SENATE AMENDMENT
Bill No. CS/HB 1253, 2nd Eng.
Amendment No. ___ Barcode 800658
CHAMBER ACTION
Senate House
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11 Senator Latvala moved the following amendment:
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13 Senate Amendment (with title amendment)
14 Delete everything after the enacting clause
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16 and insert:
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18 WHEREAS, the Legislature recognizes that the increasing
19 number of uninsured Floridians is due in part to small
20 employers' and their employees' inability to afford
21 comprehensive health insurance coverage, and
22 WHEREAS, the Legislature recognizes the need for small
23 employers and their employees to have the opportunity to
24 choose more affordable and flexible health insurance plans,
25 and
26 WHEREAS, it is the intent of the Legislature that
27 insurers and health maintenance organizations have maximum
28 flexibility in health plan design or in developing a health
29 plan design to complement a medical savings account program
30 established by a small employer for the benefit of its
31 employees, NOW, THEREFORE,
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SENATE AMENDMENT
Bill No. CS/HB 1253, 2nd Eng.
Amendment No. ___ Barcode 800658
1 Be It Enacted by the Legislature of the State of Florida:
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3 Section 1. Health flex plans.--
4 (1) INTENT.--The Legislature finds that a significant
5 portion of state residents are not able to obtain affordable
6 health insurance coverage. Therefore, it is the intent of the
7 Legislature to expand the availability of health care options
8 for lower-income uninsured state residents by encouraging
9 health insurers, health maintenance organizations, health care
10 provider-sponsored organizations, local governments, health
11 care districts, and other public or private community-based
12 organizations to develop alternative approaches to traditional
13 health insurance which emphasize coverage for basic and
14 preventive health care services. To the maximum extent
15 possible, these options should be coordinated with existing
16 governmental or community-based health services programs in a
17 manner that is consistent with the objectives and requirements
18 of such programs.
19 (2) DEFINITIONS.--As used in this section, the term:
20 (a) "Agency" means the Agency for Health Care
21 Administration.
22 (b) "Approved plan" means a health flex plan approved
23 under subsection (3) which guarantees payment by the health
24 plan entity for specified health care services provided to the
25 enrollee.
26 (c) "Enrollee" means an individual who has been
27 determined eligible for and is receiving health benefits under
28 a health flex plan approved under this section.
29 (d) "Health care coverage" means payment for health
30 care services covered as benefits under an approved plan or
31 which otherwise provides, either directly or through
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SENATE AMENDMENT
Bill No. CS/HB 1253, 2nd Eng.
Amendment No. ___ Barcode 800658
1 arrangements with other persons, covered health care services
2 on a prepaid per capita basis or on a prepaid aggregate
3 fixed-sum basis.
4 (e) "Health plan entity" means a health insurer,
5 health maintenance organization, health care
6 provider-sponsored organization, local government, health care
7 district, or other public or private community-based
8 organization that develops and implements an approved plan and
9 is responsible for financing and paying all claims by
10 enrollees of the plan.
11 (3) PILOT PROGRAM.--The agency and the Department of
12 Insurance shall jointly approve or disapprove health flex
13 plans that provide health care coverage for eligible
14 participants residing in the three areas of the state having
15 the highest number of uninsured residents as determined by the
16 agency. A plan may limit or exclude benefits otherwise
17 required by law for insurers offering coverage in this state,
18 cap the total amount of claims paid in 1 year per enrollee, or
19 limit the number of enrollees covered. The agency and the
20 Department of Insurance shall not approve, or shall withdraw
21 approval of, plans that:
22 (a) Contain any ambiguous, inconsistent, or misleading
23 provisions or any exceptions or conditions that deceptively
24 affect or limit the benefits purported to be assumed in the
25 general coverage provided by the plan;
26 (b) Provide benefits that are unreasonable in relation
27 to the premium charged, contain provisions that are unfair or
28 inequitable or contrary to the public policy of this state,
29 that encourage misrepresentation, or that result in unfair
30 discrimination in sales practices; or
31 (c) Cannot demonstrate that the plan is financially
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SENATE AMENDMENT
Bill No. CS/HB 1253, 2nd Eng.
Amendment No. ___ Barcode 800658
1 sound and that the applicant has the ability to underwrite or
2 finance the benefits provided.
3 (4) LICENSE NOT REQUIRED.--A health flex plan approved
4 under this section is not subject to the licensing
5 requirements of the Florida Insurance Code or chapter 641,
6 Florida Statutes, relating to health maintenance
7 organizations, unless expressly made applicable. However, for
8 the purposes of prohibiting unfair trade practices, health
9 flex plans shall be considered insurance subject to the
10 applicable provisions of part IX of chapter 626, Florida
11 Statutes, except as otherwise provided in this section.
12 (5) ELIGIBILITY.--Eligibility to enroll in an approved
13 health flex plan is limited to Florida residents who:
14 (a) Are 64 years of age or younger;
15 (b) Have a family income equal to or less than 200
16 percent of the federal poverty level;
17 (c) Are not covered by a private insurance policy and
18 are not eligible for coverage through a public health
19 insurance program such as Medicare or Medicaid or another
20 public health care program, including, but not limited to,
21 KidCare; and have not been covered at any time during the
22 preceding 6 months; and
23 (d) Have applied for health care benefits through an
24 approved health flex plan and agree to make any payments
25 required for participation, including, but not limited to,
26 periodic payments or payments due at the time health care
27 services are provided.
