. Such
2 revocation of an election takes effect on the first day of the
3 calendar quarter following the filing of such notice with the
4 department and subjects the carrier to all requirements of
5 paragraph (a).
6 f. While a carrier's election under sub-subparagraph
7 b. is in effect, the carrier may not write any further new
8 small employer group health benefit plans during the remainder
9 of the calendar year.
10 g. A carrier may not make an election under
11 sub-subparagraph b. more than once in any calendar year.
12 (j) A small employer carrier may not offer coverage or
13 accept applications pursuant to paragraph (a) if the
14 department finds that the acceptance of an application or
15 applications would endanger the financial condition of the
16 small employer carrier or endanger the interests of the small
17 employer carrier's insureds.
18 (j)(k) The boundaries of geographic areas used by a
19 small employer carrier must coincide with county lines. A
20 carrier may not apply different geographic rating factors to
21 the rates of small employers located within the same county.
22 (7) RENEWABILITY OF COVERAGE.--Except as provided in
23 paragraph (b), A health benefit plan that is subject to this
24 section is renewable for all eligible employees and dependents
25 pursuant to s. 627.6571. at the option of the small employer,
26 except for any of the following reasons:
27 (a) Nonpayment of required premiums;
28 (b) Fraud or misrepresentation by the small employer
29 or fraud or misrepresentation by the insured individual or
30 subscriber or the individual's or subscriber's representative;
31 (c) Noncompliance with plan provisions;
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1 (d) Noncompliance with the carrier's minimum
2 participation requirements;
3 (e) Noncompliance with the carrier's employer
4 contribution requirements;
5 (f) The small employer's termination of the business
6 in which it was engaged on the effective date of the plan; or
7 (g) A determination by the department that the
8 continuation of the coverage is not in the best interest of
9 the policyholders or certificateholders or will impair the
10 carrier's ability to meet its contractual obligations. In
11 such instances, the department must assist affected small
12 employers in finding replacement coverage.
13 (11) SMALL EMPLOYER HEALTH REINSURANCE PROGRAM.--
14 (b)1. The program shall operate subject to the
15 supervision and control of the board.
16 2. Until December 31, 1993, the board shall consist of
17 the commissioner or his designee, who shall serve as chairman,
18 and seven additional members appointed by the commissioner on
19 or before May 1, 1992, as follows:
20 a. One member shall be a representative of the largest
21 health insurer in the state, as determined by market share as
22 of December 31, 1991.
23 b. One member shall be a representative of the largest
24 health maintenance organization in the state, as determined by
25 market share as of December 31, 1991.
26 c. Three members shall be selected from a list of
27 individuals recommended by the Health Insurance Association of
28 America.
29 d. Two members shall be selected from a list of
30 individuals recommended by the Florida Insurance Council.
31
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1 The terms of members appointed under this subparagraph expire
2 on December 31, 1993. The appointment of a member under this
3 subparagraph does not preclude the commissioner from
4 appointing the same person to serve as a member under
5 subparagraph 3.
6 3. Beginning January 1, 1994, the board shall consist
7 of the commissioner or his designee, who shall serve as
8 chairman, and eight additional members who are representatives
9 of carriers and are appointed by the commissioner. and serve
10 as follows:
11 4. Effective upon this act becoming a law, the board
12 shall consist of the commissioner or his or her designee, who
13 shall serve as the chairperson, and 13 additional members who
14 are representatives of carriers and insurance agents and are
15 appointed by the commissioner and serve as follows:
16 a. The commissioner shall include representatives of
17 small employer carriers subject to assessment under this
18 subsection. If two or more carriers elect to be risk-assuming
19 carriers, the membership must include at least two
20 representatives of risk-assuming carriers; if one carrier is
21 risk-assuming, one member must be a representative of such
22 carrier. At least one member must be a carrier who is subject
23 to the assessments, but is not a small employer carrier.
24 Subject to such restrictions, at least five members shall be
25 selected from individuals recommended by small employer
26 carriers pursuant to procedures provided by rule of the
27 department. Three members shall be selected from a list of
28 health insurance carriers that issue individual health
29 insurance policies. At least two of the three members selected
30 must be reinsuring carriers. Two members shall be selected
31
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1 from a list of insurance agents who are actively engaged in
2 the sale of health insurance.
3 b. A member appointed under this subparagraph shall
4 serve a term of 4 years and shall continue in office until the
5 member's successor takes office, except that, in order to
6 provide for staggered terms, the commissioner shall designate
7 two of the initial appointees under this subparagraph to serve
8 terms of 2 years and shall designate three of the initial
9 appointees under this subparagraph to serve terms of 3 years.
10 5.4. The commissioner may remove a member for cause.
11 6.5. Vacancies on the board shall be filled in the
12 same manner as the original appointment for the unexpired
13 portion of the term.
14 7.6. The commissioner may require an entity that
15 recommends persons for appointment to submit additional lists
16 of recommended appointees.
17 (14) DISCLOSURE OF INFORMATION.--
18 (a) In connection with the offering of a health
19 benefit plan to a small employer, a small employer carrier
20 shall:
21 1. Make a reasonable disclosure to such employer, as
22 part of its solicitation and sales materials, of the
23 availability of information described in paragraph (b); and
24 2. Upon request of the small employer, provide such
25 information.
26 (b)1. Subject to subparagraph 3., with respect to a
27 small employer carrier that offers a health benefit plan to a
28 small employer, information described in this paragraph is
29 information that concerns:
30
31
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1 a. The provisions of such coverage concerning an
2 insurer's right to change premium rates and the factors that
3 may affect changes in premium rates;
4 b. The provisions of such coverage that relate to
5 renewability of coverage;
6 c. The provisions of such coverage that relate to any
7 preexisting condition exclusions; and
8 d. The benefits and premiums available under all
9 health insurance coverage for which the employer is qualified.
10 2. Information required under this subsection shall be
11 provided to small employers in a manner determined to be
12 understandable by the average small employer, and shall be
13 sufficient to reasonably inform small employers of their
14 rights and obligations under the health insurance coverage.
15 3. An insurer is not required under this subsection to
16 disclose any information that is proprietary or a trade secret
17 under state law.
18 Section 16. Section 627.9404, Florida Statutes, 1996
19 Supplement, is amended to read:
20 627.9404 Definitions.--For the purposes of this part:
21 (1) "Long-term care insurance" means any insurance
22 policy or rider advertised, marketed, offered, or designed to
23 provide coverage on an expense-incurred, indemnity, prepaid,
24 or other basis for one or more necessary or medically
25 necessary diagnostic, preventive, therapeutic, curing,
26 treating, mitigating, rehabilitative, maintenance, or personal
27 care services provided in a setting other than an acute care
28 unit of a hospital. Long-term care insurance shall not
29 include any insurance policy which is offered primarily to
30 provide basic Medicare supplement coverage, basic hospital
31 expense coverage, basic medical-surgical expense coverage,
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1 hospital confinement indemnity coverage, major medical expense
2 coverage, disability income protection coverage, accident only
3 coverage, specified disease or specified accident coverage, or
4 limited benefit health coverage.
5 (2) "Applicant" means:
6 (a) In the case of an individual long-term care
7 insurance policy, the person who seeks to contract for
8 benefits.
9 (b) In the case of a group long-term care insurance
10 policy, the proposed certificateholder.
11 (3) "Certificate" means any certificate issued under a
12 group long-term care insurance policy, which policy has been
13 delivered or issued for delivery in this state.
14 (4) "Chronically ill" means certified, within the
15 preceding 12-month period, by a licensed health care
16 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;
21 (b) Having a level of disability similar to the level
22 of disability described in paragraph (a); or
23 (c) Requiring substantial supervision for protection
24 from threats to health and safety due to severe cognitive
25 impairment.
