CODING: Words stricken are deletions; words underlined are additions.





                                                  SENATE AMENDMENT

    Bill No. CS/HBs 1927 & 961, 1st Eng.

    Amendment No.    

                            CHAMBER ACTION
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10                                                                

11  Senator Clary moved the following amendment:

12

13         Senate Amendment (with title amendment) 

14         Delete everything after the enacting clause,

15

16  and insert:

17         Section 1.  Paragraph (a) of subsection (5) of section

18  408.05, Florida Statutes, 1998 Supplement, is amended to read:

19         408.05  State Center for Health Statistics.--

20         (5)  PUBLICATIONS; REPORTS; SPECIAL STUDIES.--The

21  center shall provide for the widespread dissemination of data

22  which it collects and analyzes.  The center shall have the

23  following publication, reporting, and special study functions:

24         (a)  The center shall publish and make available

25  periodically to agencies and individuals health statistics

26  publications of general interest, including HMO report cards;

27  publications providing health statistics on topical health

28  policy issues;, publications that which provide health status

29  profiles of the people in this state;, and other topical

30  health statistics publications.

31         Section 2.  Subsections (2) and (11) of section

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                                                  SENATE AMENDMENT

    Bill No. CS/HBs 1927 & 961, 1st Eng.

    Amendment No.    





 1  408.7056, Florida Statutes, 1998 Supplement, are amended to

 2  read:

 3         408.7056  Statewide Provider and Subscriber Assistance

 4  Program.--

 5         (2)  The agency shall adopt and implement a program to

 6  provide assistance to subscribers and providers, including

 7  those whose grievances are not resolved by the managed care

 8  entity to the satisfaction of the subscriber or provider. The

 9  program shall consist of one or more panels that meet as often

10  as necessary to timely review, consider, and hear grievances

11  and recommend to the agency or the department any actions that

12  should be taken concerning individual cases heard by the

13  panel. The panel shall hear every grievance filed by

14  subscribers and providers on behalf of subscribers, unless the

15  grievance:

16         (a)  Relates to a managed care entity's refusal to

17  accept a provider into its network of providers;

18         (b)  Is part of an internal grievance in a Medicare

19  managed care entity or a reconsideration appeal through the

20  Medicare appeals process which does not involve a quality of

21  care issue;

22         (c)  Is related to a health plan not regulated by the

23  state such as an administrative services organization,

24  third-party administrator, or federal employee health benefit

25  program;

26         (d)  Is related to appeals by in-plan suppliers and

27  providers, unless related to quality of care provided by the

28  plan;

29         (e)  Is part of a Medicaid fair hearing pursued under

30  42 C.F.R. ss. 431.220 et seq.;

31         (f)  Is the basis for an action pending in state or

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                                                  SENATE AMENDMENT

    Bill No. CS/HBs 1927 & 961, 1st Eng.

    Amendment No.    





 1  federal court;

 2         (g)  Is related to an appeal by nonparticipating

 3  providers, unless related to the quality of care provided to a

 4  subscriber by the managed care entity and the provider is

 5  involved in the care provided to the subscriber;

 6         (h)  Was filed before the subscriber or provider

 7  completed the entire internal grievance procedure of the

 8  managed care entity, the managed care entity has complied with

 9  its timeframes for completing the internal grievance

10  procedure, and the circumstances described in subsection (6)

11  do not apply;

12         (i)  Has been resolved to the satisfaction of the

13  subscriber or provider who filed the grievance, unless the

14  managed care entity's initial action is egregious or may be

15  indicative of a pattern of inappropriate behavior;

16         (j)  Is limited to seeking damages for pain and

17  suffering, lost wages, or other incidental expenses, including

18  accrued interest on unpaid balances, court costs, and

19  transportation costs associated with a grievance procedure;

20         (k)  Is limited to issues involving conduct of a health

21  care provider or facility, staff member, or employee of a

22  managed care entity which constitute grounds for disciplinary

23  action by the appropriate professional licensing board and is

24  not indicative of a pattern of inappropriate behavior, and the

25  agency or department has reported these grievances to the

26  appropriate professional licensing board or to the health

27  facility regulation section of the agency for possible

28  investigation; or

29         (l)  Is withdrawn by the subscriber or provider.

30  Failure of the subscriber or the provider to attend the

31  hearing shall be considered a withdrawal of the grievance.

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                                                  SENATE AMENDMENT

    Bill No. CS/HBs 1927 & 961, 1st Eng.

    Amendment No.    





 1         (11)  The panel shall consist of members employed by

 2  the agency and members employed by the department, chosen by

 3  their respective agencies; a consumer appointed by the

 4  Governor; a physician appointed by the Governor, as a standing

 5  member; and physicians who have expertise relevant to the case

 6  to be heard, on a rotating basis. The agency may contract with

 7  a medical director and a primary care physician who shall

 8  provide additional technical expertise to the panel.  The

 9  medical director shall be selected from a health maintenance

10  organization with a current certificate of authority to

11  operate in Florida.

12         Section 3.  Present subsection (5) of section 627.6471,

13  Florida Statutes, is redesignated as subsection (6) and a new

14  subsection (5) is added to that section to read:

15         627.6471  Contracts for reduced rates of payment;

16  limitations; coinsurance and deductibles.--

17         (5)  Any policy issued under this section which does

18  not provide direct patient access to a dermatologist must

19  conform to the requirements of s. 627.6472(16). This

20  subsection shall not be construed to affect the amount the

21  insured or patient must pay as a deductible or coinsurance

22  amount authorized under this section.