28 (6) RECORDS.--Every health plan entity shall maintain
29 reasonable records of its loss, expense, and claims experience
30 and shall make such records reasonably available to enable the
31 agency and the Department of Insurance to monitor and
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SENATE AMENDMENT
Bill No. CS/HB 1253, 2nd Eng.
Amendment No. ___ Barcode 800658
1 determine the financial viability of the plan, as necessary.
2 (7) NOTICE.--The denial of coverage by the health plan
3 entity, or nonrenewal or cancellation of coverage, must be
4 accompanied by the specific reasons for denial, nonrenewal, or
5 cancellation. Notice of nonrenewal or cancellation shall be
6 provided at least 45 days in advance of such nonrenewal or
7 cancellation, except that 10 days' written notice shall be
8 given for cancellation due to nonpayment of premiums. If the
9 health plan entity fails to give the required notice, the plan
10 shall remain in effect until notice is appropriately given.
11 (8) NONENTITLEMENT.--Coverage under an approved health
12 flex plan is not an entitlement, and no cause of action shall
13 arise against the state, a local government entity or other
14 political subdivision of this state, or the agency for failure
15 to make coverage available to eligible persons under this
16 section.
17 (9) CIVIL ACTIONS.--In addition to an administrative
18 action initiated under subsection (4), the agency may seek any
19 remedy provided by law, including, but not limited to, the
20 remedies provided in section 812.035, Florida Statutes, if the
21 agency finds that a health plan entity has engaged in any act
22 resulting in injury to an enrollee covered by a plan approved
23 under this section.
24 Section 2. Subsection (1) and paragraph (a) of
25 subsection (6) of section 627.410, Florida Statutes, are
26 amended, paragraph (f) and (g) are added to subsection (6) of
27 that section, and paragraph (f) is added to subsection (7) of
28 that section, to read:
29 627.410 Filing, approval of forms.--
30 (1) No basic insurance policy or annuity contract
31 form, or application form where written application is
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SENATE AMENDMENT
Bill No. CS/HB 1253, 2nd Eng.
Amendment No. ___ Barcode 800658
1 required and is to be made a part of the policy or contract,
2 or group certificates issued under a master contract delivered
3 in this state, or printed rider or endorsement form or form of
4 renewal certificate, shall be delivered or issued for delivery
5 in this state, unless the form has been filed with the
6 department at its offices in Tallahassee by or in behalf of
7 the insurer which proposes to use such form and has been
8 approved by the department. This provision does not apply to
9 surety bonds or to policies, riders, endorsements, or forms of
10 unique character which are designed for and used with relation
11 to insurance upon a particular subject (other than as to
12 health insurance), or which relate to the manner of
13 distribution of benefits or to the reservation of rights and
14 benefits under life or health insurance policies and are used
15 at the request of the individual policyholder, contract
16 holder, or certificateholder. As to group insurance policies
17 effectuated and delivered outside this state but covering
18 persons resident in this state, the group certificates to be
19 delivered or issued for delivery in this state shall be filed
20 with the department for information purposes only, except that
21 group certificates for health insurance coverage, as described
22 in s. 627.6561(5)(a)2., which require individual underwriting
23 to determine coverage eligibility for an individual or premium
24 rates to be charged to an individual, shall be considered
25 policies issued on an individual basis and are subject to and
26 must comply with the Florida Insurance Code in the same manner
27 as individual health insurance policies issued in this state.
28 (6)(a) An insurer shall not deliver or issue for
29 delivery or renew in this state any health insurance policy
30 form until it has filed with the department a copy of every
31 applicable rating manual, rating schedule, change in rating
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SENATE AMENDMENT
Bill No. CS/HB 1253, 2nd Eng.
Amendment No. ___ Barcode 800658
1 manual, and change in rating schedule; if rating manuals and
2 rating schedules are not applicable, the insurer must file
3 with the department applicable premium rates and any change in
4 applicable premium rates. Changes in rates, rating manuals,
5 and rating schedules for individual health insurance policies
6 shall be filed for approval pursuant to this paragraph. Prior
7 approval shall not be required for an individual health
8 insurance policy rate filing which complies with the
9 requirements of paragraph (6)(f). Nothing in this paragraph
10 shall be construed to interfere with the department's
11 authority to investigate suspected violations of this section
12 or to take necessary corrective action where a violation can
13 be demonstrated. Nothing in this paragraph shall prevent an
14 insurer from filing rates or rate changes for approval or from
15 deeming rate changes approved pursuant to an approved loss
16 ratio guarantee pursuant to subsection (8). This paragraph
17 does not apply to group health insurance policies, effectuated
18 and delivered in this state, insuring groups of 51 or more
19 persons, except for Medicare supplement insurance, long-term
20 care insurance, and any coverage under which the increase in
21 claim costs over the lifetime of the contract due to advancing
22 age or duration is prefunded in the premium.
23 (f) An insurer that files changes in rates, rating
24 manuals or rating schedules, with the department, for
25 individual health policies as described in s.
26 627.6561(5)(a)2., but excluding Medicare supplement policies,
27 according to this paragraph may begin providing required
28 notice to policyholders, and charging corresponding adjusted
29 rates in accordance with s. 627.6043, upon filing provided the
30 insurer certifies that it has met the requirements of
31 subparagraphs 1. through 3. of this paragraph. Filings
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SENATE AMENDMENT
Bill No. CS/HB 1253, 2nd Eng.
Amendment No. ___ Barcode 800658
1 submitted pursuant to this paragraph shall contain the same
2 information and demonstrations and shall meet the same
3 requirements as rate filings submitted for approval under this
4 section, including the requirements of s. 627.411, except as
5 indicated in this paragraph.