26 (5)(4) "Cognitive impairment" means a deficiency in a
27 person's short-term or long-term memory, orientation as to
28 person, place, and time, deductive or abstract reasoning, or
29 judgment as it relates to safety awareness.
30 (6) "Licensed health care practitioner" means any
31 physician, nurse licensed under chapter 464, or
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1 psychotherapist licensed under chapter 490 or chapter 491, or
2 any individual who meets any requirements prescribed by rule
3 by the Insurance Commissioner.
4 (7) "Maintenance or personal care services" means any
5 care the primary purpose of which is the provision of needed
6 assistance with any of the disabilities as a result of which
7 the individual is a chronically ill individual, including the
8 protection from threats to health and safety due to severe
9 cognitive impairment.
10 (8)(5) "Policy" means any policy, contract, subscriber
11 agreement, rider, or endorsement delivered or issued for
12 delivery in this state by any of the entities specified in s.
13 627.9403.
14 (9) "Qualified long-term care services" means
15 necessary diagnostic, preventive, curing, treating,
16 mitigating, and rehabilitative services, and maintenance or
17 personal care services which are required by a chronically ill
18 individual and are provided pursuant to a plan of care
19 prescribed by a licensed health care practitioner.
20 (10) "Qualified long-term care insurance policy" means
21 an accident and health insurance contract as defined in s.
22 7702B of the Internal Revenue Code.
23 Section 17. Subsection (1) of section 627.9407,
24 Florida Statutes, is amended, and subsection (12) is added to
25 said section, to read:
26 627.9407 Disclosure, advertising, and performance
27 standards for long-term care insurance.--
28 (1) STANDARDS.--The department shall adopt rules that
29 include standards for full and fair disclosure setting forth
30 the manner, content, and required disclosures of the sale of
31 long-term care insurance policies, terms of renewability,
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1 initial and subsequent conditions of eligibility,
2 nonduplication of coverage provisions, coverage of dependents,
3 preexisting conditions, termination of insurance, continuation
4 or conversion, probationary periods, limitations, exceptions,
5 reductions, elimination periods, requirements for replacement,
6 recurrent conditions, disclosure of tax consequences, benefit
7 triggers, prohibition against post-claims underwriting,
8 reporting requirements, standards for marketing, and
9 definitions of terms.
10 (12) DISCLOSURE.--A qualified long-term care insurance
11 policy must include a disclosure statement within the policy
12 and within the outline of coverage that the policy is intended
13 to be a qualified long-term contract. A long-term care
14 insurance policy that is not intended to be a qualified
15 long-term care insurance contract must include a disclosure
16 statement within the policy and within the outline of coverage
17 that the policy is not intended to be a qualified long-term
18 care insurance contract. The disclosure shall be prominently
19 displayed and shall read as follows: "This long-term care
20 insurance policy is not intended to be a qualified long-term
21 care insurance contract. You need to be aware that benefits
22 received under this policy may create unintended, adverse
23 income tax consequences to you. You may want to consult with a
24 knowledgeable individual about such potential income tax
25 consequences."
26 Section 18. Subsections (6), (7), (8), (9), and (10)
27 are added to section 627.94071, Florida Statutes, 1996
28 Supplement, to read:
29 627.94071 Minimum standards for home health care
30 benefits.--A long-term care insurance policy, certificate, or
31 rider that contains a home health care benefit must meet or
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1 exceed the minimum standards specified in this section. The
2 policy, certificate, or rider may not exclude benefits by any
3 of the following means:
4 (6) Excluding coverage for personal care services
5 provided by a home health aide.
6 (7) Requiring that the provision of home health care
7 services be at a level of certification or licensure greater
8 than that required by the eligible service.
9 (8) Requiring that the insured/claimant have an acute
10 condition before home health care services are covered.
11 (9) Limiting benefits to services provided by
12 Medicare-certified agencies or providers.
13 (10) Excluding coverage for adult day care services.
14 Section 19. Subsection (2) of section 627.94072,
15 Florida Statutes, 1996 Supplement, is amended to read:
16 627.94072 Mandatory offers.--
17 (2) An insurer that offers a long-term care insurance
18 policy, certificate, or rider in this state must offer a
19 nonforfeiture protection provision providing reduced paid-up
20 insurance, cash surrender values which may include return of
21 premiums, extended term, shortened benefit period, or any
22 other benefits approved by the department if all or part of a
23 premium is not paid. Nonforfeiture benefits and any
24 additional premium for such benefits must be computed in an
25 actuarially sound manner, using a methodology that has been
26 filed with and approved by the department.
27 Section 20. Section 627.94073, Florida Statutes, 1996
28 Supplement, is amended to read:
29 627.94073 Notice of cancellation; grace period.--
30 (1) A long-term care policy shall provide that the
31 insured is entitled to a grace period of not less than 30
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1 days, within which payment of any premium after the first may
2 be made. The insurer may require payment of an interest
3 charge not in excess of 8 percent per year for the number of
4 days elapsing before the payment of the premium, during which
5 period the policy shall continue in force. If the policy
6 becomes a claim during the grace period before the overdue
7 premium is paid, the amount of such premium or premiums with
8 interest not in excess of 8 percent per year may be deducted
9 in any settlement under the policy.
10 (2) A long-term care policy may not be canceled for
11 nonpayment of premium unless, after expiration of the grace
12 period in subsection (1), and at least 30 days prior to the
13 effective date of such cancellation, the insurer has mailed a
14 notification of possible lapse in coverage to the policyholder
15 and to a specified secondary addressee if such addressee has
16 been designated in writing by name and address by the
17 policyholder. For policies issued or renewed on or after
18 October 1, 1996, the insurer shall notify the policyholder, at
19 least once every 2 years, of the right to designate a
20 secondary addressee. The applicant has the right to designate
21 at least one person who is to receive the notice of
22 termination, in addition to the insured. Designation shall not
23 constitute acceptance of any liability on the third party for
24 services provided to the insured. The form used for the
25 written designation must provide space clearly designated for
26 listing at least one person. The designation shall include
27 each person's full name and home address. In the case of an
28 applicant who elects not to designate an additional person,
29 the waiver shall state: "Protection against unintended
30 lapse.--I understand that I have the right to designate at
31 least one person other than myself to receive notice of lapse
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1 or termination of this long-term care insurance policy for
2 nonpayment of premium. I understand that notice will not be
3 given until 30 days after a premium is due and unpaid. I elect
4 NOT to designate any person to receive such notice." Notice
5 shall be given by first class United States mail, postage
6 prepaid, and notice may not be given until 30 days after a
7 premium is due and unpaid. Notice shall be deemed to have been
8 given as of 5 days after the date of mailing.
9 (3) If a policy is canceled due to nonpayment of
10 premium, the policyholder shall be entitled to have the policy
11 reinstated if, within a period of not less than 5 months 150
12 days after the date of cancellation, the policyholder or any
13 secondary addressee designated pursuant to subsection (2)
14 demonstrates that the failure to pay the premium when due was
15 unintentional and due to the cognitive impairment or loss of
16 functional capacity of the policyholder. Policy reinstatement
17 shall be subject to payment of overdue premiums. The standard
18 of proof of cognitive impairment or loss of functional
19 capacity shall not be more stringent than the benefit
20 eligibility criteria for cognitive impairment or the loss of
21 functional capacity, if any, contained in the policy and
22 certificate. The insurer may require payment of an interest
23 charge not in excess of 8 percent per year for the number of
24 days elapsing before the payment of the premium, during which
25 period the policy shall continue in force if the demonstration
26 of cognitive impairment is made. If the policy becomes a
27 claim during the 180-day period before the overdue premium is
28 paid, the amount of the premium or premiums with interest not
29 in excess of 8 percent per year may be deducted in any
30 settlement under the policy.
