Senate Bill 2086er
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1
2 An act relating to small employer health
3 alliances; amending s. 408.7056, F.S.;
4 providing additional definitions for the
5 Statewide Provider and Subscriber Assistance
6 Program; amending s. 627.654, F.S.; providing
7 for insuring small employers under policies
8 issued to small employer health alliances;
9 providing requirements for participation;
10 providing limitations; providing for insuring
11 spouses and dependent children; allowing a
12 single master policy to include alternative
13 health plans; amending s. 627.6571, F.S.;
14 including small employer health alliances
15 within policy nonrenewal or discontinuance,
16 coverage modification, and application
17 provisions; amending s. 627.6699, F.S.;
18 revising restrictions relating to premium rates
19 to authorize small employer carriers to modify
20 rates under certain circumstances and to
21 authorize carriers to issue group health
22 insurance policies to small employer health
23 alliances under certain circumstances;
24 requiring carriers issuing a policy to an
25 alliance to allow appointed agents to sell such
26 a policy; amending ss. 240.2995, 240.2996,
27 240.512, 381.0406, 395.3035, and 627.4301,
28 F.S.; conforming cross-references; defining the
29 term "managed care"; repealing ss. 408.70(3),
30 408.701, 408.702, 408.703, 408.704, 408.7041,
31 408.7042, 408.7045, 408.7055, and 408.706,
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1 F.S., relating to community health purchasing
2 alliances; providing an effective date.
3
4 Be It Enacted by the Legislature of the State of Florida:
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6 Section 1. Subsection (1) of section 408.7056, Florida
7 Statutes, is amended to read:
8 408.7056 Statewide Provider and Subscriber Assistance
9 Program.--
10 (1) As used in this section, the term:
11 (a) "Agency" means the Agency for Health Care
12 Administration.
13 (b) "Department" means the Department of Insurance.
14 (c) "Grievance procedure" means an established set of
15 rules that specify a process for appeal of an organizational
16 decision.
17 (d) "Health care provider" or "provider" means a
18 state-licensed or state-authorized facility, a facility
19 principally supported by a local government or by funds from a
20 charitable organization that holds a current exemption from
21 federal income tax under s. 501(c)(3) of the Internal Revenue
22 Code, a licensed practitioner, a county health department
23 established under part I of chapter 154, a prescribed
24 pediatric extended care center defined in s. 400.902, a
25 federally supported primary care program such as a migrant
26 health center or a community health center authorized under s.
27 329 or s. 330 of the United States Public Health Services Act
28 that delivers health care services to individuals, or a
29 community facility that receives funds from the state under
30 the Community Alcohol, Drug Abuse, and Mental Health Services
31 Act and provides mental health services to individuals.
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1 (e)(a) "Managed care entity" means a health
2 maintenance organization or a prepaid health clinic certified
3 under chapter 641, a prepaid health plan authorized under s.
4 409.912, or an exclusive provider organization certified under
5 s. 627.6472.
6 (f)(b) "Panel" means a statewide provider and
7 subscriber assistance panel selected as provided in subsection
8 (11).
9 Section 2. Section 627.654, Florida Statutes, is
10 amended to read:
11 627.654 Labor union, and association, and small
12 employer health alliance groups.--
13 (1)(a) A group of individuals may be insured under a
14 policy issued to an association, including a labor union,
15 which association has a constitution and bylaws and not less
16 than 25 individual members and which has been organized and
17 has been maintained in good faith for a period of 1 year for
18 purposes other than that of obtaining insurance, or to the
19 trustees of a fund established by such an association, which
20 association or trustees shall be deemed the policyholder,
21 insuring at least 15 individual members of the association for
22 the benefit of persons other than the officers of the
23 association, the association or trustees.
24 (b) A small employer, as defined in s. 627.6699 and
25 including the employer's eligible employees and the spouses
26 and dependents of such employees, may be insured under a
27 policy issued to a small employer health alliance by a carrier
28 as defined in s. 627.6699. A small employer health alliance
29 must be organized as a not-for-profit corporation under
30 chapter 617. Notwithstanding any other law, if a
31 small-employer member of an alliance loses eligibility to
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1 purchase health care through the alliance solely because the
2 business of the small-employer member expands to more than 50
3 and fewer than 75 eligible employees, the small-employer
4 member may, at its next renewal date, purchase coverage
5 through the alliance for not more than 1 additional year. A
6 small employer health alliance shall establish conditions of
7 participation in the alliance by a small employer, including,
8 but not limited to:
9 1. Assurance that the small employer is not formed for
10 the purpose of securing health benefit coverage.