6 1. The insurer has complied with annual rate filing
7 requirements then in effect pursuant to subsection (7) since
8 the effective date of this paragraph or for the previous 2
9 years, whichever is less and has filed and implemented
10 actuarially justifiable rate adjustments at least annually
11 during this period. Nothing in this section shall be construed
12 to prevent an insurer from filing rate adjustments more often
13 than annually.
14 2. The insurer has pooled experience for applicable
15 individual health policy forms in accordance with the
16 requirements of subparagraph (6)(e)3. Rate changes used on a
17 form shall not vary by the experience of that form or the
18 health status of covered individuals on that form but must be
19 based on the experience of all forms including rating
20 characteristics as defined in subparagraph 4.
21 3. Rates for the policy form are anticipated to meet a
22 minimum loss ratio of 65 percent over the expected life of the
23 form.
24 4. Rates for all individual health policy forms issued
25 on or after July 1, 2001, shall utilize the same factors for
26 each rating characteristic.
27
28 As used in this paragraph, the term "rating characteristics"
29 means demographic characteristics of individuals, including,
30 but not limited to, geographic area factors, benefit design,
31 smoking status, and health status at issue.
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SENATE AMENDMENT
Bill No. CS/HB 1253, 2nd Eng.
Amendment No. ___ Barcode 800658
1 (g) Subsequent to filing a change of rates for an
2 individual health policy pursuant to paragraph (f), an insurer
3 may be required to furnish additional information to
4 demonstrate compliance with this section. If the department
5 finds that the adjusted rates are not reasonable in relation
6 to premiums charged pursuant to the standards of this section,
7 the department may order appropriate corrective action.
8 (7)
9 (f) Insurers with fewer than 1,000 nationwide
10 policyholders or insured group members or subscribers covered
11 under any form or pooled group of forms with health insurance
12 coverage, as described in s. 627.6561(5)(a)2., excluding
13 Medicare supplement insurance coverage under part VIII, at the
14 time of a rate filing made pursuant to subparagraph (b)1., may
15 file for an annual rate increase limited to medical trend as
16 adopted by the department pursuant to s. 627.411(4). The
17 filing is in lieu of the actuarial memorandum required for a
18 rate filing prescribed by paragraph (6)(b). The filing must
19 include forms adopted by the department and a certification by
20 an officer of the company that the filing includes all similar
21 forms.
22 Section 3. Subsection (9) is added to section
23 627.6515, Florida Statutes, to read:
24 627.6515 Out-of-state groups.--
25 (9) Notwithstanding any other provision of this
26 section, any group health insurance policy or group
27 certificate for health insurance, as described in s.
28 627.6561(5)(a)2., which is issued to a resident of this state
29 and requires individual underwriting to determine coverage
30 eligibility for an individual or premium rates to be charged
31 to an individual shall be considered a policy issued on an
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SENATE AMENDMENT
Bill No. CS/HB 1253, 2nd Eng.
Amendment No. ___ Barcode 800658
1 individual basis and is subject to and must comply with the
2 Florida Insurance Code in the same manner as individual
3 insurance policies issued in this state.
4 Section 4. Section 627.411, Florida Statutes, is
5 amended to read:
6 627.411 Grounds for disapproval.--
7 (1) The department shall disapprove any form filed
8 under s. 627.410, or withdraw any previous approval thereof,
9 only if the form:
10 (a) Is in any respect in violation of, or does not
11 comply with, this code.
12 (b) Contains or incorporates by reference, where such
13 incorporation is otherwise permissible, any inconsistent,
14 ambiguous, or misleading clauses, or exceptions and conditions
15 which deceptively affect the risk purported to be assumed in
16 the general coverage of the contract.
17 (c) Has any title, heading, or other indication of its
18 provisions which is misleading.
19 (d) Is printed or otherwise reproduced in such manner
20 as to render any material provision of the form substantially
21 illegible.
22 (e) Is for health insurance, and:
23 1. Provides benefits that which are unreasonable in
24 relation to the premium charged;,
25 2. Contains provisions that which are unfair or
26 inequitable or contrary to the public policy of this state or
27 that which encourage misrepresentation;, or
28 3. Contains provisions that which apply rating
29 practices that which result in premium escalations that are
30 not viable for the policyholder market or result in unfair
31 discrimination pursuant to s. 626.9541(1)(g)2.; in sales
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SENATE AMENDMENT
Bill No. CS/HB 1253, 2nd Eng.
Amendment No. ___ Barcode 800658
1 practices.
2 4. Results in actuarially justified rate increases on
3 an annual basis:
4 a. Attributed to the insurer reducing the portion of
5 the premium used to pay claims from the loss ratio standard
6 certified in the last actuarial certification filed by the
7 insurer, in excess of the greater of 50 percent of annual
8 medical trend or 5 percent. At its option, the insurer may
9 file for approval of an actuarially justified new business
10 rate schedule for new insureds and a rate increase for
11 existing insureds that is equal to the greater of 150 percent
12 of annual medical trend or 10 percent. Future annual rate
13 increases for existing insureds shall be limited to the
14 greater of 150 percent of the rate increase approved for new
15 insureds or 10 percent until the two rate schedules converge;
16 b. In excess of the greater of 150 percent of annual
17 medical trend or 10 percent and the company did not comply
18 with the annual filing requirements of s. 627.410(7) or
19 department rule for health maintenance organizations pursuant
20 to s. 641.31. At its option the insurer may file for approval
21 of an actuarially justified new business rate schedule for new
22 insureds and a rate increase for existing insureds that is
23 equal to the rate increase allowed by the preceding sentence.