31
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1 (4) When the policyholder or certificateholder pays
2 premium for a long-term care insurance policy or certificate
3 policy through a payroll or pension deduction plan, the
4 requirements in subsection (2) need not be met until 60 days
5 after the policyholder or certificateholder is no longer on
6 such a payment plan. The application or enrollment form for
7 such policies or certificates shall clearly indicate the
8 payment plan selected by the applicant.
9 Section 21. Section 627.94074, Florida Statutes, 1996
10 Supplement, is amended to read:
11 627.94074 Standards for benefit triggers.--
12 (1)(a) A long-term care insurance policy shall
13 condition the payment of benefits on a determination of the
14 insured's ability to perform activities of daily living and on
15 cognitive impairment. Eligibility for the payment of benefits
16 shall not be more restrictive than requiring either a
17 deficiency in the ability to perform not more than three of
18 the activities of daily living or the presence of cognitive
19 impairment; or.
20 (b) If a policy is a qualified long-term care
21 insurance policy, the policy shall condition the payment of
22 benefits on a determination of the insured as being
23 chronically ill; having a level of disability similar, as
24 provided by rule of the Insurance Commissioner, to the
25 insured's ability to perform activities of daily living; or
26 being cognitively impaired as described in paragraph (6)(b).
27 Eligibility for the payment of benefits shall not be more
28 restrictive than requiring a deficiency in the ability to
29 perform not more than three of the activities of daily living.
30 (2) Activities of daily living shall include at least:
31
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1 (a) "Bathing," which means washing oneself by sponge
2 bath or in either a tub or shower, including the task of
3 getting into or out of the tub or shower.
4 (b) "Continence," which means the ability to maintain
5 control of bowel and bladder function, or, when unable to
6 maintain control of bowel or bladder function, the ability to
7 perform associated personal hygiene, including caring for
8 catheter or colostomy bag.
9 (c) "Dressing," which means putting on and taking off
10 all items of clothing and any necessary braces, fasteners, or
11 artificial limbs.
12 (d) "Eating," which means feeding oneself by getting
13 food into the body from a receptacle, such as a plate, cup, or
14 table, or by a feeding tube or intravenously.
15 (e) "Toileting," which means getting to and from the
16 toilet, getting on and off the toilet, and performing
17 associated personal hygiene.
18 (f) "Transferring," which means moving into or out of
19 a bed, chair, or wheelchair.
20 (3) Insurers may use activities of daily living to
21 trigger covered benefits in addition to those contained in
22 subsection (2) as long as they are defined in the policy.
23 (4) An issuer of qualified long-term care contracts is
24 limited to considering only the activities of daily living
25 listed in subsection (2).
26 (5)(4) An insurer may use additional provisions, for a
27 policy described in paragraph (1)(a), for the determination of
28 when benefits are payable under a policy or certificate;
29 however, the provisions shall not restrict and are not in lieu
30 of, the requirements contained in subsections (1) and (2).
31
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1 (6)(5) For purposes of this section, the determination
2 of a deficiency due to loss of functional capacity or
3 cognitive impairment shall not be more restrictive than:
4 (a) Requiring the hands-on assistance of another
5 person to perform the prescribed activities of daily living,
6 meaning physical assistance, minimal, moderate, or maximal,
7 without which the individual would not be able to perform the
8 activity of daily living; or
9 (b) If the deficiency is Due to the presence of a
10 cognitive impairment, requiring supervision, including or
11 verbal cueing by another person is needed in order to protect
12 the insured or others.
13 (7)(6) Assessment of activities of daily living and
14 cognitive impairment shall be performed by licensed or
15 certified professionals, such as physicians, nurses, or social
16 workers.
17 (8)(7) Long-term care insurance policies shall include
18 a clear description of the process for appealing and resolving
19 the benefit determinations.
20 (9)(8) The requirement set forth in this section shall
21 be effective on July 1, 1997, and shall apply as follows:
22 (a) Except as provided in paragraph (b), the
23 provisions of this section apply to a long-term care policy
24 issued in this state on or after July 1, 1997.
25 (b) The provisions of this section do not apply to
26 certificates under a group long-term care insurance policy in
27 force on July 1, 1997.
28 Section 22. Section 641.2018, Florida Statutes, is
29 created to read:
30 641.2018 High-deductible contracts for medical savings
31 accounts.--Notwithstanding the provisions of this part and
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1 part III related to the requirement for providing
2 comprehensive coverage, a health maintenance organization may
3 offer a high-deductible contract to employers that establish
4 medical savings accounts, as defined in section 220(d) of the
5 Internal Revenue Code.
6 Section 23. Subsection (18) of section 641.31, Florida
7 Statutes, 1996 Supplement, is amended to read:
8 641.31 Health maintenance contracts.--
9 (18)(a) Health maintenance contracts that which
10 provide coverage, benefits, or services for maternity care
11 must shall provide, as an option to the subscriber, the
12 services of nurse-midwives and midwives licensed pursuant to
13 chapter 467, and the services of birth centers licensed
14 pursuant to ss. 383.30-383.335, if such services are available
15 within the service area.
16 (b) Any health maintenance contract that which
17 provides maternity or newborn coverage may not limit coverage
18 for the length of a maternity or newborn stay in a hospital or
19 for followup care outside of a hospital to any time period
20 that is less than that determined to be medically necessary,
21 in accordance with prevailing medical standards and consistent
22 with proposed 1996 guidelines for perinatal care of the
23 American Academy of Pediatrics or the American College of
24 Obstetricians and Gynecologists as proposed on May 1, 1996, by
25 the treating obstetrical care provider or the pediatric care
26 provider.
27 (c) Nothing in This section does not affect affects
28 any agreement between a health maintenance organization and a
29 hospital or other health care provider with respect to
30 reimbursement for health care services provided, rate
31 negotiations with providers, or capitation of providers, and
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1 this section does not prohibit or prohibits appropriate
2 utilization review or case management by a health maintenance
3 organization.
4 (d) Any health maintenance contract that provides
5 coverage, benefits, or services for maternity or newborn care
6 must provide coverage for postdelivery care for a mother and
7 her newborn infant. The postdelivery care must include a
8 postpartum assessment and newborn assessment and may be
9 provided at the hospital, at the attending physician's office,
10 at an outpatient maternity center, or in the home by a
11 qualified licensed health care professional trained in mother
12 and baby care. The services must include physical assessment
13 of the newborn and mother, and the performance of any
14 medically necessary clinical tests and immunizations in
15 keeping with prevailing medical standards.
16 (e) A health maintenance organization subject to
17 paragraph (b) shall communicate active case questions and
18 concerns regarding postdelivery care directly to the treating
19 physician or hospital in written form, in addition to other
20 forms of communication. Such organization shall also use a
21 process that which includes a written protocol for utilization
22 review and quality assurance.
23 (f) Any health maintenance organization subject to
24 paragraph (b) may not:
25 1. Deny to a mother or her newborn infant eligibility,
26 or continued eligibility, to enroll or to renew coverage under
27 the terms of the contract for the purpose of avoiding the
28 requirements of this section.
29 2. Provide monetary payments or rebates to a mother to
30 encourage the mother to accept less than the minimum
31 protections available under this section.
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1 3. Penalize or otherwise reduce or limit the
2 reimbursement of an attending provider solely because the
3 attending provider provided care to an individual participant
4 or beneficiary in accordance with this section.
5 4. Provide incentives, monetary or otherwise, to an
6 attending provider solely to induce the provider to provide
7 care to an individual participant or beneficiary in a manner
8 inconsistent with this section.
9 5. Subject to paragraph (i), restrict benefits for any
10 portion of a period within a hospital length of stay required
11 under paragraph (b) in a manner that is less favorable than
12 the benefits provided for any preceding portion of such stay.
