HOUSE AMENDMENT
Bill No. CS/HB 1253
Amendment No. 1 (for drafter's use only)
CHAMBER ACTION
Senate House
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5 ORIGINAL STAMP BELOW
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11 The Council for Healthy Communities offered the following:
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13 Amendment (with title amendment)
14 On page 2, line 17,
15 remove from the bill: everything after the enacting clause,
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17 and insert in lieu thereof:
18 Section 1. Health flex plans.--
19 (1) INTENT.--The Legislature finds that a significant
20 portion of the residents of this state are not able to obtain
21 affordable health insurance coverage. Therefore it is the
22 intent of the Legislature to expand the availability of health
23 care options for lower income uninsured state residents by
24 encouraging health insurers, health maintenance organizations,
25 health care provider-sponsored organizations, local
26 governments, health care districts, or other public or private
27 community-based organizations to develop alternative
28 approaches to traditional health insurance which emphasize
29 coverage for basic and preventive health care services. To
30 the maximum extent possible, such options should be
31 coordinated with existing governmental or community-based
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HOUSE AMENDMENT
Bill No. CS/HB 1253
Amendment No. 1 (for drafter's use only)
1 health services programs in a manner which is consistent with
2 the objectives and requirements of such programs.
3 (2) DEFINITIONS.--As used in this section:
4 (a) "Agency" means the Agency for Health Care
5 Administration.
6 (b) "Approved plan" means a health flex plan approved
7 under subsection (3) which guarantees payment by the health
8 plan entity for specified health care services provided to the
9 enrollee.
10 (c) "Enrollee" means an individual who has been
11 determined eligible for and is receiving health benefits under
12 a health flex plan approved under this section.
13 (d) "Health care coverage" means payment for health
14 care services covered as benefits under an approved plan or
15 that otherwise provides, either directly or through
16 arrangements with other persons, covered health care services
17 on a prepaid per capita basis or on a prepaid aggregate
18 fixed-sum basis.
19 (e) "Health plan entity" means a health insurer,
20 health maintenance organization, health care
21 provider-sponsored organization, local government, health care
22 districts, or other public or private community-based
23 organization which develops and implements an approved plan,
24 and is responsible for financing and paying all claims by
25 enrollees of the plan.
26 (3) PILOT PROGRAM.--The agency and the Department of
27 Insurance shall jointly approve or disapprove health flex
28 plans which provide health care coverage for eligible
29 participants residing in the three areas of the state having
30 the highest number of uninsured residents as determined by the
31 agency. A plan may limit or exclude benefits otherwise
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HOUSE AMENDMENT
Bill No. CS/HB 1253
Amendment No. 1 (for drafter's use only)
1 required by law for insurers offering coverage in this state,
2 cap the total amount of claims paid in 1 year per enrollee, or
3 limit the number of enrollees covered. The agency and the
4 Department of Insurance shall not approve or shall withdraw
5 approval of a plan which:
6 (a) Contains any ambiguous, inconsistent, or
7 misleading provisions, or exceptions or conditions that
8 deceptively affect or limit the benefits purported to be
9 assumed in the general coverage provided by the plan;
10 (b) Provides benefits that are unreasonable in
11 relation to the premium charged, contains provisions that are
12 unfair or inequitable or contrary to the public policy of this
13 state or that encourage misrepresentation, or result in unfair
14 discrimination in sales practices; or
15 (c) Cannot demonstrate that the plan is financially
16 sound and the applicant has the ability to underwrite or
17 finance the benefits provided.
18 (4) LICENSE NOT REQUIRED.--A health flex plan approved
19 under this section shall not be subject to the licensing
20 requirements of the Florida Insurance Code or chapter 641,
21 Florida Statutes, relating to health maintenance
22 organizations, unless expressly made applicable. However, for
23 the purposes of prohibiting unfair trade practices, health
24 flex plans shall be considered insurance subject to the
25 applicable provisions of part IX of chapter 626, Florida
26 Statutes, except as otherwise provided in this section.
27 (5) ELIGIBILITY.--Eligibility to enroll in an approved
28 health flex plan is limited to residents of this state who:
29 (a) Are 64 years of age or younger.