24 Future annual rate increases for existing insureds shall be
25 limited to the greater of 150 percent of the rate increase
26 approved for new insureds or 10 percent until the two rate
27 schedules converge; or
28 c. In excess of the greater of 150 percent of annual
29 medical trend or 10 percent on a form or block of pooled forms
30 in which no form is currently available for sale. This
31 provision does not apply to pre-standardized Medicare
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SENATE AMENDMENT
Bill No. CS/HB 1253, 2nd Eng.
Amendment No. ___ Barcode 800658
1 supplement forms.
2 (f) Excludes coverage for human immunodeficiency virus
3 infection or acquired immune deficiency syndrome or contains
4 limitations in the benefits payable, or in the terms or
5 conditions of such contract, for human immunodeficiency virus
6 infection or acquired immune deficiency syndrome which are
7 different than those which apply to any other sickness or
8 medical condition.
9 (2) In determining whether the benefits are reasonable
10 in relation to the premium charged, the department, in
11 accordance with reasonable actuarial techniques, shall
12 consider:
13 (a) Past loss experience and prospective loss
14 experience within and without this state.
15 (b) Allocation of expenses.
16 (c) Risk and contingency margins, along with
17 justification of such margins.
18 (d) Acquisition costs.
19 (3) If a health insurance rate filing changes the
20 established rate relationships between insureds, the aggregate
21 effect of such change shall be revenue-neutral. The change to
22 the new relationship shall be phased-in over a period not to
23 exceed 3 years as approved by the department. The rate filing
24 may also include increases based on overall experience or
25 annual medical trend, or both, which portions shall not be
26 phased-in pursuant to this paragraph.
27 (4) Individual health insurance policies which are
28 subject to renewability requirements of s. 627.6425 shall be
29 deemed guaranteed renewable for purposes of establishing loss
30 ratio standards and shall comply with the same loss ratio
31 standards as other guaranteed renewable forms.
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SENATE AMENDMENT
Bill No. CS/HB 1253, 2nd Eng.
Amendment No. ___ Barcode 800658
1 (5) In determining medical trend for application of
2 subparagraph (1)(e)4., the department shall semiannually
3 determine medical trend for each health care market, using
4 reasonable actuarial techniques and standards. The trend must
5 be adopted by the department by rule and determined as
6 follows:
7 (a) Trend must be determined separately for medical
8 expense; preferred provider organization; Medicare supplement;
9 health maintenance organization; and other coverage for
10 individual, small group, and large group, where applicable.
11 (b) The department shall survey insurers and health
12 maintenance organizations currently issuing products and
13 representing at least an 80-percent market share based on
14 premiums earned in the state for the most recent calendar year
15 for each of the categories specified in paragraph (a).
16 (c) Trend must be computed as the average annual
17 medical trend approved for the carriers surveyed, giving
18 appropriate weight to each carrier's statewide market share of
19 earned premiums.
20 (d) The annual trend is the annual change in claims
21 cost per unit of exposure. Trend includes the combined effect
22 of medical provider price changes, changes in utilization, new
23 medical procedures, and technology and cost shifting.
24 Section 5. Subsections (4) and (8) of section
25 627.6487, Florida Statutes, are amended to read:
26 627.6487 Guaranteed availability of individual health
27 insurance coverage to eligible individuals.--
28 (4)(a) The health insurance issuer may elect to limit
29 the coverage offered under subsection (1) if the issuer offers
30 at least two different policy forms of health insurance
31 coverage, both of which:
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SENATE AMENDMENT
Bill No. CS/HB 1253, 2nd Eng.
Amendment No. ___ Barcode 800658
1 1. Are designed for, made generally available to,
2 actively marketed to, and enroll both eligible and other
3 individuals by the issuer; and
4 2. Meet the requirement of paragraph (b).
5
6 For purposes of this subsection, policy forms that have
7 different cost-sharing arrangements or different riders are
8 considered to be different policy forms.
9 (b) The requirement of this subsection is met for
10 health insurance coverage policy forms offered by an issuer in
11 the individual market if the issuer offers the basic and
12 standard health benefit plans as established pursuant to s.
13 627.6699(12) or policy forms for individual health insurance
14 coverage with the largest, and next to largest, premium volume
15 of all such policy forms offered by the issuer in this state
16 or applicable marketing or service area, as prescribed in
17 rules adopted by the department, in the individual market in
18 the period involved. To the greatest extent possible, such
19 rules must be consistent with regulations adopted by the
20 United States Department of Health and Human Services.
21 (8) This section does not:
22 (a) Restrict the issuer from applying the same
23 nondiscriminatory underwriting and rating practices that are
24 applied by the issuer to other individuals applying for
25 coverage amount of the premium rates that an issuer may charge
26 an individual for individual health insurance coverage; or
27 (b) Prevent a health insurance issuer that offers
28 individual health insurance coverage from establishing premium
29 discounts or rebates or modifying otherwise applicable
30 copayments or deductibles in return for adherence to programs
31 of health promotion and disease prevention.
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SENATE AMENDMENT
Bill No. CS/HB 1253, 2nd Eng.
Amendment No. ___ Barcode 800658
1 Section 6. Subsection (12) of section 627.6482,
2 Florida Statutes, is amended, and subsections (15) and (16)
3 are added to that section, to read:
4 627.6482 Definitions.--As used in ss.