13 (g) This subsection does not require a mother who is a
14 participant or beneficiary to:
15 1. Give birth in a hospital.
16 2. Stay in the hospital for a fixed period of time
17 following the birth of her infant.
18 (h) This subsection does not apply with respect to any
19 coverage offered by a health maintenance organization that
20 does not provide benefits for hospital lengths of stay in
21 connection with childbirth for a mother or her newborn infant.
22 (i) This subsection does not prevent a health
23 maintenance organization from imposing deductibles,
24 coinsurance, or other cost-sharing in relation to benefits for
25 hospital lengths of stay in connection with childbirth for a
26 mother or her newborn infant under the contract or under
27 health insurance coverage offered in connection with a group
28 health plan, except that such coinsurance or other
29 cost-sharing for any portion of a period within a hospital
30 length of stay required under paragraph (b) may not be greater
31
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1 than such coinsurance or cost-sharing for any preceding
2 portion of such stay.
3 Section 24. Section 641.3102, Florida Statutes, is
4 amended to read:
5 641.3102 Restrictions upon expulsion or refusal to
6 issue or renew contract.--
7 (1) A health maintenance organization that offers
8 individual health maintenance contracts in this state may not
9 decline to offer coverage to an eligible individual as
10 required in s. 627.6487.
11 (2) A health maintenance organization shall not expel
12 or refuse to renew the coverage of, or refuse to enroll, any
13 individual member of a subscriber group on the basis of the
14 race, color, creed, marital status, sex, or national origin of
15 the subscriber or individual. A health maintenance
16 organization shall not expel or refuse to renew the coverage
17 of any individual member of a subscriber group on the basis of
18 the age, health status, health care needs, or prospective
19 costs of health care services of the subscriber or individual.
20 Nothing in this section shall prohibit a health maintenance
21 organization from requiring that, as a condition of continued
22 eligibility for membership, dependents of a subscriber, upon
23 reaching a specified age, convert to a converted contract or
24 that individuals entitled to have payments for health costs
25 made under Title XVIII of the United States Social Security
26 Act, as amended, be issued a health maintenance contract for
27 Medicare beneficiaries so long as the health maintenance
28 organization is authorized to issue health maintenance
29 contracts for Medicare beneficiaries.
30 Section 25. Section 641.31071, Florida Statutes, is
31 created to read:
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1 641.31071 Preexisting conditions.--
2 (1) As used in this section, the term:
3 (a) "Enrollment date" means, with respect to an
4 individual covered under a group health maintenance
5 organization contract, the date of enrollment of the
6 individual in the plan or coverage or, if earlier, the first
7 day of the waiting period of such enrollment.
8 (b) "Late enrollee" means, with respect to coverage
9 under a group health maintenance organization contract, a
10 participant or beneficiary who enrolls under the contract
11 other than during:
12 1. The first period in which the individual is
13 eligible to enroll under the plan.
14 2. A special enrollment period, as provided under s.
15 641.31072.
16 (c) "Waiting period" means, with respect to a group
17 health maintenance organization contract and an individual who
18 is a potential participant or beneficiary under the contract,
19 the period that must pass with respect to the individual
20 before the individual is eligible to be covered for benefits
21 under the terms of the contract.
22 (2) Subject to the exceptions specified in subsection
23 (4), a health maintenance organization that offers group
24 coverage, may, with respect to a participant or beneficiary,
25 impose a preexisting condition exclusion only if:
26 (a) Such exclusion relates to a physical or mental
27 condition, regardless of the cause of the condition, for which
28 medical advice, diagnosis, care, or treatment was recommended
29 or received within the 6-month period ending on the enrollment
30 date;
31
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1 (b) Such exclusion extends for a period of not more
2 than 12 months, or 18 months in the case of a late enrollee,
3 after the enrollment date; and
4 (c) The period of any such preexisting condition
5 exclusion is reduced by the aggregate of the periods of
6 creditable coverage, as defined in subsection (5), applicable
7 to the participant or beneficiary as of the enrollment date.
8 (3) Genetic information shall not be treated as a
9 condition described in paragraph (2)(a) in the absence of a
10 diagnosis of the condition related to such information.
11 (4)(a) Subject to paragraph (b), a health maintenance
12 organization that offers group coverage may not impose any
13 preexisting condition exclusion in the case of:
14 1. An individual who, as of the last day of the 30-day
15 period beginning with the date of birth, is covered under
16 creditable coverage.
17 2. A child who is adopted or placed for adoption
18 before attaining 18 years of age and who, as of the last day
19 of the 30-day period beginning on the date of the adoption or
20 placement for adoption, is covered under creditable coverage.
21 This provision shall not apply to coverage before the date of
22 such adoption or placement for adoption.
23 3. Pregnancy.
24 (b) Subparagraphs (a)1. and 2. do not apply to an
25 individual after the end of the first 63-day period during all
26 of which the individual was not covered under any creditable
27 coverage.
28 (5)(a) The term, "creditable coverage," means, with
29 respect to an individual, coverage of the individual under any
30 of the following:
31
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1 1. A group health plan, as defined in s. 2791, of the
2 Public Health Service Act.
3 2. Health insurance coverage consisting of medical
4 care, provided directly, through insurance or reimbursement or
5 otherwise, and including terms and services paid for as
6 medical care, under any hospital or medical service policy or
7 certificate, hospital or medical service plan contract, or
8 health maintenance contract offered by a health insurance
9 issuer.
10 3. Medicare, part A or part B of Title XVIII of the
11 Social Security Act, as amended.
12 4. Medicaid, Title XIX of the Social Security Act, as
13 amended, other than children eligible solely for the federal
14 program for the distribution of pediatric vaccines.
15 5. Chapter 55 of Title 10, United States Code.
16 6. A medical care program of the Indian Health Service
17 or of a tribal organization.
18 7. The Florida Comprehensive Health Association or
19 another state health benefit risk pool.
20 8. A health plan offered under chapter 89 of Title 5,
21 United States Code.
22 9. A public health plan as defined by rule of the
23 department. To the greatest extent possible, such rules must
24 be consistent with regulations adopted by the United States
25 Department of Health and Human Services.
26 10. A health benefit plan under s. 5(e) of the Peace
27 Corps Act (22 United States Code, 2504(e)).
28 (b) Creditable coverage does not include coverage that
29 consists solely of one or more or any combination thereof of
30 the following excepted benefits:
31
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1 1. Coverage only for accident, or disability income
2 insurance, or any combination thereof.
3 2. Coverage issued as a supplement to liability
4 insurance.
5 3. Liability insurance, including general liability
6 insurance and automobile liability insurance.
7 4. Workers' compensation or similar insurance.
8 5. Automobile medical payment insurance.
9 6. Credit-only insurance.
10 7. Coverage for onsite medical clinics.
11 8. Other similar insurance coverage, specified in
12 rules adopted by the department, under which benefits for
13 medical care are secondary or incidental to other insurance
14 benefits. To the greatest extent possible, such rules must be
15 consistent with regulations adopted by the United States
16 Department of Health and Human Services.
17 (c) The following benefits do not constitute
18 creditable coverage, if offered separately:
19 1. Limited scope dental or vision benefits.
20 2. Benefits or long-term care, nursing home care, home
21 health care, community-based care, or any combination of
22 these.
23 3. Such other similar, limited benefits as are
24 specified in rules adopted by the department. To the greatest
25 extent possible, such rules must be consistent with
26 regulations adopted by the United States Department of Health
27 and Human Services.
28 (d) The following benefits do not constitute
29 creditable coverage if offered as independent, noncoordinated
30 benefits:
31 1. Coverage only for a specified disease or illness.
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1 2. Hospital indemnity or other fixed indemnity
2 insurance.