30 (b) Have a family income equal to or less than 200
31 percent of the federal poverty level.
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HOUSE AMENDMENT
Bill No. CS/HB 1253
Amendment No. 1 (for drafter's use only)
1 (c) Are not covered by a private insurance policy and
2 are not eligible for coverage through a public health
3 insurance program such as Medicare or Medicaid, or other
4 public health care program, including, but not limited to,
5 Kidcare, and have not been covered at any time during the past
6 6 months.
7 (d) Have applied for health care benefits through an
8 approved health flex plan and agree to make any payments
9 required for participation, including, but not limited to,
10 periodic payments and payments due at the time health care
11 services are provided.
12 (6) RECORDS.--Every health flex plan provider shall
13 maintain reasonable records of its loss, expense, and claims
14 experience and shall make such records reasonably available to
15 enable the agency and the Department of Insurance to monitor
16 and determine the financial viability of the plan, as
17 necessary.
18 (7) NOTICE.--The denial of coverage by the health plan
19 entity shall be accompanied by the specific reasons for
20 denial, nonrenewal, or cancellation. Notice of nonrenewal or
21 cancellation shall be provided at least 45 days in advance of
22 such nonrenewal or cancellation except that 10 days' written
23 notice shall be given for cancellation due to nonpayment of
24 premiums. If the health plan entity fails to give the
25 required notice, the plan shall remain in effect until notice
26 is appropriately given.
27 (8) NONENTITLEMENT.--Coverage under an approved health
28 flex plan is not an entitlement and no cause of action shall
29 arise against the state, local governmental entity, or other
30 political subdivision of this state or the agency for failure
31 to make coverage available to eligible persons under this
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HOUSE AMENDMENT
Bill No. CS/HB 1253
Amendment No. 1 (for drafter's use only)
1 section.
2 (9) CIVIL ACTIONS.--In addition to an administrative
3 action initiated under subsection (4), the agency may seek any
4 remedy provided by law, including, but not limited to, the
5 remedies provided in s. 812.035, Florida Statutes, if the
6 agency finds that a health plan entity has engaged in any act
7 resulting in injury to an enrollee covered by a plan approved
8 under this section.
9 Section 2. Paragraph (m) of subsection (3), paragraphs
10 (a), (d), and (e) of subsection (12), and paragraph (a) of
11 subsection (15) of section 627.6699, Florida Statutes, are
12 amended to read:
13 627.6699 Employee Health Care Access Act.--
14 (3) DEFINITIONS.--As used in this section, the term:
15 (m) "Limited benefit policy or contract" means a
16 policy or contract that provides coverage for each person
17 insured under the policy for a specifically named disease or
18 diseases, a specifically named accident, or a specifically
19 named limited market that fulfills a an experimental or
20 reasonable need by providing more affordable health insurance,
21 such as the small group market.
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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HOUSE AMENDMENT
Bill No. CS/HB 1253
Amendment No. 1 (for drafter's use only)
1 board to submit additional recommendations of individuals for
2 appointment.
3 2. The plans shall comply with all of the requirements
4 of this subsection.
5 3. The plans must be filed with and approved by the
6 department prior to issuance or delivery by any small employer
7 carrier.
8 4. Before October 1, 2001, and in every fourth year
9 thereafter, the commissioner shall appoint a new health
10 benefit plan committee in the manner provided in subparagraph
11 1. to determine if modifications to a plan might be
12 appropriate and to submit recommended modifications to the
13 department for approval. Such determination shall be based
14 upon prevailing industry standards regarding managed care and
15 cost containment provisions and shall be for the purpose of
16 ensuring that the benefit plans offered to small employers on
17 a guaranteed issue basis are consistent with the low-priced to
18 mid-priced benefit plans offered in the large group market.