23         Section 4.  Subsection (36) is added to section 641.31,

24  Florida Statutes, 1998 Supplement, to read:

25         641.31  Health maintenance contracts.--

26         (36)(a)  Notwithstanding any other provision of this

27  part, a health maintenance organization that meets the

28  requirements of paragraph (b) may, through a point-of-service

29  rider to its contract providing comprehensive health care

30  services, include a point-of-service benefit. Under such a

31  rider, a subscriber or other covered person of the health

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                                                  SENATE AMENDMENT

    Bill No. CS/HBs 1927 & 961, 1st Eng.

    Amendment No.    





 1  maintenance organization may choose, at the time of covered

 2  service, a provider with whom the health maintenance

 3  organization does not have a health maintenance organization

 4  provider contract. The rider may not require a referral from

 5  the health maintenance organization for the point-of-service

 6  benefits.

 7         (b)  A health maintenance organization offering a

 8  point-of-service rider under this subsection must have a valid

 9  certificate of authority issued under the provisions of the

10  chapter, must have been licensed under this chapter for a

11  minimum of 3 years, and must at all times that it has riders

12  in effect maintain a minimum surplus of $5 million.

13         (c)  Premiums paid in for the point-of-service riders

14  may not exceed 15 percent of total premiums for all health

15  plan products sold by the health maintenance organization

16  offering the rider. If the premiums paid for point-of-service

17  riders exceed 15 percent, the health maintenance organization

18  must notify the department and, once this fact is known, must

19  immediately cease offering such a rider until it is in

20  compliance with the rider premium cap.

21         (d)  Notwithstanding the limitations of deductibles and

22  copayment provisions in this part, a point-of-service rider

23  may require the subscriber to pay a reasonable copayment for

24  each visit for services provided by a noncontracted provider

25  chosen at the time of the service. The copayment by the

26  subscriber may either be a specific dollar amount or a

27  percentage of the reimbursable provider charges covered by the

28  contract and must be paid by the subscriber to the

29  noncontracted provider upon receipt of covered services. The

30  point-of-service rider may require that a reasonable annual

31  deductible for the expenses associated with the

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                                                  SENATE AMENDMENT

    Bill No. CS/HBs 1927 & 961, 1st Eng.

    Amendment No.    





 1  point-of-service rider be met and may include a lifetime

 2  maximum benefit amount. The rider must include the language

 3  required by s. 627.6044 and must comply with copayment limits

 4  described in s. 627.6471. Section 641.315(2) and (3) does not

 5  apply to a point-of-service rider authorized under this

 6  subsection.

 7         (e)  The term "point of service" may not be used by a

 8  health maintenance organization except with riders permitted

 9  under this section or with forms approved by the department in

10  which a point-of-service product is offered with an indemnity

11  carrier.

12         (f)  A point-of-service rider must be filed and

13  approved under ss. 627.410 and 627.411.

14         Section 5.  Subsection (4) is added to section

15  641.3155, Florida Statutes, 1998 Supplement, to read:

16         641.3155  Provider contracts; payment of claims.--

17         (4)  Any retroactive reductions of payments or demands

18  for refund of previous overpayments which are due to

19  retroactive review-of-coverage decisions or payment levels

20  must be reconciled to specific claims unless the parties agree

21  to other reconciliation methods and terms. Any retroactive

22  demands by providers for payment due to underpayments or

23  nonpayments for covered services must be reconciled to

24  specific claims unless the parties agree to other

25  reconciliation methods and terms. The look-back period may be

26  specified by the terms of the contract.

27         Section 6.  The Director of the Agency for Health Care

28  Administration shall establish an advisory group composed of

29  eight members, with three members from health maintenance

30  organizations licensed in Florida, one representative from a

31  not-for-profit hospital, one representative from a for-profit

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                                                  SENATE AMENDMENT

    Bill No. CS/HBs 1927 & 961, 1st Eng.

    Amendment No.    





 1  hospital, one representative who is a licensed physician, one

 2  representative from the Office of the Insurance Commissioner,

 3  and one representative from the Agency for Health Care

 4  Administration. The advisory group shall study and make

 5  recommendations concerning:

 6         (1)  Trends and issues relating to legislative,

 7  regulatory, or private-sector solutions for timely and

 8  accurate submission and payment of health claims.

 9         (2)  Development of electronic billing and claims

10  processing for providers and health care facilities that

11  provide for electronic processing of eligibility requests;

12  benefit verification; authorizations; precertifications;

13  business expensing of assets, including software, used for

14  electronic billing and claims processing; and claims status,

15  including use of models such as those compatible with federal

16  billing systems.

17         (3)  The form and content of claims.

18         (4)  Measures to reduce fraud and abuse relating to the

19  submission and payment of claims.