5 627.648-627.6498, the term:
6 (12) "Premium" means the entire cost of an insurance
7 plan, including the administrative fee, the risk assumption
8 charge, and, in the instance of a minimum premium plan or
9 stop-loss coverage, the incurred claims whether or not such
10 claims are paid directly by the insurer. "Premium" shall not
11 include a health maintenance organization's annual earned
12 premium revenue for Medicare and Medicaid contracts for any
13 assessment due for calendar years 1990 and 1991. For
14 assessments due for calendar year 1992 and subsequent years, A
15 health maintenance organization's annual earned premium
16 revenue for Medicare and Medicaid contracts is subject to
17 assessments unless the department determines that the health
18 maintenance organization has made a reasonable effort to amend
19 its Medicare or Medicaid government contract for 1992 and
20 subsequent years to provide reimbursement for any assessment
21 on Medicare or Medicaid premiums paid by the health
22 maintenance organization and the contract does not provide for
23 such reimbursement.
24 (15) "Federal poverty level" means the most current
25 federal poverty guidelines, as established by the federal
26 Department of Health and Human Services and published in the
27 Federal Register, and in effect on the date of the policy and
28 its annual renewal.
29 (16) "Family income" means the adjusted gross income,
30 as defined in s. 62 of the United States Internal Revenue
31 Code, of all members of a household.
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SENATE AMENDMENT
Bill No. CS/HB 1253, 2nd Eng.
Amendment No. ___ Barcode 800658
1 Section 7. Section 627.6486, Florida Statutes, is
2 amended to read:
3 627.6486 Eligibility.--
4 (1) Except as provided in subsection (2), any person
5 who is a resident of this state and has been a resident of
6 this state for the previous 6 months is shall be eligible for
7 coverage under the plan, including:
8 (a) The insured's spouse.
9 (b) Any dependent unmarried child of the insured, from
10 the moment of birth. Subject to the provisions of ss. s.
11 627.6041 and 627.6562, such coverage shall terminate at the
12 end of the premium period in which the child marries, ceases
13 to be a dependent of the insured, or attains the age of 19,
14 whichever occurs first. However, if the child is a full-time
15 student at an accredited institution of higher learning, the
16 coverage may continue while the child remains unmarried and a
17 full-time student, but not beyond the premium period in which
18 the child reaches age 23.
19 (c) The former spouse of the insured whose coverage
20 would otherwise terminate because of annulment or dissolution
21 of marriage, if the former spouse is dependent upon the
22 insured for financial support. The former spouse shall have
23 continued coverage and shall not be subject to waiting periods
24 because of the change in policyholder status.
25 (2)(a) The board or administrator shall require
26 verification of residency for the preceding 6 months and shall
27 require any additional information or documentation, or
28 statements under oath, when necessary to determine residency
29 upon initial application and for the entire term of the
30 policy. A person may demonstrate his or her residency by
31 maintaining his or her residence in this state for the
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Bill No. CS/HB 1253, 2nd Eng.
Amendment No. ___ Barcode 800658
1 preceding 6 months, purchasing a home that has been occupied
2 by him or her as his or her primary residence for the previous
3 6 months, or having established a domicile in this state
4 pursuant to s. 222.17 for the preceding 6 months.
5 (b) No person who is currently eligible for health
6 care benefits under Florida's Medicaid program is eligible for
7 coverage under the plan unless:
8 1. He or she has an illness or disease which requires
9 supplies or medication which are covered by the association
10 but are not included in the benefits provided under Florida's
11 Medicaid program in any form or manner; and
12 2. He or she is not receiving health care benefits or
13 coverage under Florida's Medicaid program.
14 (c) No person who is covered under the plan and
15 terminates the coverage is again eligible for coverage.
16 (d) No person on whose behalf the plan has paid out
17 the lifetime maximum benefit currently being offered by the
18 association of $500,000 in covered benefits is eligible for
19 coverage under the plan.
20 (e) The coverage of any person who ceases to meet the
21 eligibility requirements of this section may be terminated
22 immediately. If such person again becomes eligible for
23 subsequent coverage under the plan, any previous claims
24 payments shall be applied towards the $500,000 lifetime
25 maximum benefit and any limitation relating to preexisting
26 conditions in effect at the time such person again becomes
27 eligible shall apply to such person. However, no such person
28 may again become eligible for coverage after June 30, 1991.
29 (f) No person is eligible for coverage under the plan
30 unless such person has been rejected by two insurers for
31 coverage substantially similar to the plan coverage and no
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SENATE AMENDMENT
Bill No. CS/HB 1253, 2nd Eng.
Amendment No. ___ Barcode 800658
1 insurer has been found through the market assistance plan
2 pursuant to s. 627.6484 that is willing to accept the
3 application. As used in this paragraph, "rejection" includes
4 an offer of coverage with a material underwriting restriction
5 or an offer of coverage at a rate greater than the association
6 plan rate.
7 (g) No person is eligible for coverage under the plan
8 if such person has, or is eligible for, on the date of issue
9 of coverage under the plan, substantially similar coverage
10 under another contract or policy, unless such coverage is
11 provided pursuant to the Consolidated Omnibus Budget
12 Reconciliation Act of 1985, Pub. L. No. 99-272, 100 Stat. 82
13 (1986) (COBRA), as amended, or such coverage is provided
14 pursuant to s. 627.6692 and such coverage is scheduled to end
15 at a time certain and the person meets all other requirements
16 of eligibility. Coverage provided by the association shall be
17 secondary to any coverage provided by an insurer pursuant to
18 COBRA or pursuant to s. 627.6692.
19 (h) A person is ineligible for coverage under the plan
20 if such person is currently eligible for health care benefits
21 under the Medicare program, except for a person who is insured
22 by the Florida Comprehensive Health Association and enrolled
23 under Medicare on July 1, 2001. All eligible persons who are
24 classified as high-risk individuals pursuant to s.
