House Bill 1415
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Florida House of Representatives - 1999 HB 1415
By Representatives Roberts, Lawson, Turnbull, Goode,
Henriquez, Peaden and Ritchie
1 A bill to be entitled
2 An act relating to the state group insurance
3 program; amending s. 110.123, F.S.; requiring
4 the state group insurance plan to provide an
5 enrollee continued access to a treating health
6 care provider who loses provider status under
7 the program; providing limitations; providing
8 applicability; providing an effective date.
9
10 Be It Enacted by the Legislature of the State of Florida:
11
12 Section 1. Paragraph (h) of subsection (3) of section
13 110.123, Florida Statutes, 1998 Supplement, is amended to
14 read:
15 110.123 State group insurance program.--
16 (3) STATE GROUP INSURANCE PROGRAM.--
17 (h)1. A person eligible to participate in the state
18 group health insurance plan may be authorized by rules adopted
19 by the division, in lieu of participating in the state group
20 health insurance plan, to exercise an option to elect
21 membership in a health maintenance organization plan which is
22 under contract with the state in accordance with criteria
23 established by this section and by said rules. The offer of
24 optional membership in a health maintenance organization plan
25 permitted by this paragraph may be limited or conditioned by
26 rule as may be necessary to meet the requirements of state and
27 federal laws.
28 2. The division shall contract with health maintenance
29 organizations to participate in the state group insurance
30 program through a request for proposal based upon a premium
31 and a minimum benefit package as follows:
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1 a. A minimum benefit package to be provided by a
2 participating HMO shall include: physician services; inpatient
3 and outpatient hospital services; emergency medical services,
4 including out-of-area emergency coverage; diagnostic
5 laboratory and diagnostic and therapeutic radiologic services;
6 mental health, alcohol, and chemical dependency treatment
7 services meeting the minimum requirements of state and federal
8 law; skilled nursing facilities and services; prescription
9 drugs; and other benefits as may be required by the division.
10 Additional services may be provided subject to the contract
11 between the division and the HMO.
12 b. A uniform schedule for deductibles and copayments
13 may be established for all participating HMOs.
14 c. Based upon the minimum benefit package and
15 copayments and deductibles contained in sub-subparagraphs a.
16 and b., the division shall issue a request for proposal for
17 all HMOs which are interested in participating in the state
18 group insurance program. Upon receipt of all proposals, the
19 division may, as it deems appropriate, enter into contract
20 negotiations with HMOs submitting bids. As part of the request
21 for proposal process, the division may require detailed
22 financial data from each HMO which participates in the bidding
23 process for the purpose of determining the financial stability
24 of the HMO.
25 d. In determining which HMOs to contract with, the
26 division shall, at a minimum, consider: each proposed
27 contractor's previous experience and expertise in providing
28 prepaid health benefits; each proposed contractor's historical
29 experience in enrolling and providing health care services to
30 participants in the state group insurance program; the cost of
31 the premiums; the plan's ability to adequately provide service
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Florida House of Representatives - 1999 HB 1415
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1 coverage and administrative support services as determined by
2 the division; plan benefits in addition to the minimum benefit
3 package; accessibility to providers; and the financial
4 solvency of the plan. Nothing shall preclude the division from
5 negotiating regional or statewide contracts with health
6 maintenance organization plans when this is cost-effective and
7 when the division determines the plan has the best overall
8 benefit package for the service areas involved. However, no
9 HMO shall be eligible for a contract if the HMO's retiree
10 Medicare premium exceeds the retiree rate as set by the
11 division for the state group health insurance plan.
12 e. The division may limit the number of HMOs that it
13 contracts with in each service area based on the nature of the
14 bids the division receives, the number of state employees in
15 the service area, and any unique geographical characteristics
16 of the service area. The division shall establish by rule
17 service areas throughout the state.
18 f. All persons participating in the state group
19 insurance program who are required to contribute towards a
20 total state group health premium shall be subject to the same
21 dollar contribution regardless of whether the enrollee enrolls
22 in the state group health insurance plan or in an HMO plan.
23 3. The division is authorized to negotiate and to
24 contract with specialty psychiatric hospitals for mental
25 health benefits, on a regional basis, for alcohol, drug abuse,
26 and mental and nervous disorders. The division may establish,
27 subject to the approval of the Legislature pursuant to
28 subsection (5), any such regional plan upon completion of an
29 actuarial study to determine any impact on plan benefits and
30 premiums.
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1 4. In addition to contracting pursuant to subparagraph
2 2., the division shall enter into contract with any HMO to
3 participate in the state group insurance program which:
4 a. Serves greater than 5,000 recipients on a prepaid
5 basis under the Medicaid program;
6 b. Does not currently meet the 25 percent
7 non-Medicare/non-Medicaid enrollment composition requirement
8 established by the Department of Health and Human Services
9 excluding participants enrolled in the state group insurance
10 program;
11 c. Meets the minimum benefit package and copayments
12 and deductibles contained in sub-subparagraphs 2.a. and b.;
13 d. Is willing to participate in the state group
14 insurance program at a cost of premiums that is not greater
15 than 95 percent of the cost of HMO premiums accepted by the
16 division in each service area; and
17 e. Meets the minimum surplus requirements of s.