20

21  The advisory group shall be appointed and convened by July 1,

22  1999, and shall meet in Tallahassee. Members of the advisory

23  group shall not receive per diem or travel reimbursement. The

24  advisory group shall submit its recommendations in a report,

25  by January 1, 2000, to the President of the Senate and the

26  Speaker of the House of Representatives.

27         Section 7.  Subsections (8), (9), and (10) of section

28  641.51, Florida Statutes, are amended to read:

29         641.51  Quality assurance program; second medical

30  opinion requirement.--

31         (8)  Each organization shall release to the agency data

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                                                  SENATE AMENDMENT

    Bill No. CS/HBs 1927 & 961, 1st Eng.

    Amendment No.    





 1  that which are indicators of access and quality of care.  The

 2  agency shall develop rules specifying data-reporting

 3  requirements for these indicators.  The indicators shall

 4  include the following characteristics:

 5         (a)  They must relate to access and quality of care

 6  measures.

 7         (b)  They must be consistent with data collected

 8  pursuant to accreditation activities and standards.

 9         (c)  They must be consistent with frequency

10  requirements under the accreditation process.

11         (d)  They must include measures of the management of

12  chronic diseases.

13         (e)  They must include preventive health care for

14  adults and children.

15         (f)  They must include measures of prenatal care.

16         (g)  They must include measures of health checkups for

17  children.

18

19  The agency shall develop by rule a uniform format for

20  publication of the data for the public which shall contain

21  explanations of the data collected and the relevance of such

22  data. The agency shall publish such data no less frequently

23  than every 2 years.

24         (9)  Each organization shall conduct a standardized

25  customer satisfaction survey, as developed by the agency by

26  rule, of its membership at intervals specified by the agency.

27  The survey shall be consistent with surveys required by

28  accrediting organizations and may contain up to 10 additional

29  questions based on concerns specific to Florida.  Survey data

30  shall be submitted to the agency, which shall make comparative

31  findings available to the public.

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                                                  SENATE AMENDMENT

    Bill No. CS/HBs 1927 & 961, 1st Eng.

    Amendment No.    





 1         (9)(10)  Each organization shall adopt recommendations

 2  for preventive pediatric health care which are consistent with

 3  the early periodic screening, diagnosis, and treatment

 4  requirements for health checkups for children developed for

 5  the Medicaid program.  Each organization shall establish goals

 6  to achieve 80-percent compliance by July 1, 1998, and

 7  90-percent compliance by July 1, 1999, for their enrolled

 8  pediatric population.

 9         Section 8.  Subsection (4) of section 641.58, Florida

10  Statutes, is amended to read:

11         641.58  Regulatory assessment; levy and amount; use of

12  funds; tax returns; penalty for failure to pay.--

13         (4)  The moneys so received and deposited into the

14  Health Care Trust Fund shall be used to defray the expenses of

15  the agency in the discharge of its administrative and

16  regulatory powers and duties under this part, including

17  conducting an annual survey of the satisfaction of members of

18  health maintenance organizations; contracting with physician

19  consultants for the Statewide Provider and Subscriber

20  Assistance Panel; the maintaining of offices and necessary

21  supplies, essential equipment, and other materials, salaries

22  and expenses of required personnel;, and discharging all other

23  legitimate expenses relating to the discharge of the

24  administrative and regulatory powers and duties imposed under

25  this such part.

26         Section 9.  Subsections (4) and (7) of section 409.910,

27  Florida Statutes, 1998 Supplement, are amended to read:

28         409.910  Responsibility for payments on behalf of

29  Medicaid-eligible persons when other parties are liable.--

30         (4)  After the department has provided medical

31  assistance under the Medicaid program, it shall seek recovery

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                                                  SENATE AMENDMENT

    Bill No. CS/HBs 1927 & 961, 1st Eng.

    Amendment No.    





 1  of reimbursement from third-party benefits to the limit of

 2  legal liability and for the full amount of third-party

 3  benefits, but not in excess of the amount of medical

 4  assistance paid by Medicaid, as to:

 5         (a)  Claims for which the department has a waiver

 6  pursuant to federal law; or

 7         (b)  Situations in which the department learns of the

 8  existence of a liable third party or in which third-party

 9  benefits are discovered or become available after medical

10  assistance has been provided by Medicaid.

11         (7)  The department shall recover the full amount of

12  all medical assistance provided by Medicaid on behalf of the

13  recipient to the full extent of third-party benefits.

14         (a)  Recovery of such benefits shall be collected

15  directly from:

16         1.  Any third party;

17         2.  The recipient or legal representative, if he or she

18  has received third-party benefits;

19         3.  The provider of a recipient's medical services if

20  third-party benefits have been recovered by the provider;

21  notwithstanding any provision of this section, to the

22  contrary, however, no provider shall be required to refund or

23  pay to the department any amount in excess of the actual

24  third-party benefits received by the provider from a

25  third-party payor for medical services provided to the

26  recipient; or

27         4.  Any person who has received the third-party

28  benefits.

29         (b)  Upon receipt of any recovery or other collection

30  pursuant to this section, the department shall distribute the

31  amount collected as follows:

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                                                  SENATE AMENDMENT

    Bill No. CS/HBs 1927 & 961, 1st Eng.

    Amendment No.    





 1         1.  To itself, an amount equal to the state Medicaid

 2  expenditures for the recipient plus any incentive payment made

 3  in accordance with paragraph (14)(a).