11 2. Assurance that the employees of a small employer
12 have not been added for the purpose of securing health benefit
13 coverage.
14 (2) No such policy of insurance as defined in
15 subsection (1) may be issued to any such association or
16 alliance, unless all individual members of such association,
17 or all small-employer members of an alliance, or all of any
18 class or classes thereof, are declared eligible and acceptable
19 to the insurer at the time of issuance of the policy.
20 (3) Any such policy issued under paragraph (1)(a) may
21 insure the spouse or dependent children with or without the
22 member being insured.
23 (4) A single master policy issued to an association,
24 labor union, or small-employer health alliance may include
25 more than one health plan from the same insurer or affiliated
26 insurer group as alternatives for an employer, employee, or
27 member to select.
28 Section 3. Paragraph (f) of subsection (2), paragraph
29 (b) of subsection (4), and subsection (6) of section 627.6571,
30 Florida Statutes, are amended to read:
31 627.6571 Guaranteed renewability of coverage.--
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1 (2) An insurer may nonrenew or discontinue a group
2 health insurance policy based only on one or more of the
3 following conditions:
4 (f) In the case of health insurance coverage that is
5 made available only through one or more bona fide associations
6 as defined in subsection (5) or through one or more small
7 employer health alliances as described in s. 627.654(1)(b),
8 the membership of an employer in the association or in the
9 small employer health alliance, on the basis of which the
10 coverage is provided, ceases, but only if such coverage is
11 terminated under this paragraph uniformly without regard to
12 any health-status-related factor that relates to any covered
13 individuals.
14 (4) At the time of coverage renewal, an insurer may
15 modify the health insurance coverage for a product offered:
16 (b) In the small-group market if, for coverage that is
17 available in such market other than only through one or more
18 bona fide associations as defined in subsection (5) or through
19 one or more small employer health alliances as described in s.
20 627.654(1)(b), such modification is consistent with s.
21 627.6699 and effective on a uniform basis among group health
22 plans with that product.
23 (6) In applying this section in the case of health
24 insurance coverage that is made available by an insurer in the
25 small-group market or large-group market to employers only
26 through one or more associations or through one or more small
27 employer health alliances as described in s. 627.654(1)(b), a
28 reference to "policyholder" is deemed, with respect to
29 coverage provided to an employer member of the association, to
30 include a reference to such employer.
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1 Section 4. Paragraph (h) of subsection (5), paragraph
2 (b) of subsection (6), and paragraph (a) of subsection (12) of
3 section 627.6699, Florida Statutes, are amended to read:
4 627.6699 Employee Health Care Access Act.--
5 (5) AVAILABILITY OF COVERAGE.--
6 (h) All health benefit plans issued under this section
7 must comply with the following conditions:
8 1. For employers who have fewer than two employees, a
9 late enrollee may be excluded from coverage for no longer than
10 24 months if he or she was not covered by creditable coverage
11 continually to a date not more than 63 days before the
12 effective date of his or her new coverage.
13 2. Any requirement used by a small employer carrier in
14 determining whether to provide coverage to a small employer
15 group, including requirements for minimum participation of
16 eligible employees and minimum employer contributions, must be
17 applied uniformly among all small employer groups having the
18 same number of eligible employees applying for coverage or
19 receiving coverage from the small employer carrier, except
20 that a small employer carrier that participates in,
21 administers, or issues health benefits pursuant to s. 381.0406
22 which do not include a preexisting condition exclusion may
23 require as a condition of offering such benefits that the
24 employer has had no health insurance coverage for its
25 employees for a period of at least 6 months. A small employer
26 carrier may vary application of minimum participation
27 requirements and minimum employer contribution requirements
28 only by the size of the small employer group.
29 3. In applying minimum participation requirements with
30 respect to a small employer, a small employer carrier shall
31 not consider as an eligible employee employees or dependents
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1 who have qualifying existing coverage in an employer-based
2 group insurance plan or an ERISA qualified self-insurance plan
3 in determining whether the applicable percentage of
4 participation is met. However, a small employer carrier may
5 count eligible employees and dependents who have coverage
6 under another health plan that is sponsored by that employer
7 except if such plan is offered pursuant to s. 408.706.
8 4. A small employer carrier shall not increase any
9 requirement for minimum employee participation or any
10 requirement for minimum employer contribution applicable to a
11 small employer at any time after the small employer has been
12 accepted for coverage, unless the employer size has changed,
13 in which case the small employer carrier may apply the
14 requirements that are applicable to the new group size.