3 (e) Benefits provided through Medicare supplemental
4 health insurance, as defined under s. 1882(g)(1) of the Social
5 Security Act, coverage supplemental to the coverage provided
6 under chapter 55 of Title 10, United States Code, and similar
7 supplemental coverage provided to coverage under a group
8 health plan are not considered creditable coverage if offered
9 as a separate insurance policy.
10 (6)(a) A period of creditable coverage may not be
11 counted, with respect to enrollment of an individual under a
12 group health maintenance organization contract, if, after such
13 period and before the enrollment date, there was a 63-day
14 period during all of which the individual was not covered
15 under any creditable coverage.
16 (b) Any period during which an individual is in a
17 waiting period, or in an affiliation period as defined in
18 subsection (9), for any coverage under a group health
19 maintenance organization contract may not be taken into
20 account in determining the 63-day period under paragraph (a)
21 or paragraph (4)(b).
22 (7)(a) Except as otherwise provided under paragraph
23 (b), a health maintenance organization shall count a period of
24 creditable coverage without regard to the specific benefits
25 covered under the period.
26 (b) A health maintenance organization may elect to
27 count as creditable coverage, coverage of benefits within each
28 of several classes or categories of benefits specified in
29 rules adopted by the department rather than as provided under
30 paragraph (a). Such election shall be made on a uniform basis
31 for all participants and beneficiaries. Under such election, a
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1 health maintenance organization shall count a period of
2 creditable coverage with respect to any class or category of
3 benefits if any level of benefits is covered within such class
4 or category.
5 (c) In the case of an election with respect to a
6 health maintenance organization under paragraph (b), the
7 organization shall:
8 1. Prominently state in 10-point type or larger in any
9 disclosure statements concerning the contract, and state to
10 each enrollee at the time of enrollment under the contract,
11 that the organization has made such election; and
12 2. Include in such statements a description of the
13 effect of this election.
14 (8)(a) Periods of creditable coverage with respect to
15 an individual shall be established through presentation of
16 certifications described in this subsection or in such other
17 manner as may be specified in rules adopted by the department.
18 (b) A health maintenance organization that offers
19 group coverage shall provide the certification described in
20 paragraph (a):
21 1. At the time an individual ceases to be covered
22 under the plan or otherwise becomes covered under a COBRA
23 continuation provision or continuation pursuant to s.
24 627.6692.
25 2. In the case of an individual becoming covered under
26 a COBRA continuation provision or pursuant to s. 627.6692, at
27 the time the individual ceases to be covered under such a
28 provision.
29 3. Upon the request on behalf of an individual made
30 not later than 24 months after the date of cessation of the
31 coverage described in this paragraph.
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1
2 The certification under subparagraph 1. may be provided, to
3 the extent practicable, at a time consistent with notices
4 required under any applicable COBRA continuation provision or
5 continuation pursuant to s. 627.6692.
6 (c) The certification is a written certification of:
7 1. The period of creditable coverage of the individual
8 under the contract and the coverage, if any, under such COBRA
9 continuation provision or continuation pursuant to s.
10 627.6692; and
11 2. The waiting period, if any, imposed with respect to
12 the individual for any coverage under such contract.
13 (d) In the case of an election described in subsection
14 (7) by a health maintenance organization, if the organization
15 enrolls an individual for coverage under the plan and the
16 individual provides a certification of coverage of the
17 individual, as provided by this subsection:
18 1. Upon request of such health maintenance
19 organization, the insurer or health maintenance organization
20 that issued the certification provided by the individual shall
21 promptly disclose to such requesting organization information
22 on coverage of classes and categories of health benefits
23 available under such insurer's or health maintenance
24 organization's plan or coverage.
25 2. Such insurer or health maintenance organization may
26 charge the requesting organization for the reasonable cost of
27 disclosing such information.
28 (e) The department shall adopt rules to prevent an
29 insurer's or health maintenance organization's failure to
30 provide information under this subsection with respect to
31 previous coverage of an individual from adversely affecting
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1 any subsequent coverage of the individual under another group
2 health plan or health maintenance organization coverage.
3 (9)(a) A health maintenance organization may provide
4 for an affiliation period with respect to coverage through the
5 organization only if:
6 1. No preexisting condition exclusion is imposed with
7 respect to coverage through the organization;
8 2. The period is applied uniformly without regard to
9 any health-status-related factors; and
10 3. Such period does not exceed 2 months or 3 months in
11 the case of a late enrollee.
12 (b) For the purposes of this section, the term
13 "affiliation period" means a period that, under the terms of
14 the coverage offered by the health maintenance organization,
15 must expire before the coverage becomes effective. The
16 organization is not required to provide health care services
17 or benefits during such period and no premium may be charged
18 to the participant or beneficiary for any coverage during the
19 period. Such period begins on the enrollment date and runs
20 concurrently with any waiting period under the plan.
21 (c) As an alternative to the method authorized by
22 paragraph (a), a health maintenance organization may address
23 adverse selection in a method approved by the department.
24 (10)(a) Except as provided in paragraph (b), no period
25 before July 1, 1996, shall be taken into account in
26 determining creditable coverage.
27 (b) The department shall adopt rules that provide a
28 process whereby individuals who need to establish creditable
29 coverage for periods before July 1, 1996, and who would have
30 such coverage credited but for paragraph (a), may be given
31
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1 credit for creditable coverage for such periods through the
2 presentation of documents or other means.
3 (11) Except as otherwise provided in this subsection,
4 the requirements of paragraph (8)(b) shall apply to events
5 that occur on or after July 1, 1996.
6 (a) In no case is a certification required to be
7 provided under paragraph (8)(b) prior to June 1, 1997.
8 (b) In the case of an event that occurs on or after
9 July 1, 1996, and before October 1, 1996, a certification is
10 not required to be provided under paragraph (8)(b), unless an
11 individual, with respect to whom the certification is required
12 to be made, requests such certification in writing.
13 (12) In the case of an individual who seeks to
14 establish creditable coverage for any period for which
15 certification is not required because it relates to an event
16 occurring before July 1, 1996:
17 (a) The individual may present evidence of other
18 creditable coverage in order to establish the period of
19 creditable coverage.
20 (b) A health maintenance organization is not subject
21 to any penalty or enforcement action with respect to the
22 organization's crediting, or not crediting, such coverage if
23 the organization has sought to comply in good faith with
24 applicable provisions of this section.
25 (13) For purposes of subsection (10), any plan
26 amendment made pursuant to a collective bargaining agreement
27 relating to the plan which amends the plan solely to conform
28 to any requirement of this section may not be treated as a
29 termination of such collective bargaining agreement.
30 Section 26. Section 641.31072, Florida Statutes, is
31 created to read:
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1 641.31072 Special enrollment periods.--
2 (1) A health maintenance organization that issues a
3 group health insurance policy shall permit an employee who is
4 eligible, but not enrolled, for coverage under the terms of
5 the contract, or a dependent of such an employee if the
6 dependent is eligible but not enrolled for coverage under such
7 terms, to enroll for coverage under the terms of the contract
8 if each of the following conditions is met:
9 (a) The employee or dependent was covered under a
10 group health plan or had health insurance coverage at the time
11 coverage was previously offered to the employee or dependent.
12 For the purpose of this section, the terms "group health plan"
13 and "health insurance coverage" have the same meaning ascribed
14 in s. 2791 of the Public Health Service Act.
15 (b) The employee stated in writing at such time that
16 coverage under a group health plan or health insurance
17 coverage was the reason for declining enrollment, but only if
18 the plan sponsor or health maintenance organization, if
19 applicable, required such a statement at such time and
20 provided the employee with notice of such requirement and the
21 consequences of such requirement at such time.