 4         2.  To the Federal Government, the federal share of the

 5  state Medicaid expenditures minus any incentive payment made

 6  in accordance with paragraph (14)(a) and federal law, and

 7  minus any other amount permitted by federal law to be

 8  deducted.

 9         3.  To the recipient, after deducting any known amounts

10  owed to the department for any related medical assistance or

11  to health care providers, any remaining amount. This amount

12  shall be treated as income or resources in determining

13  eligibility for Medicaid.

14

15  The provisions of this subsection do not apply to any proceeds

16  received by the state, or any agency thereof, pursuant to a

17  final order, judgment, or settlement agreement, in any matter

18  in which the state asserts claims brought on its own behalf,

19  and not as a subrogee of a recipient, or under other theories

20  of liability. The provisions of this subsection do not apply

21  to any proceeds received by the state, or an agency thereof,

22  pursuant to a final order, judgment, or settlement agreement,

23  in any matter in which the state asserted both claims as a

24  subrogee and additional claims, except as to those sums

25  specifically identified in the final order, judgment, or

26  settlement agreement as reimbursements to the recipient as

27  expenditures for the named recipient on the subrogation claim.

28         Section 10.  The amendments to section 409.910, Florida

29  Statutes, 1998 Supplement, made by this act are intended to

30  clarify existing law and are remedial in nature.  As such,

31  they are specifically made retroactive to October 1, 1990, and

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                                                  SENATE AMENDMENT

    Bill No. CS/HBs 1927 & 961, 1st Eng.

    Amendment No.    





 1  shall apply to all causes of action arising on or after

 2  October 1, 1990.

 3         Section 11.  Subsection (1) of section 627.6645,

 4  Florida Statutes, is amended and subsection (5) is added to

 5  that section to read:

 6         627.6645  Notification of cancellation, expiration,

 7  nonrenewal, or change in rates.--

 8         (1)  Every insurer delivering or issuing for delivery a

 9  group health insurance policy under the provisions of this

10  part shall give the policyholder at least 45 days' advance

11  notice of cancellation, expiration, nonrenewal, or a change in

12  rates.  Such notice shall be mailed to the policyholder's last

13  address as shown by the records of the insurer.  However, if

14  cancellation is for nonpayment of premium, only the

15  requirements of subsection (5) this section shall not apply.

16  Upon receipt of such notice, the policyholder shall forward,

17  as soon as practicable, the notice of expiration,

18  cancellation, or nonrenewal to each certificateholder covered

19  under the policy.

20         (5)  If cancellation is due to nonpayment of premium,

21  the insurer may not retroactively cancel the policy to a date

22  prior to the date that notice of cancellation was provided to

23  the policyholder unless the insurer mails notice of

24  cancellation to the policyholder prior to 45 days after the

25  date the premium was due. Such notice must be mailed to the

26  policyholder's last address as shown by the records of the

27  insurer and may provide for a retroactive date of cancellation

28  no earlier than midnight of the date that the premium was due.

29         Section 12.  Section 627.6675, Florida Statutes, 1998

30  Supplement, is amended to read:

31         627.6675  Conversion on termination of

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                                                  SENATE AMENDMENT

    Bill No. CS/HBs 1927 & 961, 1st Eng.

    Amendment No.    





 1  eligibility.--Subject to all of the provisions of this

 2  section, a group policy delivered or issued for delivery in

 3  this state by an insurer or nonprofit health care services

 4  plan that provides, on an expense-incurred basis, hospital,

 5  surgical, or major medical expense insurance, or any

 6  combination of these coverages, shall provide that an employee

 7  or member whose insurance under the group policy has been

 8  terminated for any reason, including discontinuance of the

 9  group policy in its entirety or with respect to an insured

10  class, and who has been continuously insured under the group

11  policy, and under any group policy providing similar benefits

12  that the terminated group policy replaced, for at least 3

13  months immediately prior to termination, shall be entitled to

14  have issued to him or her by the insurer a policy or

15  certificate of health insurance, referred to in this section

16  as a "converted policy." A group insurer may meet the

17  requirements of this section by contracting with another

18  insurer, authorized in this state, to issue an individual

19  converted policy, which policy has been approved by the

20  department under s. 627.410. An employee or member shall not

21  be entitled to a converted policy if termination of his or her

22  insurance under the group policy occurred because he or she

23  failed to pay any required contribution, or because any

24  discontinued group coverage was replaced by similar group

25  coverage within 31 days after discontinuance.

26         (1)  TIME LIMIT.--Written application for the converted

27  policy shall be made and the first premium must be paid to the

28  insurer, not later than 63 days after termination of the group

29  policy. However, if termination was the result of failure to

30  pay any required premium or contribution and such nonpayment

31  of premium was due to acts of an employer or policyholder

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                                                  SENATE AMENDMENT

    Bill No. CS/HBs 1927 & 961, 1st Eng.

    Amendment No.    





 1  other than the employee or certificateholder, written

 2  application for the converted policy must be made and the

 3  first premium must be paid to the insurer not later than 63

 4  days after notice of termination is mailed by the insurer or

 5  the employer, whichever is earlier, to the employee's or

 6  certificateholder's last address as shown by the record of the

 7  insurer or the employer, whichever is applicable. In such case

 8  of termination due to nonpayment of premium by the employer or

 9  policyholder, the premium for the converted policy may not

10  exceed the rate for the prior group coverage for the period of

11  coverage under the converted policy prior to the date notice

12  of termination is mailed to the employee or certificateholder.