19 This determination shall be included in a report submitted to
20 the President of the Senate and the Speaker of the House of
21 Representatives annually by October 1. After approval of the
22 revised health benefit plans, if the department determines
23 that modifications to a plan might be appropriate, the
24 commissioner shall appoint a new health benefit plan committee
25 in the manner provided in subparagraph 1. to submit
26 recommended modifications to the department for approval.
27 (d)1. Upon offering coverage under a standard health
28 benefit plan, a basic health benefit plan, or a limited
29 benefit policy or contract for any small employer, the small
30 employer carrier shall disclose in writing to the employer
31 provide such employer group with a written statement that
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HOUSE AMENDMENT
Bill No. CS/HB 1253
Amendment No. 1 (for drafter's use only)
1 contains, at a minimum:
2 a. An explanation of those mandated benefits and
3 providers that are not covered by the policy or contract;
4 a.b. An outline of coverage An explanation of the
5 managed care and cost control features of the policy or
6 contract, along with all appropriate mailing addresses and
7 telephone numbers to be used by insureds in seeking
8 information. or authorization; and
9 b.c. An explanation of The primary and preventive care
10 features of the policy or contract.
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12 Such disclosure statement must be presented in a clear and
13 understandable form and format and must be separate from the
14 policy or certificate or evidence of coverage provided to the
15 employer group.
16 2. Before a small employer carrier issues a standard
17 health benefit plan, a basic health benefit plan, or a limited
18 benefit policy or contract, it must obtain from the
19 prospective policyholder a signed written statement in which
20 the prospective policyholder:
21 a. Certifies as to eligibility for coverage under the
22 standard health benefit plan, basic health benefit plan, or
23 limited benefit policy or contract;
24 c.b. Acknowledges The limited nature of the coverage
25 and an understanding of the managed care and the cost control
26 features of the policy or contract.;
27 c. Acknowledges that if misrepresentations are made
28 regarding eligibility for coverage under a standard health
29 benefit plan, a basic health benefit plan, or a limited
30 benefit policy or contract, the person making such
31 misrepresentations forfeits coverage provided by the policy or
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HOUSE AMENDMENT
Bill No. CS/HB 1253
Amendment No. 1 (for drafter's use only)
1 contract; and
2 2.d. If a limited plan is requested, the prospective
3 policyholder must acknowledge in writing acknowledges that he
4 or she the prospective policyholder had been offered, at the
5 time of application for the insurance policy or contract, the
6 opportunity to purchase any health benefit plan offered by the
7 carrier and that the prospective policyholder had rejected
8 that coverage.
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10 A copy of such written statement shall be provided to the
11 prospective policyholder no later than at the time of delivery
12 of the policy or contract, and the original of such written
13 statement shall be retained in the files of the small employer
14 carrier for the period of time that the policy or contract
15 remains in effect or for 5 years, whichever period is longer.
16 3. Any material statement made by an applicant for
17 coverage under a health benefit plan which falsely certifies
18 as to the applicant's eligibility for coverage serves as the
19 basis for terminating coverage under the policy or contract.
20 3.4. Each marketing communication that is intended to
21 be used in the marketing of a health benefit plan in this
22 state must be submitted for review by the department prior to
23 use and must contain the disclosures stated in this
24 subsection.
25 4. The contract, policy, and certificates evidencing
26 coverage under a limited benefit policy or contract and the
27 application for coverage under such plans must state in not
28 less than 10 point type on the first page in contrasting color
29 the following: "The benefits provided by this health plan are
30 limited and may not cover all of your medical needs. You
31 should carefully review the benefits offered under this health
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HOUSE AMENDMENT
Bill No. CS/HB 1253
Amendment No. 1 (for drafter's use only)
1 plan."