15 5. If a small employer carrier offers coverage to a
16 small employer, it must offer coverage to all the small
17 employer's eligible employees and their dependents. A small
18 employer carrier may not offer coverage limited to certain
19 persons in a group or to part of a group, except with respect
20 to late enrollees.
21 6. A small employer carrier may not modify any health
22 benefit plan issued to a small employer with respect to a
23 small employer or any eligible employee or dependent through
24 riders, endorsements, or otherwise to restrict or exclude
25 coverage for certain diseases or medical conditions otherwise
26 covered by the health benefit plan.
27 7. An initial enrollment period of at least 30 days
28 must be provided. An annual 30-day open enrollment period
29 must be offered to each small employer's eligible employees
30 and their dependents. A small employer carrier must provide
31 special enrollment periods as required by s. 627.65615.
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1 (6) RESTRICTIONS RELATING TO PREMIUM RATES.--
2 (b) For all small employer health benefit plans that
3 are subject to this section and are issued by small employer
4 carriers on or after January 1, 1994, premium rates for health
5 benefit plans subject to this section are subject to the
6 following:
7 1. Small employer carriers must use a modified
8 community rating methodology in which the premium for each
9 small employer must be determined solely on the basis of the
10 eligible employee's and eligible dependent's gender, age,
11 family composition, tobacco use, or geographic area as
12 determined under paragraph (5)(j).
13 2. Rating factors related to age, gender, family
14 composition, tobacco use, or geographic location may be
15 developed by each carrier to reflect the carrier's experience.
16 The factors used by carriers are subject to department review
17 and approval.
18 3. Small employer carriers may not modify the rate for
19 a small employer for 12 months from the initial issue date or
20 renewal date, unless the composition of the group changes or
21 benefits are changed. However, a small employer carrier may
22 modify the rate one time prior to 12 months after the initial
23 issue date for a small employer who enrolls under a previously
24 issued group policy that has a common anniversary date for all
25 employers covered under the policy if:
26 a. The carrier discloses to the employer in a clear
27 and conspicuous manner the date of the first renewal and the
28 fact that the premium may increase on or after that date.
29 b. The insurer demonstrates to the department that
30 efficiencies in administration are achieved and reflected in
31 the rates charged to small employers covered under the policy.
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1 4. A carrier may issue a group health insurance policy
2 to a small employer health alliance or other group association
3 with rates that reflect a premium credit for expense savings
4 attributable to administrative activities being performed by
5 the alliance or group association if such expense savings are
6 specifically documented in the insurer's rate filing and are
7 approved by the department. Any such credit may not be based
8 on different morbidity assumptions or on any other factor
9 related to the health status or claims experience of any
10 person covered under the policy. Nothing in this subparagraph
11 exempts an alliance or group association from licensure for
12 any activities that require licensure under the Insurance
13 Code. A carrier issuing a group health insurance policy to a
14 small-employer health alliance or other group association
15 shall allow any properly licensed and appointed agent of that
16 carrier to market and sell the small-employer health alliance
17 or other group association policy. Such agent shall be paid
18 the usual and customary commission paid to any agent selling
19 the policy. Carriers participating in the alliance program, in
20 accordance with ss. 408.70-408.706, may apply a different
21 community rate to business written in that program.
22 (12) STANDARD, BASIC, AND LIMITED HEALTH BENEFIT
23 PLANS.--
24 (a)1. By May 15, 1993, the commissioner shall appoint
25 a health benefit plan committee composed of four
26 representatives of carriers which shall include at least two
27 representatives of HMOs, at least one of which is a staff
28 model HMO, two representatives of agents, four representatives
29 of small employers, and one employee of a small employer. The
30 carrier members shall be selected from a list of individuals
31 recommended by the board. The commissioner may require the
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1 board to submit additional recommendations of individuals for
2 appointment. As alliances are established under s. 408.702,
3 each alliance shall also appoint an additional member to the
4 committee.
5 2. The committee shall develop changes to the form and
6 level of coverages for the standard health benefit plan and
7 the basic health benefit plan, and shall submit the forms, and
8 levels of coverages to the department by September 30, 1993.
9 The department must approve such forms and levels of coverages
10 by November 30, 1993, and may return the submissions to the
11 committee for modification on a schedule that allows the
12 department to grant final approval by November 30, 1993.
13 3. The plans shall comply with all of the requirements
14 of this subsection.
15 4. The plans must be filed with and approved by the
16 department prior to issuance or delivery by any small employer
17 carrier.
18 5. After approval of the revised health benefit plans,
19 if the department determines that modifications to a plan
20 might be appropriate, the commissioner shall appoint a new
21 health benefit plan committee in the manner provided in
22 subparagraph 1. to submit recommended modifications to the
23 department for approval.