13  For the period of coverage after such date, the premium for

14  the converted policy is subject to the requirements of

15  subsection (3).

16         (2)  EVIDENCE OF INSURABILITY.--The converted policy

17  shall be issued without evidence of insurability.

18         (3)  CONVERSION PREMIUM; EFFECT ON PREMIUM RATES FOR

19  GROUP COVERAGE.--

20         (a)  The premium for the converted policy shall be

21  determined in accordance with premium rates applicable to the

22  age and class of risk of each person to be covered under the

23  converted policy and to the type and amount of insurance

24  provided.  However, the premium for the converted policy may

25  not exceed 200 percent of the standard risk rate as

26  established by the department, pursuant to this subsection.

27         (b)  Actual or expected experience under converted

28  policies may be combined with such experience under group

29  policies for the purposes of determining premium and loss

30  experience and establishing premium rate levels for group

31  coverage.

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                                                  SENATE AMENDMENT

    Bill No. CS/HBs 1927 & 961, 1st Eng.

    Amendment No.    





 1         (c)  The department shall annually determine standard

 2  risk rates, using reasonable actuarial techniques and

 3  standards adopted by the department by rule. The standard risk

 4  rates must be determined as follows:

 5         1.  Standard risk rates for individual coverage must be

 6  determined separately for indemnity policies, preferred

 7  provider/exclusive provider policies, and health maintenance

 8  organization contracts.

 9         2.  The department shall survey insurers and health

10  maintenance organizations representing at least an 80 percent

11  market share, based on premiums earned in the state for the

12  most recent calendar year, for each of the categories

13  specified in subparagraph 1.

14         3.  Standard risk rate schedules must be determined,

15  computed as the average rates charged by the carriers

16  surveyed, giving appropriate weight to each carrier's

17  statewide market share of earned premiums.

18         4.  The rate schedule shall be determined from analysis

19  of the one county with the largest market share in the state

20  of all such carriers.

21         5.  The rate for other counties must be determined by

22  using the weighted average of each carrier's county factor

23  relationship to the county determined in subparagraph 4.

24         6.  The rate schedule must be determined for different

25  age brackets and family size brackets.

26         (4)  EFFECTIVE DATE OF COVERAGE.--The effective date of

27  the converted policy shall be the day following the

28  termination of insurance under the group policy.

29         (5)  SCOPE OF COVERAGE.--The converted policy shall

30  cover the employee or member and his or her dependents who

31  were covered by the group policy on the date of termination of

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                                                  SENATE AMENDMENT

    Bill No. CS/HBs 1927 & 961, 1st Eng.

    Amendment No.    





 1  insurance.  At the option of the insurer, a separate converted

 2  policy may be issued to cover any dependent.

 3         (6)  OPTIONAL COVERAGE.--The insurer shall not be

 4  required to issue a converted policy covering any person who

 5  is or could be covered by Medicare.  The insurer shall not be

 6  required to issue a converted policy covering a person if

 7  paragraphs (a) and (b) apply to the person:

 8         (a)  If any of the following apply to the person:

 9         1.  The person is covered for similar benefits by

10  another hospital, surgical, medical, or major medical expense

11  insurance policy or hospital or medical service subscriber

12  contract or medical practice or other prepayment plan, or by

13  any other plan or program.

14         2.  The person is eligible for similar benefits,

15  whether or not actually provided coverage, under any

16  arrangement of coverage for individuals in a group, whether on

17  an insured or uninsured basis.

18         3.  Similar benefits are provided for or are available

19  to the person under any state or federal law.

20         (b)  If the benefits provided under the sources

21  referred to in subparagraph (a)1. or the benefits provided or

22  available under the sources referred to in subparagraphs (a)2.

23  and 3., together with the benefits provided by the converted

24  policy, would result in overinsurance according to the

25  insurer's standards.  The insurer's standards must bear some

26  reasonable relationship to actual health care costs in the

27  area in which the insured lives at the time of conversion and

28  must be filed with the department prior to their use in

29  denying coverage.

30         (7)  INFORMATION REQUESTED BY INSURER.--

31         (a)  A converted policy may include a provision under

                                  16
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                                                  SENATE AMENDMENT

    Bill No. CS/HBs 1927 & 961, 1st Eng.

    Amendment No.    





 1  which the insurer may request information, in advance of any

 2  premium due date, of any person covered thereunder as to

 3  whether:

 4         1.  The person is covered for similar benefits by

 5  another hospital, surgical, medical, or major medical expense

 6  insurance policy or hospital or medical service subscriber

 7  contract or medical practice or other prepayment plan or by

 8  any other plan or program.

 9         2.  The person is covered for similar benefits under

10  any arrangement of coverage for individuals in a group,

11  whether on an insured or uninsured basis.

12         3.  Similar benefits are provided for or are available

13  to the person under any state or federal law.

14         (b)  The converted policy may provide that the insurer

15  may refuse to renew the policy or the coverage of any person

16  only for one or more of the following reasons:

17         1.  Either the benefits provided under the sources

18  referred to in subparagraphs (a)1. and 2. for the person or

19  the benefits provided or available under the sources referred

20  to in subparagraph (a)3. for the person, together with the

21  benefits provided by the converted policy, would result in

22  overinsurance according to the insurer's standards on file

23  with the department.

