House Bill 0549e1

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                                       HB 549, First Engrossed/ntc



  1                      A bill to be entitled

  2         An act relating to state group insurance

  3         program; amending s. 110.123, F.S.; requiring

  4         provision of a comprehensive indemnity dental

  5         plan providing unrestricted enrollee access to

  6         dentists; providing an effective date.

  7

  8  Be It Enacted by the Legislature of the State of Florida:

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10         Section 1.  Paragraph (g) of subsection (3) of section

11  110.123, Florida Statutes, is amended to read:

12         110.123  State group insurance program.--

13         (3)  STATE GROUP INSURANCE PROGRAM.--

14         (g)1.  A person eligible to participate in the state

15  group insurance program may be authorized by rules adopted by

16  the department, in lieu of participating in the state group

17  health insurance plan, to exercise an option to elect

18  membership in a health maintenance organization plan which is

19  under contract with the state in accordance with criteria

20  established by this section and by said rules.  The offer of

21  optional membership in a health maintenance organization plan

22  permitted by this paragraph may be limited or conditioned by

23  rule as may be necessary to meet the requirements of state and

24  federal laws.

25         2.  The department shall contract with health

26  maintenance organizations seeking to participate in the state

27  group insurance program through a request for proposal or

28  other procurement process, as developed by the Department of

29  Management Services and determined to be appropriate.

30         a.  The department shall establish a schedule of

31  minimum benefits for health maintenance organization coverage,


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                                       HB 549, First Engrossed/ntc



  1  and that schedule shall include: physician services; inpatient

  2  and outpatient hospital services; emergency medical services,

  3  including out-of-area emergency coverage; diagnostic

  4  laboratory and diagnostic and therapeutic radiologic services;

  5  mental health, alcohol, and chemical dependency treatment

  6  services meeting the minimum requirements of state and federal

  7  law; skilled nursing facilities and services; prescription

  8  drugs; and other benefits as may be required by the

  9  department.  Additional services may be provided subject to

10  the contract between the department and the HMO.

11         b.  The department may establish uniform deductibles,

12  copayments, or coinsurance schedules for all participating HMO

13  plans.

14         c.  The department may require detailed information

15  from each health maintenance organization participating in the

16  procurement process, including information pertaining to

17  organizational status, experience in providing prepaid health

18  benefits, accessibility of services, financial stability of

19  the plan, quality of management services, accreditation

20  status, quality of medical services, network access and

21  adequacy, performance measurement, ability to meet the

22  department's reporting requirements, and the actuarial basis

23  of the proposed rates and other data determined by the

24  director to be necessary for the evaluation and selection of

25  health maintenance organization plans and negotiation of

26  appropriate rates for these plans.  Upon receipt of proposals

27  by health maintenance organization plans and the evaluation of

28  those proposals, the department may enter into negotiations

29  with all of the plans or a subset of the plans, as the

30  department determines appropriate. Nothing shall preclude the

31  department from negotiating regional or statewide contracts


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                                       HB 549, First Engrossed/ntc



  1  with health maintenance organization plans when this is

  2  cost-effective and when the department determines that the

  3  plan offers high value to enrollees.

  4         d.  The department may limit the number of HMOs that it

  5  contracts with in each service area based on the nature of the

  6  bids the department receives, the number of state employees in

  7  the service area, or any unique geographical characteristics

  8  of the service area. The department shall establish by rule

  9  service areas throughout the state.

10         e.  All persons participating in the state group

11  insurance program who are required to contribute towards a

12  total state group health premium shall be subject to the same

13  dollar contribution regardless of whether the enrollee enrolls

14  in the state group health insurance plan or in an HMO plan.

15         3.  The division is authorized to negotiate and to

16  contract with specialty psychiatric hospitals for mental

17  health benefits, on a regional basis, for alcohol, drug abuse,

18  and mental and nervous disorders. The division may establish,

19  subject to the approval of the Legislature pursuant to

20  subsection (5), any such regional plan upon completion of an

21  actuarial study to determine any impact on plan benefits and

22  premiums.

23         4.  In addition to contracting pursuant to subparagraph

24  2., the department shall enter into contract with any HMO to

25  participate in the state group insurance program which:

26         a.  Serves greater than 5,000 recipients on a prepaid

27  basis under the Medicaid program;

28         b.  Does not currently meet the 25 percent

29  non-Medicare/non-Medicaid enrollment composition requirement

30  established by the Department of Health excluding participants

31  enrolled in the state group insurance program;


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                                       HB 549, First Engrossed/ntc



  1         c.  Meets the minimum benefit package and copayments

  2  and deductibles contained in sub-subparagraphs 2.a. and b.;

  3         d.  Is willing to participate in the state group

  4  insurance program at a cost of premiums that is not greater

  5  than 95 percent of the cost of HMO premiums accepted by the

  6  department in each service area; and

  7         e.  Meets the minimum surplus requirements of s.