25 627.6498(4)(a)4. shall, upon application or renewal, agree to
26 be placed in a case management system when it is determined by
27 the board and the plan case manager that such system will be
28 cost-effective and provide quality care to the individual.
29 (i) A person is ineligible for coverage under the plan
30 if such person's premiums are paid for or reimbursed under any
31 government-sponsored program or by any government agency or
18
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Bill No. CS/HB 1253, 2nd Eng.
Amendment No. ___ Barcode 800658
1 health care provider.
2 (j) An eligible individual, as defined in s. 627.6487,
3 and his or her dependents, as described in subsection (1), are
4 automatically eligible for coverage in the association unless
5 the association has ceased accepting new enrollees under s.
6 627.6488. If the association has ceased accepting new
7 enrollees, the eligible individual is subject to the coverage
8 rights set forth in s. 627.6487.
9 (3) A person's coverage ceases:
10 (a) On the date a person is no longer a resident of
11 this state;
12 (b) On the date a person requests coverage to end;
13 (c) Upon the date of death of the covered person;
14 (d) On the date state law requires cancellation of the
15 policy; or
16 (e) Sixty days after the person receives notice from
17 the association making any inquiry concerning the person's
18 eligibility or place or residence to which the person does not
19 reply.
20 (4) All eligible persons must, upon application or
21 renewal, agree to be placed in a case-management system when
22 the association and case manager find that such system will be
23 cost-effective and provide quality care to the individual.
24 (5) Except for persons who are insured by the
25 association on December 31, 2001, and who renew such coverage,
26 persons may apply for coverage beginning January 1, 2002, and
27 coverage for such persons shall begin on or after April 1,
28 2002, as determined by the board pursuant to s.
29 627.6488(4)(n).
30 Section 8. Subsection (3) of section 627.6487, Florida
31 Statutes, is amended to read:
19
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SENATE AMENDMENT
Bill No. CS/HB 1253, 2nd Eng.
Amendment No. ___ Barcode 800658
1 627.6487 Guaranteed availability of individual health
2 insurance coverage to eligible individuals.--
3 (3) For the purposes of this section, the term
4 "eligible individual" means an individual:
5 (a)1. For whom, as of the date on which the individual
6 seeks coverage under this section, the aggregate of the
7 periods of creditable coverage, as defined in s. 627.6561(5)
8 and (6), is 18 or more months; and
9 2.a. Whose most recent prior creditable coverage was
10 under a group health plan, governmental plan, or church plan,
11 or health insurance coverage offered in connection with any
12 such plan; or
13 b. Whose most recent prior creditable coverage was
14 under an individual plan issued in this state by a health
15 insurer or health maintenance organization, which coverage is
16 terminated due to the insurer or health maintenance
17 organization becoming insolvent or discontinuing the offering
18 of all individual coverage in the State of Florida, or due to
19 the insured no longer living in the service area in the State
20 of Florida of the insurer or health maintenance organization
21 that provides coverage through a network plan in the State of
22 Florida;
23 (b) Who is not eligible for coverage under:
24 1. A group health plan, as defined in s. 2791 of the
25 Public Health Service Act;
26 2. A conversion policy or contract issued by an
27 authorized insurer or health maintenance organization under s.
28 627.6675 or s. 641.3921, respectively, offered to an
29 individual who is no longer eligible for coverage under either
30 an insured or self-insured employer plan;
31 3. Part A or part B of Title XVIII of the Social
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SENATE AMENDMENT
Bill No. CS/HB 1253, 2nd Eng.
Amendment No. ___ Barcode 800658
1 Security Act; or
2 4. A state plan under Title XIX of such act, or any
3 successor program, and does not have other health insurance
4 coverage; or
5 5. The Florida Comprehensive Health Association, if
6 the association is accepting and issuing coverage to new
7 enrollees, provided that the 63-day period specified in s.
8 627.6561(6) shall be tolled from the time the association
9 receives an application from an individual until the
10 association notifies the individual that it is not accepting
11 and issuing coverage to that individual;
12 (c) With respect to whom the most recent coverage
13 within the coverage period described in paragraph (a) was not
14 terminated based on a factor described in s. 627.6571(2)(a) or
15 (b), relating to nonpayment of premiums or fraud, unless such
16 nonpayment of premiums or fraud was due to acts of an employer
17 or person other than the individual;
18 (d) Who, having been offered the option of
19 continuation coverage under a COBRA continuation provision or
20 under s. 627.6692, elected such coverage; and
21 (e) Who, if the individual elected such continuation
22 provision, has exhausted such continuation coverage under such
23 provision or program.
24 Section 9. Section 627.6488, Florida Statutes, is
25 amended to read:
26 627.6488 Florida Comprehensive Health Association.--
27 (1) There is created a nonprofit legal entity to be
28 known as the "Florida Comprehensive Health Association." All
29 insurers, as a condition of doing business, shall be members
30 of the association.
31 (2)(a) The association shall operate subject to the
21
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SENATE AMENDMENT
Bill No. CS/HB 1253, 2nd Eng.