18 641.225.
19
20 The division is authorized to contract with HMOs that meet the
21 requirements of sub-subparagraphs a. through d. prior to the
22 open enrollment period for state employees. The division is
23 not required to renew the contract with the HMOs as set forth
24 in this paragraph more than twice. Thereafter, the HMOs shall
25 be eligible to participate in the state group insurance
26 program only through the request for proposal process
27 described in subparagraph 2.
28 5. All enrollees in the state group health insurance
29 plan or any health maintenance organization plan shall have
30 the option of changing to any other health plan which is
31 offered by the state within any open enrollment period
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1 designated by the division. Open enrollment shall be held at
2 least once each calendar year.
3 6. When a treating health care provider under the
4 state group insurance program or any health maintenance
5 organization loses his or her network provider status for any
6 reason other than for cause, the state group insurance plan
7 shall allow any enrollee in the state group health insurance
8 plan or any health maintenance organization plan for whom the
9 terminated provider was a treating provider to continue care
10 with the terminated treating provider through completion of
11 treatment of a condition for which the enrollee was receiving
12 care at the time of termination, until the enrollee selects
13 another treating provider, or until the next open enrollment
14 period designated by the division, whichever occurs first, but
15 no longer than 1 year after termination of the treating
16 provider. The state group health insurance plan shall allow
17 an enrollee who is in the third trimester of pregnancy to
18 continue care with a terminated treating provider until
19 completion of postpartum care. For care continued under this
20 subparagraph, the program and the provider shall continue to
21 be bound by the terms of the terminated contract for such
22 continued care. This subparagraph shall not apply to treating
23 health care providers who have been terminated by the program
24 for cause.
25 7.6. Any HMO participating in the state group
26 insurance program shall, upon the request of the division,
27 submit to the division standardized data for the purpose of
28 comparison of the appropriateness, quality, and efficiency of
29 care provided by the HMO. Such standardized data shall
30 include: membership profiles; inpatient and outpatient
31 utilization by age and sex, type of service, provider type,
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1 and facility; and emergency care experience. Requirements and
2 timetables for submission of such standardized data and such
3 other data as the division deems necessary to evaluate the
4 performance of participating HMOs shall be adopted by rule.
5 8.7. The division shall, after consultation with
6 representatives from each of the unions representing state and
7 university employees, establish a comprehensive package of
8 insurance benefits including, but not limited to, supplemental
9 health and life coverage, dental care, long-term care, and
10 vision care to allow state employees the option to choose the
11 benefit plans which best suit their individual needs.
12 a. Based upon a desired benefit package, the division
13 shall issue a request for proposal for health insurance
14 providers interested in participating in the state group
15 insurance program, and the division shall issue a request for
16 proposal for insurance providers interested in participating
17 in the non-health-related components of the state group
18 insurance program. Upon receipt of all proposals, the
19 division may enter into contract negotiations with insurance
20 providers submitting bids or negotiate a specially designed
21 benefit package. Insurance providers offering or providing
22 supplemental coverage as of May 30, 1991, which qualify for
23 pretax benefit treatment pursuant to s. 125 of the Internal
24 Revenue Code of 1986, with 5,500 or more state employees
25 currently enrolled may be included by the division in the
26 supplemental insurance benefit plan established by the
27 division without participating in a request for proposal,
28 submitting bids, negotiating contracts, or negotiating a
29 specially designed benefit package. These contracts shall
30 provide state employees with the most cost-effective and
31 comprehensive coverage available; however, no state or agency
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1 funds shall be contributed toward the cost of any part of the
2 premium of such supplemental benefit plans.
3 b. Pursuant to the applicable provisions of s.
4 110.161, and s. 125 of the Internal Revenue Code of 1986, the
5 division shall enroll in the pretax benefit program those
6 state employees who voluntarily elect coverage in any of the
7 supplemental insurance benefit plans as provided by
8 sub-subparagraph a.
9 c. Nothing herein contained shall be construed to
10 prohibit insurance providers from continuing to provide or
11 offer supplemental benefit coverage to state employees as
12 provided under existing agency plans.
13 Section 2. This act shall take effect upon becoming a
14 law.
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17 HOUSE SUMMARY
18
Requires the state group insurance plan to provide an
19 enrollee continued access to a treating health care
provider who loses provider status under the program, for
20 any reason other than for cause, through completion of
treatment of a condition for which the enrollee was
21 receiving care at the time of loss of provider status,
until the enrollee selects another treating provider, or
22 until the next open enrollment period, whichever occurs
first. Provides a 1-year limit on such continued access.
23 Allows an enrollee who is in the third trimester of
pregnancy to continue care with a terminated treating
24 provider until completion of postpartum care. Provides
limitations.
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