2 (d)(e) A small employer carrier may not use any
3 policy, contract, form, or rate under this section, including
4 applications, enrollment forms, policies, contracts,
5 certificates, evidences of coverage, riders, amendments,
6 endorsements, and disclosure forms, until the insurer has
7 filed it with the department and the department has approved
8 it under ss. 627.410, 627.4106, and 627.411, and 641.31.
9 (15) APPLICABILITY OF OTHER STATE LAWS.--
10 (a) Except as expressly provided in this section, a
11 law requiring coverage for a specific health care service or
12 benefit, or a law requiring reimbursement, utilization, or
13 consideration of a specific category of licensed health care
14 practitioner, does not apply to a standard or basic health
15 benefit plan policy or contract or a limited benefit policy or
16 contract offered or delivered to a small employer unless that
17 law is made expressly applicable to such policies or
18 contracts. A law restricting or limiting deductibles,
19 copayments, or annual or lifetime maximum payments does not
20 apply to a limited benefit policy or contract offered or
21 delivered to a small employer unless such law is made
22 expressly applicable to such policy or contract. A limited
23 benefit policy or contract which is offered or delivered to a
24 small employer may also be offered or delivered to an employer
25 with 51 or more eligible employees. Any covered disease or
26 condition may be treated by any physician, without
27 discrimination, licensed or certified to treat the disease or
28 condition.
29 Section 3. This act shall take effect October 1, 2001.
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HOUSE AMENDMENT
Bill No. CS/HB 1253
Amendment No. 1 (for drafter's use only)
1 ================ T I T L E A M E N D M E N T ===============
2 And the title is amended as follows:
3 On page 1, line 2, through page 2, line 14,
4 remove from the title of the bill: all of said lines,
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6 and insert in lieu thereof:
7 An act relating to health care; making
8 legislative findings and providing legislative
9 intent; providing definitions; providing for a
10 pilot program for health flex plans for certain
11 uninsured persons; providing criteria;
12 exempting approved health flex plans from
13 certain licensing requirements; providing
14 criteria for eligibility to enroll in a health
15 flex plan; requiring health flex plan providers
16 to maintain certain records; providing
17 requirements for denial, nonrenewal, or
18 cancellation of coverage; specifying coverage
19 under an approved health flex plan is not an
20 entitlement; providing for civil actions
21 against health plan entities by the Agency for
22 Health Care Administration under certain
23 circumstances; amending s. 627.6699, F.S.;
24 revising a definition; requiring the Insurance
25 Commissioner to appoint a health benefit plan
26 committee to modify the standard, basic, and
27 limited health benefit plans; revising the
28 disclosure that a carrier must make to a small
29 employer upon offering certain policies;
30 prohibiting small employer carriers from using
31 certain policies, contracts, forms, or rates
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HOUSE AMENDMENT
Bill No. CS/HB 1253
Amendment No. 1 (for drafter's use only)
1 unless filed with and approved by the
2 Department of Insurance pursuant to certain
3 provisions; restricting application of certain
4 laws to limited benefit policies under certain
5 circumstances; authorizing offering or
6 delivering limited benefit policies or
7 contracts to certain employers; providing
8 requirements for benefits in limited benefit
9 policies or contracts for small employers;
10 providing an effective date.
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12 WHEREAS, the Legislature recognizes that the increasing
13 number of uninsured Floridians is due in part to small
14 employers' and their employees' inability to afford
15 comprehensive health insurance coverage, and
16 WHEREAS, the Legislature recognizes the need for small
17 employers and their employees to have the opportunity to
18 choose more affordable and flexible health insurance plans,
19 and
20 WHEREAS, it is the intent of the Legislature that
21 insurers and health maintenance organizations have maximum
22 flexibility in health plan design or in developing a health
23 plan design to complement a medical savings account program
24 established by a small employer for the benefit of its
25 employees, NOW, THEREFORE,
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