22 (c) The employee's or dependent's coverage described
23 in paragraph (a):
24 1. Was under a COBRA continuation provision or
25 continuation pursuant to s. 627.6692, and the coverage under
26 such provision was exhausted; or
27 2. Was not under such a provision and the coverage was
28 terminated as a result of loss of eligibility for the
29 coverage, including legal separation, divorce, death,
30 termination of employment, or reduction in the number of hours
31 of employment, or the coverage was terminated as a result of
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1 the termination of employer contributions toward such
2 coverage.
3 (d) Under the terms of the contract, the employee
4 requests such enrollment not later than 30 days after the date
5 of exhaustion of coverage described in subparagraph (c)1., or
6 termination or employer contribution described in subparagraph
7 (c)2.
8 (2) For dependent beneficiaries, if:
9 (a) A group health maintenance organization contract
10 makes coverage available with respect to a dependent of an
11 individual;
12 (b) The individual is a participant under the
13 contract, or has met any waiting period applicable to becoming
14 a participant under the contract, and is eligible to be
15 enrolled under the contract but for a failure to enroll during
16 a previous enrollment period; and
17 (c) A person becomes such a dependent of the
18 individual through marriage, birth, or adoption or placement
19 for adoption,
20
21 the health maintenance organization shall provide for a
22 dependent special enrollment period described in subsection
23 (3) during which the person, or, if not otherwise enrolled,
24 the individual, may be enrolled under the plan as a dependent
25 of the individual, and in the case of the birth or adoption of
26 a child, the spouse of the individual may be enrolled as a
27 dependent of the individual if such spouse is otherwise
28 eligible for coverage.
29 (3) A dependent special enrollment period under
30 subsection (2) shall be a period of not less than 30 days and
31 shall begin on the later of:
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1 (a) The date dependent coverage is made available; or
2 (b) The date of the marriage, birth, or adoption or
3 placement for adoption described in subsection (2)(c).
4 (4) If an individual seeks to enroll a dependent
5 during the first 30 days of such a dependent special
6 enrollment period, the coverage of the dependent shall become
7 effective:
8 (a) In the case of marriage, not later than the first
9 day of the first month beginning after the date the completed
10 request for enrollment is received.
11 (b) In the case of a dependent's birth, as of the date
12 of such birth.
13 (c) In the case of a dependent's adoption or placement
14 for adoption, the date of such adoption or placement for
15 adoption.
16 Section 27. Section 641.31073, Florida Statutes, is
17 created to read:
18 641.31073 Prohibiting discrimination against
19 individual participants and beneficiaries based on health
20 status.--
21 (1) Subject to subsection (2), a health maintenance
22 organization that offers group health insurance coverage may
23 not establish rules for eligibility, including continued
24 eligibility, of an individual to enroll under the terms of the
25 contract based on any of the following health-status-related
26 factors in relation to the individual or a dependent of the
27 individual:
28 (a) Health status.
29 (b) Medical condition, including physical and mental
30 illnesses.
31 (c) Claims experience.
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1 (d) Receipt of health care.
2 (e) Medical history.
3 (f) Genetic information.
4 (g) Evidence of insurability, including conditions
5 arising out of acts of domestic violence.
6 (h) Disability.
7 (2) Subsection (1) does not:
8 (a) Require a health maintenance organization to
9 provide particular benefits other than those provided under
10 the terms of such plan or coverage.
11 (b) Prevent such a plan or coverage from establishing
12 limitations or restrictions on the amount, level, extent, or
13 nature of the benefits or coverage for similarly situated
14 individuals enrolled in the plan or coverage.
15 (3) For purposes of subsection (1), rules for
16 eligibility to enroll under a contract include rules for
17 defining any applicable affiliation or waiting periods of
18 enrollment.
19 (4)(a) A health maintenance organization that offers
20 health insurance coverage may not require any individual, as a
21 condition of enrollment or continued enrollment under the
22 contract, to pay a premium or contribution that is greater
23 than such premium or contribution for a similarly situated
24 individual enrolled under the contract on the basis of any
25 health-status-related factor in relation to the individual or
26 to an individual enrolled under the contract as a dependent of
27 the individual.
28 (b) This subsection does not:
29 1. Restrict the amount that an employer may be charged
30 for coverage under a group health insurance contract.
31
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1 2. Prevent a health maintenance organization offering
2 group health insurance coverage from establishing premium
3 discounts or rebates or modifying otherwise applicable
4 copayments or deductibles in return for adherence to programs
5 of health promotion and disease prevention.
6 Section 28. Section 641.31074, Florida Statutes, is
7 created to read:
8 641.31074 Guaranteed renewability of coverage.--
9 (1) Except as otherwise provided in this section, a
10 health maintenance organization that issues a group health
11 insurance contract must renew or continue in force such
12 coverage at the option of the contract holder.
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 (a) The contract holder has failed to pay premiums or
17 contributions in accordance with the terms of the contract or
18 the health maintenance organization has not received timely
19 premium payments.
20 (b) The contract holder has performed an act or
21 practice that constitutes fraud or made an intentional
22 misrepresentation of material fact under the terms of the
23 contract.
24 (c) The contract holder has failed to comply with a
25 material provision of the plan which relates to rules for
26 employer contributions or group participation.
27 (d) The health maintenance organization is ceasing to
28 offer coverage in such a market in accordance with subsection
29 (3) and applicable state law.
30 (e) There is no longer any enrollee in connection with
31 such plan who lives, resides, or works in the service area of
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1 the health maintenance organization or in the area in which
2 the health maintenance organization is authorized to do
3 business and, in the case of the small-group market, the
4 organization would deny enrollment with respect to such plan
5 under s. 627.6699(5)(i).
6 (f) In the case of coverage that is made available
7 only through one or more bona fide associations as defined in
8 s. 627.6571(5), the membership of an employer in the
9 association, on the basis of which the coverage is provided,
10 ceases, but only if such coverage is terminated under this
11 paragraph uniformly without regard to any
12 health-status-related factor that relates to any covered
13 individuals.
14 (3)(a) A health maintenance organization may
15 discontinue offering a particular contract form for group
16 coverage offered in the small-group market or large-group
17 market only if:
18 1. The health maintenance organization provides notice
19 to each contract holder provided coverage of this form in such
20 market, and participants and beneficiaries covered under such
21 coverage, of such discontinuation at least 90 days prior to
22 the date of the discontinuation of such coverage;
23 2. The health maintenance organization offers to each
24 contract holder provided coverage of this form in such market
25 the option to purchase all other health insurance coverage
26 currently being offered by the health maintenance organization
27 in such market; and
28 3. In exercising the option to discontinue coverage of
29 this form and in offering the option of coverage under
30 subparagraph 2., the health maintenance organization acts
31 uniformly without regard to the claims experience of those
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1 contract holders or any health-status-related factor that
2 relates to any participants or beneficiaries covered or new
3 participants or beneficiaries who may become eligible for such
4 coverage.
5 (b)1. In any case in which a health maintenance
6 organization elects to discontinue offering all coverage in
7 the small-group market or the large-group market, or both, in
8 this state, coverage may be discontinued by the insurer only
9 if:
10 a. The health maintenance organization provides notice
11 to the department and to each contract holder, and
12 participants and beneficiaries covered under such coverage, of
13 such discontinuation at least 180 days prior to the date of
14 the discontinuation of such coverage; and
15 b. All health insurance issued or delivered for
16 issuance in this state in such markets are discontinued and
17 coverage under such health insurance coverage in such market
18 is not renewed.
19 2. In the case of a discontinuation under subparagraph
20 1. in a market, the health maintenance organization may not
21 provide for the issuance of any health maintenance
22 organization contract coverage in the market in this state
23 during the 5-year period beginning on the date of the
24 discontinuation of the last insurance contract not renewed.