Amendment No. ___ Barcode 800658
1 supervision and approval of a five-member three-member board
2 of directors consisting of the Insurance Commissioner, or his
3 or her designee, who shall serve as chairperson of the board,
4 and four additional members who must be state residents. At
5 least one member must be a representative of an authorized
6 health insurer or health maintenance organization authorized
7 to transact business in this state. The board of directors
8 shall be appointed by the Insurance Commissioner as follows:
9 1. The chair of the board shall be the Insurance
10 Commissioner or his or her designee.
11 2. One representative of policyholders who is not
12 associated with the medical profession, a hospital, or an
13 insurer.
14 3. One representative of insurers.
15
16 The administrator or his or her affiliate shall not be a
17 member of the board. Any board member appointed by the
18 commissioner may be removed and replaced by him or her at any
19 time without cause.
20 (b) All board members, including the chair, shall be
21 appointed to serve for staggered 3-year terms beginning on a
22 date as established in the plan of operation.
23 (c) The board of directors may shall have the power to
24 employ or retain such persons as are necessary to perform the
25 administrative and financial transactions and responsibilities
26 of the association and to perform other necessary and proper
27 functions not prohibited by law. Employees of the association
28 shall be reimbursed as provided in s. 112.061 from moneys of
29 the association for expenses incurred in carrying out their
30 responsibilities under this act.
31 (d) Board members may be reimbursed as provided in s.
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SENATE AMENDMENT
Bill No. CS/HB 1253, 2nd Eng.
Amendment No. ___ Barcode 800658
1 112.061 from moneys of the association for actual and
2 necessary expenses incurred by them as members in carrying out
3 their responsibilities under the Florida Comprehensive Health
4 Association Act, but may not otherwise be compensated for
5 their services.
6 (e) There shall be no liability on the part of, and no
7 cause of action of any nature shall arise against, any member
8 insurer, or its agents or employees, agents or employees of
9 the association, members of the board of directors of the
10 association, or the departmental representatives for any act
11 or omission taken by them in the performance of their powers
12 and duties under this act, unless such act or omission by such
13 person is in intentional disregard of the rights of the
14 claimant.
15 (f) Meetings of the board are subject to s. 286.011.
16 (3) The association shall adopt a plan pursuant to
17 this act and submit its articles, bylaws, and operating rules
18 to the department for approval. If the association fails to
19 adopt such plan and suitable articles, bylaws, and operating
20 rules within 180 days after the appointment of the board, the
21 department shall adopt rules to effectuate the provisions of
22 this act; and such rules shall remain in effect until
23 superseded by a plan and articles, bylaws, and operating rules
24 submitted by the association and approved by the department.
25 Such plan shall be reviewed, revised as necessary, and
26 annually submitted to the department for approval.
27 (4) The association shall:
28 (a) Establish administrative and accounting procedures
29 and internal controls for the operation of the association and
30 provide for an annual financial audit of the association by an
31 independent certified public accountant licensed pursuant to
23
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SENATE AMENDMENT
Bill No. CS/HB 1253, 2nd Eng.
Amendment No. ___ Barcode 800658
1 chapter 473.
2 (b) Establish procedures under which applicants and
3 participants in the plan may have grievances reviewed by an
4 impartial body and reported to the board. Individuals
5 receiving care through the association under contract from a
6 health maintenance organization must follow the grievance
7 procedures established in ss. 408.7056 and 641.31(5).
8 (c) Select an administrator in accordance with s.
9 627.649.
10 (d) Collect assessments from all insurers to provide
11 for operating losses incurred or estimated to be incurred
12 during the period for which the assessment is made. The level
13 of payments shall be established by the board, as formulated
14 in s. 627.6492(1). Annual assessment of the insurers for each
15 calendar year shall occur as soon thereafter as the operating
16 results of the plan for the calendar year and the earned
17 premiums of insurers being assessed for that year are known.
18 Annual assessments are due and payable within 30 days of
19 receipt of the assessment notice by the insurer.
20 (e) Require that all policy forms issued by the
21 association conform to standard forms developed by the
22 association. The forms shall be approved by the department.
23 (f) Develop and implement a program to publicize the
24 existence of the plan, the eligibility requirements for the
25 plan, and the procedures for enrollment in the plan and to
26 maintain public awareness of the plan.
27 (g) Design and employ cost containment measures and
28 requirements which may include preadmission certification,
29 home health care, hospice care, negotiated purchase of medical
30 and pharmaceutical supplies, and individual case management.
31 (h) Contract with preferred provider organizations and
24
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SENATE AMENDMENT
Bill No. CS/HB 1253, 2nd Eng.
Amendment No. ___ Barcode 800658
1 health maintenance organizations giving due consideration to
2 the preferred provider organizations and health maintenance
3 organizations which have contracted with the state group
4 health insurance program pursuant to s. 110.123. If
5 cost-effective and available in the county where the
6 policyholder resides, the board, upon application or renewal
7 of a policy, shall place a high-risk individual, as
8 established under s. 627.6498(4)(a)4., with the plan case
9 manager who shall determine the most cost-effective quality
10 care system or health care provider and shall place the
11 individual in such system or with such health care provider.
12 If cost-effective and available in the county where the
13 policyholder resides, the board, with the consent of the
14 policyholder, may place a low-risk or medium-risk individual,
15 as established under s. 627.6498(4)(a)4., with the plan case
16 manager who may determine the most cost-effective quality care
17 system or health care provider and shall place the individual
18 in such system or with such health care provider. Prior to and
19 during the implementation of case management, the plan case
20 manager shall obtain input from the policyholder, parent, or
21 guardian.