24         2.  The converted policyholder fails to provide the

25  information requested pursuant to paragraph (a).

26         3.  Fraud or intentional misrepresentation in applying

27  for any benefits under the converted policy.

28         4.  Other reasons approved by the department.

29         (8)  BENEFITS OFFERED.--

30         (a)  An insurer shall not be required to issue a

31  converted policy that provides benefits in excess of those

                                  17
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                                                  SENATE AMENDMENT

    Bill No. CS/HBs 1927 & 961, 1st Eng.

    Amendment No.    





 1  provided under the group policy from which conversion is made.

 2         (b)  An insurer shall offer the benefits specified in

 3  s. 627.668 and the benefits specified in s. 627.669 if those

 4  benefits were provided in the group plan.

 5         (c)  An insurer shall offer maternity benefits and

 6  dental benefits if those benefits were provided in the group

 7  plan.

 8         (9)  PREEXISTING CONDITION PROVISION.--The converted

 9  policy shall not exclude a preexisting condition not excluded

10  by the group policy. However, the converted policy may provide

11  that any hospital, surgical, or medical benefits payable under

12  the converted policy may be reduced by the amount of any such

13  benefits payable under the group policy after the termination

14  of covered under the group policy. The converted policy may

15  also provide that during the first policy year the benefits

16  payable under the converted policy, together with the benefits

17  payable under the group policy, shall not exceed those that

18  would have been payable had the individual's insurance under

19  the group policy remained in force.

20         (10)  REQUIRED OPTION FOR MAJOR MEDICAL

21  COVERAGE.--Subject to the provisions and conditions of this

22  part, the employee or member shall be entitled to obtain a

23  converted policy providing major medical coverage under a plan

24  meeting the following requirements:

25         (a)  A maximum benefit equal to the lesser of the

26  policy limit of the group policy from which the individual

27  converted or $500,000 per covered person for all covered

28  medical expenses incurred during the covered person's

29  lifetime.

30         (b)  Payment of benefits at the rate of 80 percent of

31  covered medical expenses which are in excess of the

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                                                  SENATE AMENDMENT

    Bill No. CS/HBs 1927 & 961, 1st Eng.

    Amendment No.    





 1  deductible, until 20 percent of such expenses in a benefit

 2  period reaches $2,000, after which benefits will be paid at

 3  the rate of 90 percent during the remainder of the contract

 4  year unless the insured is in the insurer's case management

 5  program, in which case benefits shall be paid at the rate of

 6  100 percent during the remainder of the contract year.  For

 7  the purposes of this paragraph, "case management program"

 8  means the specific supervision and management of the medical

 9  care provided or prescribed for a specific individual, which

10  may include the use of health care providers designated by the

11  insurer.  Payment of benefits for outpatient treatment of

12  mental illness, if provided in the converted policy, may be at

13  a lesser rate but not less than 50 percent.

14         (c)  A deductible for each calendar year that must be

15  $500, $1,000, or $2,000, at the option of the policyholder.

16         (d)  The term "covered medical expenses," as used in

17  this subsection, shall be consistent with those customarily

18  offered by the insurer under group or individual health

19  insurance policies but is not required to be identical to the

20  covered medical expenses provided in the group policy from

21  which the individual converted.

22         (11)  ALTERNATIVE PLANS.--The insurer shall, in

23  addition to the option required by subsection (10), offer the

24  standard health benefit plan, as established pursuant to s.

25  627.6699(12). The insurer may, at its option, also offer

26  alternative plans for group health conversion in addition to

27  the plans required by this section.

28         (12)  RETIREMENT COVERAGE.--If coverage would be

29  continued under the group policy on an employee following the

30  employee's retirement prior to the time he or she is or could

31  be covered by Medicare, the employee may elect, instead of

                                  19
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                                                  SENATE AMENDMENT

    Bill No. CS/HBs 1927 & 961, 1st Eng.

    Amendment No.    





 1  such continuation of group insurance, to have the same

 2  conversion rights as would apply had his or her insurance

 3  terminated at retirement by reason or termination of

 4  employment or membership.

 5         (13)  REDUCTION OF COVERAGE DUE TO MEDICARE.--The

 6  converted policy may provide for reduction of coverage on any

 7  person upon his or her eligibility for coverage under Medicare

 8  or under any other state or federal law providing for benefits

 9  similar to those provided by the converted policy.

10         (14)  CONVERSION PRIVILEGE ALLOWED.--The conversion

11  privilege shall also be available to any of the following:

12         (a)  The surviving spouse, if any, at the death of the

13  employee or member, with respect to the spouse and the

14  children whose coverages under the group policy terminate by

15  reason of the death, otherwise to each surviving child whose

16  coverage under the group policy terminates by reason of such

17  death, or, if the group policy provides for continuation of

18  dependents' coverages following the employee's or member's

19  death, at the end of such continuation.

20         (b)  The former spouse whose coverage would otherwise

21  terminate because of annulment or dissolution of marriage, if

22  the former spouse is dependent for financial support.