24 Section 5. Subsection (1) of section 240.2995, Florida
25 Statutes, is amended to read:
26 240.2995 University health services support
27 organizations.--
28 (1) Each state university is authorized to establish
29 university health services support organizations which shall
30 have the ability to enter into, for the benefit of the
31 university academic health sciences center, and arrangements
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1 with other entities as providers for accountable health
2 partnerships, as defined in s. 408.701, and providers in other
3 integrated health care systems or similar entities. To the
4 extent required by law or rule, university health services
5 support organizations shall become licensed as insurance
6 companies, pursuant to chapter 624, or be certified as health
7 maintenance organizations, pursuant to chapter 641.
8 University health services support organizations shall have
9 sole responsibility for the acts, debts, liabilities, and
10 obligations of the organization. In no case shall the state
11 or university have any responsibility for such acts, debts,
12 liabilities, and obligations incurred or assumed by university
13 health services support organizations.
14 Section 6. Paragraph (a) of subsection (2) of section
15 240.2996, Florida Statutes, is amended to read:
16 240.2996 University health services support
17 organization; confidentiality of information.--
18 (2) The following university health services support
19 organization's records and information are confidential and
20 exempt from the provisions of s. 119.07(1) and s. 24(a), Art.
21 I of the State Constitution:
22 (a) Contracts for managed care arrangements, as
23 managed care is defined in s. 408.701, under which the
24 university health services support organization provides
25 health care services, including preferred provider
26 organization contracts, health maintenance organization
27 contracts, alliance network arrangements, and exclusive
28 provider organization contracts, and any documents directly
29 relating to the negotiation, performance, and implementation
30 of any such contracts for managed care arrangements or
31 alliance network arrangements. As used in this paragraph, the
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1 term "managed care" means systems or techniques generally used
2 by third-party payors or their agents to affect access to and
3 control payment for health care services. Managed-care
4 techniques most often include one or more of the following:
5 prior, concurrent, and retrospective review of the medical
6 necessity and appropriateness of services or site of services;
7 contracts with selected health care providers; financial
8 incentives or disincentives related to the use of specific
9 providers, services, or service sites; controlled access to
10 and coordination of services by a case manager; and payor
11 efforts to identify treatment alternatives and modify benefit
12 restrictions for high-cost patient care.
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14 The exemptions in this subsection are subject to the Open
15 Government Sunset Review Act of 1995 in accordance with s.
16 119.15 and shall stand repealed on October 2, 2001, unless
17 reviewed and saved from repeal through reenactment by the
18 Legislature.
19 Section 7. Paragraph (b) of subsection (8) of section
20 240.512, Florida Statutes, is amended to read:
21 240.512 H. Lee Moffitt Cancer Center and Research
22 Institute.--There is established the H. Lee Moffitt Cancer
23 Center and Research Institute at the University of South
24 Florida.
25 (8)
26 (b) Proprietary confidential business information is
27 confidential and exempt from the provisions of s. 119.07(1)
28 and s. 24(a), Art. I of the State Constitution. However, the
29 Auditor General and Board of Regents, pursuant to their
30 oversight and auditing functions, must be given access to all
31 proprietary confidential business information upon request and
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1 without subpoena and must maintain the confidentiality of
2 information so received. As used in this paragraph, the term
3 "proprietary confidential business information" means
4 information, regardless of its form or characteristics, which
5 is owned or controlled by the not-for-profit corporation or
6 its subsidiaries; is intended to be and is treated by the
7 not-for-profit corporation or its subsidiaries as private and
8 the disclosure of which would harm the business operations of
9 the not-for-profit corporation or its subsidiaries; has not
10 been intentionally disclosed by the corporation or its
11 subsidiaries unless pursuant to law, an order of a court or
12 administrative body, a legislative proceeding pursuant to s.