  8  641.225.

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10  The department is authorized to contract with HMOs that meet

11  the requirements of sub-subparagraphs a. through d. prior to

12  the open enrollment period for state employees.  The

13  department is not required to renew the contract with the HMOs

14  as set forth in this paragraph more than twice. Thereafter,

15  the HMOs shall be eligible to participate in the state group

16  insurance program only through the request for proposal

17  process described in subparagraph 2.

18         5.  All enrollees in the state group health insurance

19  plan or any health maintenance organization plan shall have

20  the option of changing to any other health plan which is

21  offered by the state within any open enrollment period

22  designated by the department. Open enrollment shall be held at

23  least once each calendar year.

24         6.  When a contract between a treating provider and the

25  state-contracted health maintenance organization is terminated

26  for any reason other than for cause, each party shall allow

27  any enrollee for whom treatment was active to continue

28  coverage and care when medically necessary, through completion

29  of treatment of a condition for which the enrollee was

30  receiving care at the time of the termination, until the

31  enrollee selects another treating provider, or until the next


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                                       HB 549, First Engrossed/ntc



  1  open enrollment period offered, whichever is longer, but no

  2  longer than 6 months after termination of the contract. Each

  3  party to the terminated contract shall allow an enrollee who

  4  has initiated a course of prenatal care, regardless of the

  5  trimester in which care was initiated, to continue care and

  6  coverage until completion of postpartum care. This does not

  7  prevent a provider from refusing to continue to provide care

  8  to an enrollee who is abusive, noncompliant, or in arrears in

  9  payments for services provided. For care continued under this

10  subparagraph, the program and the provider shall continue to

11  be bound by the terms of the terminated contract. Changes made

12  within 30 days before termination of a contract are effective

13  only if agreed to by both parties.

14         7.  Any HMO participating in the state group insurance

15  program shall submit health care utilization and cost data to

16  the department, in such form and in such manner as the

17  division shall require, as a condition of participating in the

18  program.  The department shall enter into negotiations with

19  its contracting HMOs to determine the nature and scope of the

20  data submission and the final requirements, format, penalties

21  associated with noncompliance, and timetables for submission.

22  These determinations shall be adopted by rule.

23         8.  The department may establish and direct, with

24  respect to collective bargaining issues, a comprehensive

25  package of insurance benefits that may include supplemental

26  health and life coverage, dental care, long-term care, vision

27  care, and other benefits it determines necessary to enable

28  state employees to select from among benefit options that best

29  suit their individual and family needs.

30         a.  Based upon a desired benefit package, the

31  department shall issue a request for proposal for health


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                                       HB 549, First Engrossed/ntc



  1  insurance providers interested in participating in the state

  2  group insurance program, and the division shall issue a

  3  request for proposal for insurance providers interested in

  4  participating in the non-health-related components of the

  5  state group insurance program.  The division shall issue a

  6  request for proposal for a comprehensive indemnity dental plan

  7  providing enrollees with a completely unrestricted choice of

  8  dentists. Upon receipt of all proposals, the department may

  9  enter into contract negotiations with insurance providers

10  submitting bids or negotiate a specially designed benefit

11  package. Insurance providers offering or providing

12  supplemental coverage as of May 30, 1991, which qualify for

13  pretax benefit treatment pursuant to s. 125 of the Internal

14  Revenue Code of 1986, with 5,500 or more state employees

15  currently enrolled may be included by the department in the

16  supplemental insurance benefit plan established by the

17  department without participating in a request for proposal,

18  submitting bids, negotiating contracts, or negotiating a

19  specially designed benefit package. These contracts shall

20  provide state employees with the most cost-effective and

21  comprehensive coverage available; however, no state or agency

22  funds shall be contributed toward the cost of any part of the

23  premium of such supplemental benefit plans. With respect to

24  dental coverage, the state group insurance program shall offer

25  a comprehensive indemnity dental plan providing enrollees with

26  a completely unrestricted choice of dentists.  If a dental

27  plan is endorsed, or in some manner recognized as the

28  preferred product, such endorsement or recognition shall

29  include a comprehensive indemnity dental plan providing

30  enrollees with a completely unrestricted choice of dentists.

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                                       HB 549, First Engrossed/ntc



  1         b.  Pursuant to the applicable provisions of s.

  2  110.161, and s. 125 of the Internal Revenue Code of 1986, the

  3  department shall enroll in the pretax benefit program those

  4  state employees who voluntarily elect coverage in any of the

  5  supplemental insurance benefit plans as provided by

  6  sub-subparagraph a.

  7         c.  Nothing herein contained shall be construed to

  8  prohibit insurance providers from continuing to provide or

  9  offer supplemental benefit coverage to state employees as

10  provided under existing agency plans.

11         Section 2.  This act shall take effect upon becoming a

12  law.

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