23         (c)  The spouse of the employee or member upon

24  termination of coverage of the spouse, while the employee or

25  member remains insured under the group policy, by reason of

26  ceasing to be a qualified family member under the group

27  policy, with respect to the spouse and the children whose

28  coverages under the group policy terminate at the same time.

29         (d)  A child solely with respect to himself or herself

30  upon termination of his or her coverage by reason of ceasing

31  to be a qualified family member under the group policy, if a

                                  20
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                                                  SENATE AMENDMENT

    Bill No. CS/HBs 1927 & 961, 1st Eng.

    Amendment No.    





 1  conversion privilege is not otherwise provided in this

 2  subsection with respect to such termination.

 3         (15)  BENEFIT LEVELS.--If the benefit levels required

 4  in subsection (10) exceed the benefit levels provided under

 5  the group policy, the conversion policy may offer benefits

 6  which are substantially similar to those provided under the

 7  group policy in lieu of those required in subsection (10).

 8         (16)  GROUP COVERAGE INSTEAD OF INDIVIDUAL

 9  COVERAGE.--The insurer may elect to provide group insurance

10  coverage instead of issuing a converted individual policy.

11         (17)  NOTIFICATION.--A notification of the conversion

12  privilege shall be included in each certificate of coverage.

13  The insurer shall mail an election and premium notice form,

14  including an outline of coverage, on a form approved by the

15  department, within 14 days after an individual who is eligible

16  for a converted policy gives notice to the insurer that the

17  individual is considering applying for the converted policy or

18  otherwise requests such information. The outline of coverage

19  must contain a description of the principal benefits and

20  coverage provided by the policy and its principal exclusions

21  and limitations, including, but not limited to, deductibles

22  and coinsurance.

23         (18)  OUTSIDE CONVERSIONS.--A converted policy that is

24  delivered outside of this state must be on a form that could

25  be delivered in the other jurisdiction as a converted policy

26  had the group policy been issued in that jurisdiction.

27         (19)  APPLICABILITY.--This section does not require

28  conversion on termination of eligibility for a policy or

29  contract that provides benefits for specified diseases, or for

30  accidental injuries only, disability income, Medicare

31  supplement, hospital indemnity, limited benefit,

                                  21
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                                                  SENATE AMENDMENT

    Bill No. CS/HBs 1927 & 961, 1st Eng.

    Amendment No.    





 1  nonconventional, or excess policies.

 2         (20)  Nothing in this section or in the incorporation

 3  of it into insurance policies shall be construed to require

 4  insurers to provide benefits equal to those provided in the

 5  group policy from which the individual converted, provided,

 6  however, that comprehensive benefits are offered which shall

 7  be subject to approval by the Insurance Commissioner.

 8         Section 13.  Section 641.3108, Florida Statutes, is

 9  amended to read:

10         641.3108  Notice of cancellation of contract.--

11         (1)  Except for nonpayment of premium or termination of

12  eligibility, no health maintenance organization may cancel or

13  otherwise terminate or fail to renew a health maintenance

14  contract without giving the subscriber at least 45 days'

15  notice in writing of the cancellation, termination, or

16  nonrenewal of the contract. The written notice shall state the

17  reason or reasons for the cancellation, termination, or

18  nonrenewal.  All health maintenance contracts shall contain a

19  clause which requires that this notice be given.

20         (2)  If cancellation is due to nonpayment of premium,

21  the health maintenance organization may not retroactively

22  cancel the contract to a date prior to the date that notice of

23  cancellation was provided to the subscriber unless the

24  organization mails notice of cancellation to the subscriber

25  prior to 45 days after the date the premium was due. Such

26  notice must be mailed to the subscriber's last address as

27  shown by the records of the organization and may provide for a

28  retroactive date of cancellation no earlier than midnight of

29  the date that the premium was due.

30         (3)  In the case of a health maintenance contract

31  issued to an employer or person holding the contract on behalf

                                  22
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                                                  SENATE AMENDMENT

    Bill No. CS/HBs 1927 & 961, 1st Eng.

    Amendment No.    





 1  of the subscriber group, the health maintenance organization

 2  may make the notification through the employer or group

 3  contract holder, and, if the health maintenance organization

 4  elects to take this action through the employer or group

 5  contract holder, the organization shall be deemed to have

 6  complied with the provisions of this section upon notifying

 7  the employer or group contract holder of the requirements of

 8  this section and requesting the employer or group contract

 9  holder to forward to all subscribers the notice required

10  herein.

11         Section 14.  Subsection (1) of section 641.3922,

12  Florida Statutes, 1998 Supplement, is amended to read:

13         641.3922  Conversion contracts; conditions.--Issuance

14  of a converted contract shall be subject to the following

15  conditions:

16         (1)  TIME LIMIT.--Written application for the converted

17  contract shall be made and the first premium paid to the

18  health maintenance organization not later than 63 days after

19  such termination. However, if termination was the result of

20  failure to pay any required premium or contribution and such

21  nonpayment of premium was due to acts of an employer or group

22  contract holder other than the employee or individual

23  subscriber, written application for the contract must be made

24  and the first premium must be paid not later than 63 days

25  after notice of termination is mailed by the organization or

26  the employer, whichever is earlier, to the employee's or

27  individual's last address as shown by the record of the

28  organization or the employer, whichever is applicable. In such

29  case of termination due to non-payment of premium by the

30  employer or group contract holder, the premium for the

31  converted contract may not exceed the rate for the prior group

                                  23
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                                                  SENATE AMENDMENT

    Bill No. CS/HBs 1927 & 961, 1st Eng.