13 5, Art. III of the State Constitution, or a private agreement
14 that provides that the information may be released to the
15 public; and which is information concerning:
16 1. Internal auditing controls and reports of internal
17 auditors;
18 2. Matters reasonably encompassed in privileged
19 attorney-client communications;
20 3. Contracts for managed-care arrangements, as managed
21 care is defined in s. 408.701, including preferred provider
22 organization contracts, health maintenance organization
23 contracts, and exclusive provider organization contracts, and
24 any documents directly relating to the negotiation,
25 performance, and implementation of any such contracts for
26 managed-care arrangements;
27 4. Bids or other contractual data, banking records,
28 and credit agreements the disclosure of which would impair the
29 efforts of the not-for-profit corporation or its subsidiaries
30 to contract for goods or services on favorable terms;
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1 5. Information relating to private contractual data,
2 the disclosure of which would impair the competitive interest
3 of the provider of the information;
4 6. Corporate officer and employee personnel
5 information;
6 7. Information relating to the proceedings and records
7 of credentialing panels and committees and of the governing
8 board of the not-for-profit corporation or its subsidiaries
9 relating to credentialing;
10 8. Minutes of meetings of the governing board of the
11 not-for-profit corporation and its subsidiaries, except
12 minutes of meetings open to the public pursuant to subsection
13 (9);
14 9. Information that reveals plans for marketing
15 services that the corporation or its subsidiaries reasonably
16 expect to be provided by competitors;
17 10. Trade secrets as defined in s. 688.002, including
18 reimbursement methodologies or rates; or
19 11. The identity of donors or prospective donors of
20 property who wish to remain anonymous or any information
21 identifying such donors or prospective donors. The anonymity
22 of these donors or prospective donors must be maintained in
23 the auditor's report.
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25 As used in this paragraph, the term "managed care" means
26 systems or techniques generally used by third-party payors or
27 their agents to affect access to and control payment for
28 health care services. Managed-care techniques most often
29 include one or more of the following: prior, concurrent, and
30 retrospective review of the medical necessity and
31 appropriateness of services or site of services; contracts
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1 with selected health care providers; financial incentives or
2 disincentives related to the use of specific providers,
3 services, or service sites; controlled access to and
4 coordination of services by a case manager; and payor efforts
5 to identify treatment alternatives and modify benefit
6 restrictions for high-cost patient care.
7 Section 8. Subsection (14) of section 381.0406,
8 Florida Statutes, is amended to read:
9 381.0406 Rural health networks.--
10 (14) NETWORK FINANCING.--Networks may use all sources
11 of public and private funds to support network activities.
12 Nothing in this section prohibits networks from becoming
13 managed care providers, or accountable health partnerships,
14 provided they meet the requirements for an accountable health
15 partnership as specified in s. 408.706.
16 Section 9. Paragraph (a) of subsection (2) of section
17 395.3035, Florida Statutes, is amended to read:
18 395.3035 Confidentiality of hospital records and
19 meetings.--
20 (2) The following records and information of any
21 hospital that is subject to chapter 119 and s. 24(a), Art. I
22 of the State Constitution are confidential and exempt from the
23 provisions of s. 119.07(1) and s. 24(a), Art. I of the State
24 Constitution:
25 (a) Contracts for managed care arrangements, as
26 managed care is defined in s. 408.701, under which the public
27 hospital provides health care services, including preferred
28 provider organization contracts, health maintenance
29 organization contracts, exclusive provider organization
30 contracts, and alliance network arrangements, and any
31 documents directly relating to the negotiation, performance,
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1 and implementation of any such contracts for managed care or
2 alliance network arrangements. As used in this paragraph, the
3 term "managed care" means systems or techniques generally used
4 by third-party payors or their agents to affect access to and
5 control payment for health care services. Managed-care
6 techniques most often include one or more of the following:
7 prior, concurrent, and retrospective review of the medical
8 necessity and appropriateness of services or site of services;
9 contracts with selected health care providers; financial
10 incentives or disincentives related to the use of specific
11 providers, services, or service sites; controlled access to
12 and coordination of services by a case manager; and payor
13 efforts to identify treatment alternatives and modify benefit
14 restrictions for high-cost patient care.
15 Section 10. Paragraph (b) of subsection (1) of section
16 627.4301, Florida Statutes, is amended to read:
17 627.4301 Genetic information for insurance purposes.--
18 (1) DEFINITIONS.--As used in this section, the term:
19 (b) "Health insurer" means an authorized insurer
20 offering health insurance as defined in s. 624.603, a
21 self-insured plan as defined in s. 624.031, a
22 multiple-employer welfare arrangement as defined in s.
23 624.437, a prepaid limited health service organization as
24 defined in s. 636.003, a health maintenance organization as
25 defined in s. 641.19, a prepaid health clinic as defined in s.
26 641.402, a fraternal benefit society as defined in s. 632.601,
27 an accountable health partnership as defined in s. 408.701, or
28 any health care arrangement whereby risk is assumed.
29 Section 11. Subsection (3) of section 408.70, and
30 sections 408.701, 408.702, 408.703, 408.704, 408.7041,
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1 408.7042, 408.7045, 408.7055, and 408.706, Florida Statutes,
2 are repealed.
3 Section 12. This act shall take effect October 1,
4 2000.
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