25 (4) At the time of coverage renewal, a health
26 maintenance organization may modify the coverage for a product
27 offered:
28 (a) In the large-group market; or
29 (b) In the small-group market if, for coverage that is
30 available in such market other than only through one or more
31 bona fide associations, as defined in s. 627.6571(5), such
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1 modification is consistent with s. 627.6699 and effective on a
2 uniform basis among group health plans with that product.
3 (5) In applying this section in the case of health
4 insurance coverage that is made available by a health
5 maintenance organization in the small-group market or
6 large-group market to employers only through one or more
7 associations, a reference to "contract holder" is deemed, with
8 respect to coverage provided to an employer member of the
9 association, to include a reference to such employer.
10 Section 29. Section 641.3921, Florida Statutes, is
11 amended to read:
12 641.3921 Conversion on termination of eligibility.--A
13 group health maintenance contract delivered or issued for
14 delivery in this state by a health maintenance organization
15 shall provide that a subscriber or covered dependent whose
16 coverage under the group health maintenance contract has been
17 terminated for any reason, including discontinuance of the
18 group health maintenance contract in its entirety or with
19 respect to a covered class, and who has been continuously
20 covered under the group health maintenance contract, and under
21 any group health maintenance contract providing similar
22 benefits which it replaces, for at least 3 months immediately
23 prior to termination, shall be entitled to have issued to him
24 by the health maintenance organization a health maintenance
25 contract, hereafter referred to as a "converted contract." A
26 subscriber or covered dependent shall not be entitled to have
27 a converted contract issued to him if termination of his
28 coverage under the group health maintenance contract occurred
29 for any of the following reasons:
30
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1 (1) Failure to pay any required premium or
2 contribution unless such nonpayment of premium was due to acts
3 of an employer or person other than the individual;
4 (2) Replacement of any discontinued group coverage by
5 similar group coverage within 31 days;
6 (3) Fraud or material misrepresentation in applying
7 for any benefits under the health maintenance contract;
8 (4) Disenrollment for cause. When the requirements of
9 paragraphs (a), (b), and (c) have been met, a health
10 maintenance organization may disenroll a subscriber for cause
11 if the subscriber's behavior is disruptive, unruly, abusive,
12 or uncooperative to the extent that his continuing membership
13 in the organization seriously impairs the organization's
14 ability to furnish services to either the subscriber or other
15 subscribers.
16 (a) Effort to resolve the problem. The organization
17 must make a serious effort to resolve the problem presented by
18 the subscriber, including the use or attempted use of
19 subscriber grievance procedures.
20 (b) Consideration of extenuating circumstances. The
21 organization must ascertain that the subscriber's behavior
22 does not directly result from an existing medical condition.
23 (c) Documentation. The organization must document the
24 problems, efforts, and medical conditions as described in this
25 subsection;
26 (5) Willful and knowing misuse of the health
27 maintenance organization identification membership card by the
28 subscriber;
29 (6) Willful and knowing furnishing to the organization
30 by the subscriber of incorrect or incomplete information for
31
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1 the purpose of fraudulently obtaining coverage or benefits
2 from the organization; or
3 (7) The subscriber has left the geographic area of the
4 health maintenance organization with the intent to relocate or
5 establish a new residence outside the organization's
6 geographic area.
7 Section 30. Section 641.3922, Florida Statutes, is
8 amended to read:
9 641.3922 Conversion contracts; conditions.--Issuance
10 of a converted contract shall be subject to the following
11 conditions:
12 (1) TIME LIMIT.--Written application for the converted
13 contract shall be made and the first premium paid to the
14 health maintenance organization not later than 63 31 days
15 after such termination.
16 (2) EVIDENCE OF INSURABILITY.--The converted contract
17 shall be issued without evidence of insurability.
18 (3) CONVERSION PREMIUM.--The premium for the converted
19 contract shall be determined in accordance with premium rates
20 applicable to the age and class of risk of each person to be
21 covered under the converted contract and to the type and
22 amount of coverage provided. However, the premium for the
23 converted contract may not exceed 200 percent of the standard
24 risk rate, as established by the Florida Comprehensive Health
25 Association and adjusted for differences in benefit levels and
26 structure between the converted policy and the policy offered
27 by the Florida Comprehensive Health Association. The mode of
28 payment for the converted contract shall be quarterly or more
29 frequently at the option of the organization, unless otherwise
30 mutually agreed upon between the subscriber and the
31 organization.
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1 (4) EFFECTIVE DATE OF COVERAGE.--The effective date of
2 the converted contract shall be the day following the
3 termination of coverage under the group health maintenance
4 contract. However, until application is made and the first
5 premium is paid, the health maintenance organization may
6 charge the subscriber, on a fee-for-service basis, for any
7 services rendered to the subscriber after the date in which
8 the subscriber ceases to be eligible under the group health
9 maintenance contract. When application is made and the first
10 premium is paid, the organization shall reimburse the
11 subscriber for any payment made by the subscriber for covered
12 services under the converted contract.
13 (5) SCOPE OF COVERAGE.--The converted contract shall
14 cover the subscriber or dependents who were covered by the
15 group health maintenance contract on the date of termination
16 of coverage. At the option of the health maintenance
17 organization, a separate converted contract may be issued to
18 cover any dependent.
19 (6) OPTIONAL COVERAGE.--The health maintenance
20 organization shall not be required to issue a converted
21 contract covering any person if such person is or could be
22 covered by Medicare, Title XVIII of the Social Security Act,
23 as added by the Social Security Amendments of 1965, or as
24 later amended or superseded. Furthermore, the health
25 maintenance organization shall not be required to issue a
26 converted health maintenance contract covering any person if:
27 (a)1. The person is covered for similar benefits by
28 another hospital, surgical, medical, or major medical expense
29 insurance policy or hospital or medical service subscriber
30 contract or medical practice or other prepayment plan or by
31 any other plan or program;
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1 2. The person is eligible for similar benefits,
2 whether or not covered therefor, under any arrangement of
3 coverage for individuals in a group, whether on an insured or
4 uninsured basis; or
5 3. Similar benefits are provided for or are available
6 to the person pursuant to or in accordance with the
7 requirements of any state or federal law; and
8 (b) A converted health maintenance contract may
9 include a provision whereby the health maintenance
10 organization may request information, in advance of any
11 premium due date of a health maintenance contract, of any
12 person covered thereunder as to whether:
13 1. He is covered for similar benefits by another
14 hospital, surgical, medical, or major medical expense
15 insurance policy or hospital or medical service subscriber
16 contract or medical practice or other prepayment plan or by
17 any other plan or program;
18 2. He is covered for similar benefits under any
19 arrangement of coverage for individuals in a group, whether on
20 an insured or uninsured basis; or
21 3. Similar benefits are provided for or are available
22 to the person pursuant to or in accordance with the
23 requirements of any state or federal law.
24 (7) REASONS FOR CANCELLATION; TERMINATION.--The
25 converted health maintenance contract must contain a
26 cancellation or nonrenewability clause providing that the
27 health maintenance organization may refuse to renew the
28 contract of any person covered thereunder, but cancellation or
29 nonrenewal must be limited to one or more of the following
30 reasons:
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1 (a) Fraud or material misrepresentation, subject to
2 the limitations of s. 641.31(23), in applying for any benefits
3 under the converted health maintenance contract;
4 (b) Eligibility of the covered person for coverage
5 under Medicare, Title XVIII of the Social Security Act, as
6 added by the Social Security Amendments of 1965, or as later
7 amended or superseded, or under any other state or federal law
8 providing for benefits similar to those provided by the
9 converted health maintenance contract, except for Medicaid,
10 Title XIX of the Social Security Act, as amended by the Social
11 Security Amendments of 1965, or as later amended or
12 superseded.
13 (c) Disenrollment for cause, after following the
14 procedures outlined in s. 641.3921(4).