    Amendment No.    





 1  coverage for the period of coverage under the converted

 2  contract prior to the date notice of termination is mailed to

 3  the employee or individual subscriber. For the period of

 4  coverage after such date, the premium for the converted

 5  contract is subject to the requirements of subsection (3).

 6         Section 15.  Subsection (9) is added to section 20.41,

 7  Florida Statutes, to read:

 8         20.41  Department of Elderly Affairs.--There is created

 9  a Department of Elderly Affairs.

10         (9)  Area agencies on aging are subject to chapter 119,

11  relating to public records, and, when considering any

12  contracts requiring the expenditure of funds, are subject to

13  ss. 286.011-286.012, relating to public meetings.

14         Section 16.  There is appropriated to the Agency for

15  Health Care Administration for fiscal year 1999-2000

16  $1,439,000 from the Health Care Trust Fund for 12 months of

17  funding for the purpose of implementing this act.

18         Section 17.  This act shall take effect upon becoming a

19  law.

20

21

22  ================ T I T L E   A M E N D M E N T ===============

23  And the title is amended as follows:

24         Delete everything before the enacting clause,

25

26  and insert:

27                      A bill to be entitled

28         An act relating to governmental agencies;

29         amending s. 20.41, F.S.; providing that area

30         agencies on aging are subject to ch. 119 and

31         ss. 286.011-286.012, F.S., as specified;

                                  24
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                                                  SENATE AMENDMENT

    Bill No. CS/HBs 1927 & 961, 1st Eng.

    Amendment No.    





 1         amending s. 408.05, F.S., relating to the State

 2         Center for Health Statistics; requiring the

 3         Agency for Health Care Administration to

 4         publish health maintenance organization report

 5         cards; amending s. 408.7056, F.S.; excluding

 6         certain additional grievances from

 7         consideration by a statewide provider and

 8         subscriber assistance panel; revising the

 9         membership of the panel; amending s. 627.6471,

10         F.S.; requiring preferred provider organization

11         policies which do not provide direct patient

12         access for dermatological services to conform

13         to certain requirements imposed on exclusive

14         provider organization contracts; amending s.

15         627.6645, F.S.; revising the notice

16         requirements for cancellation or nonrenewal of

17         a group health insurance policy; specifying

18         conditions under which the insurer may

19         retroactively cancel coverage due to nonpayment

20         of premium; amending s. 627.6675, F.S.;

21         revising the time limits for an employee or

22         group member to apply for an individual

23         converted policy when termination of group

24         coverage is due to failure of the employer to

25         pay the premium; revising the requirements for

26         the premium for the converted policy; allowing

27         a group insurer to contract with another

28         insurer to issue an individual converted policy

29         under certain conditions; amending s. 641.3108,

30         F.S.; revising the notice requirements for

31         cancellation or nonrenewal of a health

                                  25
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                                                  SENATE AMENDMENT

    Bill No. CS/HBs 1927 & 961, 1st Eng.

    Amendment No.    





 1         maintenance organization contract; specifying

 2         conditions under which the organization may

 3         retroactively cancel coverage due to nonpayment

 4         of premium; amending s. 641.3922, F.S.;

 5         revising the time limits for an employee or

 6         group member to apply for a converted contract

 7         from a health maintenance organization when

 8         termination of group coverage is due to failure

 9         of the employer to pay the premium; revising

10         the requirements for the premium for the

11         converted contract; amending s. 641.31, F.S.,

12         relating to health maintenance contracts;

13         providing for a point-of-service benefit rider

14         on a health maintenance contract; providing

15         requirements; providing restrictions;

16         authorizing reasonable copayment and annual

17         deductible; providing exceptions relating to

18         subscriber liability for services received;

19         amending s. 641.3155, F.S., relating to health

20         maintenance organization provider contracts and

21         payment of claims; requiring health maintenance

22         organizations to reconcile retroactive

23         reductions of payment to specific claims;

24         requiring providers to reconcile retroactive

25         demands for underpayment or nonpayment to

26         specific claims; providing an exception;

27         providing for the contract to specify the

28         look-back period; providing for an advisory

29         group established in the Agency for Health Care

30         Administration; requiring a report; amending s.

31         641.51, F.S.; requiring that health maintenance

                                  26
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                                                  SENATE AMENDMENT

    Bill No. CS/HBs 1927 & 961, 1st Eng.

    Amendment No.    





 1         organizations provide additional information to

 2         the Agency for Health Care Administration

 3         indicating quality of care; removing a

 4         requirement that organizations conduct customer

 5         satisfaction surveys; revising requirements for

 6         preventive pediatric health care provided by

 7         health maintenance organizations; amending s.

 8         641.58, F.S.; providing for moneys in the

 9         Health Care Trust Fund to be used for

10         additional purposes; amending s. 409.910, F.S.;

11         clarifying that the state may recover and

12         retain damages in excess of Medicaid payments

13         made under certain circumstances; providing for

14         retroactive application; providing an

15         appropriation; providing an effective date.

16

17

18

19

20

21

22

23

24

25

26

27

28

29

30

31

                                  27
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