15 (d) Willful and knowing misuse of the health
16 maintenance organization identification membership card by the
17 subscriber or the willful and knowing furnishing to the
18 organization by the subscriber of incorrect or incomplete
19 information for the purpose of fraudulently obtaining coverage
20 or benefits from the organization.
21 (e) Failure, after notice, to pay required premiums.
22 (f) The subscriber has left the geographic area of the
23 health maintenance organization with the intent to relocate or
24 establish a new residence outside the organization's
25 geographic area.
26 (g) A dependent of the subscriber has reached the
27 limiting age under the converted contract, subject to
28 subsection (12); but the refusal to renew coverage shall apply
29 only to coverage of the dependent, except in the case of
30 handicapped children.
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1 (h) A change in marital status that makes a person
2 ineligible under the original terms of the converted contract,
3 subject to subsection (12).
4 (8) BENEFITS OFFERED.--A health maintenance
5 organization shall not be required to issue a converted
6 contract which provides benefits in excess of those provided
7 under the group health maintenance contract from which
8 conversion is made. The converted health maintenance contract
9 shall meet the requirements of law pertaining to health
10 maintenance contracts and shall include a level of benefits
11 for minimum services which is substantially similar to the
12 level of benefits for these services included in the group
13 health maintenance organization contract from which the
14 termination is made.
15 (9) PREEXISTING CONDITION PROVISION.--The converted
16 health maintenance contract shall not exclude a preexisting
17 condition not excluded by the group contract. However, the
18 converted health maintenance contract may provide that any
19 coverage benefits thereunder may be reduced by the amount of
20 any coverage or benefits under the group health maintenance
21 contract after the termination of the person's coverage or
22 benefits thereunder. The converted health maintenance
23 contract may also include provisions so that during the first
24 coverage year the coverage or benefits under the converted
25 contract, together with the coverage or benefits under the
26 group health maintenance contract, shall not exceed those that
27 would have been provided had the individual's coverage or
28 benefits under the group contract remained in force and
29 effect.
30 (10) ALTERNATE PLANS.--The health maintenance
31 organization shall offer a standard health benefit plan as
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1 established pursuant to s. 627.6699(12). The health
2 maintenance organization may, at its option, also offer
3 alternative plans for group health conversion in addition to
4 those required by this section, provided any alternative plan
5 is approved by the department or is a converted policy,
6 approved under s. 627.6675 and issued by an insurance company
7 authorized to transact insurance in this state. Approval by
8 the department of an alternative plan shall be based on
9 compliance by the alternative plan with the provisions of this
10 part and the rules promulgated thereunder, applicable
11 provisions of the Florida Insurance Code and rules promulgated
12 thereunder, and any other applicable law.
13 (11) RETIREMENT COVERAGE.--In the event that coverage
14 would be continued under the group health maintenance contract
15 on an employee following his retirement prior to the time he
16 is or could be covered by Medicare, he may elect, in lieu of
17 such continuation of group coverage, to have the same
18 conversion rights as would apply had his coverage terminated
19 at retirement by reason of termination of employment or
20 membership.
21 (12) CONVERSION PRIVILEGE ALLOWED.--Subject to the
22 conditions set forth above, the conversion privilege shall
23 also be available:
24 (a) To the surviving spouse, if any, at the death of
25 the subscriber, with respect to the spouse and such children
26 whose coverages under the group health maintenance contract
27 terminate by reason of such death, otherwise to each surviving
28 child whose coverage under the group health maintenance
29 contract terminates by reason of such death or, if the group
30 contract provides for continuation of dependents' coverages
31
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1 following the subscriber's death, at the end of such
2 continuation;
3 (b) To the former spouse whose coverage would
4 otherwise terminate because of annulment or dissolution of
5 marriage, if the former spouse is dependent for financial
6 support;
7 (c) To the spouse of the subscriber upon termination
8 of coverage of the spouse, while the subscriber remains
9 covered under the group health maintenance contract, by reason
10 of ceasing to be a qualified family member under the group
11 health maintenance contract, with respect to the spouse and
12 such children whose coverages under the group health
13 maintenance contract terminate at the same time; or
14 (d) To a child solely with respect to himself upon
15 termination of his coverage by reason of ceasing to be a
16 qualified family member under the group health maintenance
17 contract or under any converted contract, if a conversion
18 privilege is not otherwise provided above with respect to such
19 termination.
20 (13) GROUP COVERAGE IN LIEU OF INDIVIDUAL
21 COVERAGE.--The health maintenance organization may elect to
22 provide group health maintenance organization coverage through
23 a group converted contract in lieu of the issuance of an
24 individual converted contract.
25 (14) NOTIFICATION.--A notification of the conversion
26 privilege shall be included in each health maintenance
27 contract and in any certificate or member's handbook.
28 Section 31. (1) The changes made by this act to
29 section 641.3922, Florida Statutes, apply to conversion
30 policies offered, sold, issued, or renewed on or after January
31 1, 1998.
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1 (2) An individual who was entitled on July 1, 1997, to
2 a conversion contract under section 641.3922, Florida
3 Statutes, shall be entitled on January 1, 1998, to a
4 conversion contract meeting the requirements of section
5 641.3922, Florida Statutes, as amended by this act. Such an
6 individual shall remain entitled to a conversion contract for
7 the same period of time after January 1, 1998, that the
8 individual would have remained eligible after July 1, 1997,
9 including the condition that application for coverage be made
10 within 63 days of the termination of the group coverage.
11 Section 32. The provisions of this act fulfill an
12 important state interest.
13 Section 33. Section 627.6576, Florida Statutes, is
14 repealed.
15 Section 34. (1) Except as provided in subsection (2)
16 and as otherwise provided in this act, the changes made by
17 this act apply to policies or contracts with plan years that
18 begin on or after July 1, 1997.
19 (2) Except as provided in section 627.6561(9), (10),
20 and (11), and section 641.31071(10), (11), and (12), Florida
21 Statutes, in the case of a group health plan or group health
22 insurance contract maintained pursuant to one or more
23 collective bargaining agreements between employee
24 representatives and one or more employers which is ratified
25 before this act becomes a law, sections 627.6561, 627.65615,
26 627.65625, 627.6571, 627.6699, 641.31071, 641.31072,
27 641.31073, and 641.31074, Florida Statutes, except for section
28 627.6561(8)(b), Florida Statutes, as amended or created by
29 this act, apply to policies or contracts with plan years that
30 begin on or after the later of:
31
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1 (a) The date on which the last of any collective
2 bargaining agreement that relates to the plan terminates,
3 determined without regard to any extension thereof, which is
4 agreed to after the date this act becomes a law; or
5 (b) July 1, 1997.
6 Section 35. The Banking and Insurance Committee of the
7 Senate and the Health Care Services Committee of the House of
8 Representatives are directed to conduct an interim study to
9 make recommendations to the Legislature for the 1998 Regular
10 Session regarding high cost insureds and potential insureds
11 and how the needs of such insureds are being met under this
12 act. The Department of Insurance is directed to assist with
13 the provision of information and the gathering of data as
14 required or deemed appropriate by the committees.
15 Section 36. The amendments in this act to s.
16 627.6487(3)(b)2., Florida Statutes, and to ss. 627.6675 and
17 641.3922, Florida Statutes, shall not take effect unless the
18 Health Care Finance Administration of the United States
19 Department of Health and Human Services approves this act as
20 providing an acceptable alternative mechanism, as provided in
21 s. 2744 of the Public Health Service Act, or the act is deemed
22 approved due to the expiration of the time periods prescribed
23 in s. 2744(b)(5) of the Public Health Service Act.
24 Section 37. Except as otherwise provided in this act,
25 this act shall take effect upon becoming a law.
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27
28
29
30
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