22 (h)(i) Make a report to the Governor, the President of
23 the Senate, the Speaker of the House of Representatives, and
24 the Minority Leaders of the Senate and the House of
25 Representatives not later than March 1 October 1 of each year.
26 The report shall summarize the activities of the plan for the
27 prior fiscal 12-month period ending July 1 of that year,
28 including then-current data and estimates as to net written
29 and earned premiums, the expense of administration, and the
30 paid and incurred losses for the year. The report shall also
31 include analysis and recommendations for legislative changes
25
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SENATE AMENDMENT
Bill No. CS/HB 1253, 2nd Eng.
Amendment No. ___ Barcode 800658
1 regarding utilization review, quality assurance, an evaluation
2 of the administrator of the plan, access to cost-effective
3 health care, and cost containment/case management policy and
4 recommendations concerning the opening of enrollment to new
5 entrants as of July 1, 1992.
6 (i)(j) Make a report to the Governor, the Insurance
7 Commissioner, the President of the Senate, the Speaker of the
8 House of Representatives, and the Minority Leaders of the
9 Senate and House of Representatives, not later than 45 days
10 after the close of each calendar quarter, which includes, for
11 the prior quarter, current data and estimates of net written
12 and earned premiums, the expenses of administration, and the
13 paid and incurred losses. The report shall identify any
14 statutorily mandated program that has not been fully
15 implemented by the board.
16 (j)(k) To facilitate preparation of assessments and
17 for other purposes, the board shall engage an independent
18 certified public account licensed pursuant to chapter 473 to
19 conduct an annual financial audit of the association direct
20 preparation of annual audited financial statements for each
21 calendar year as soon as feasible following the conclusion of
22 that calendar year, and shall, within 30 days after the
23 issuance rendition of such statements, file with the
24 department the annual report containing such information as
25 required by the department to be filed on March 1 of each
26 year.
27 (k)(l) Employ a plan case manager or managers to
28 supervise and manage the medical care or coordinate the
29 supervision and management of the medical care, with the
30 administrator, of specified individuals. The plan case
31 manager, with the approval of the board, shall have final
26
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SENATE AMENDMENT
Bill No. CS/HB 1253, 2nd Eng.
Amendment No. ___ Barcode 800658
1 approval over the case management for any specific individual.
2 If cost-effective and available in the county where the
3 policyholder resides, the association, upon application or
4 renewal of a policy, may place an individual with the plan
5 case manager, who shall determine the most cost-effective
6 quality care system or health care provider and shall place
7 the individual in such system or with such health care
8 provider. Prior to and during the implementation of case
9 management, the plan case manager shall obtain input from the
10 policyholder, parent or guardian, and the health care
11 providers.
12 (l) Administer the association in a fiscally
13 responsible manner that ensures that its expenditures are
14 reasonable in relation to the services provided and that the
15 financial resources of the association are adequate to meet
16 its obligations.
17 (m) At least annually, but no more than quarterly,
18 evaluate or cause to be evaluated the actuarial soundness of
19 the association. The association shall contract with an
20 actuary to evaluate the pool of insureds in the association
21 and monitor the financial condition of the association. The
22 actuary shall determine the feasibility of enrolling new
23 members in the association, which must be based on the
24 projected revenues and expenses of the association.
25 (n) Restrict at any time the number of participants in
26 the association based on a determination by the board that the
27 revenues will be inadequate to fund new participants. However,
28 any person denied participation solely on the basis of such
29 restriction must be granted priority for participation in the
30 succeeding period in which the association is reopened for
31 participants. Effective April 1, 2002, the association may
27
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SENATE AMENDMENT
Bill No. CS/HB 1253, 2nd Eng.
Amendment No. ___ Barcode 800658
1 provide coverage for up to 500 persons for the period ending
2 December 31, 2002. On or after January 1, 2003, the
3 association may enroll an additional 1,500 persons. At no time
4 may the association provide coverage for more than 2,000
5 persons. Except as provided in s. 627.6486(2)(j), applications
6 for enrollment must be processed on a first-in, first-out
7 basis.
8 (o) Establish procedures to maintain separate accounts
9 and recordkeeping for policyholders prior to January 1, 2002,
10 and policyholders issued coverage on and after January 1,
11 2002.
12 (p) Appoint an executive director to serve as the
13 chief administrative and operational officer of the
14 association and operate within the specifications of the plan
15 of operation and perform other duties assigned to him or her
16 by the board.
17 (5) The association may:
18 (a) Exercise powers granted to insurers under the laws
19 of this state.
20 (b) Sue or be sued.
21 (c) In addition to imposing annual assessments under
22 paragraph (4)(d), levy interim assessments against insurers to
23 ensure the financial ability of the plan to cover claims
24 expenses and administrative expenses paid or estimated to be
25 paid in the operation of the plan for a calendar year prior to
26 the association's anticipated receipt of annual assessments
27 for that calendar year. Any interim assessment shall be due
28 and payable within 30 days after of receipt by an insurer of
29 an interim assessment notice. Interim assessment payments
30 shall be credited against the insurer's annual assessment.
31 Such assessments may be levied only for costs and expenses
28
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SENATE AMENDMENT
Bill No. CS/HB 1253, 2nd Eng.
Amendment No. ___ Barcode 800658
1 associated with policyholders insured with the association
2 prior to January 1, 2002.
3 (d) Prepare or contract for a performance audit of the
4 administrator of the association.
5 (e) Appear in its own behalf before boards,
6 commissions, or other governmental agencies.
7 (f) Solicit and accept gifts, grants, loans, and other
8 aid from any source or participate in any way in any
9 government program to carry out the purposes of the Florida
10 Comprehensive Health Association Act.
11 (g) Require and collect administrative fees and
12 charges in connection with any transaction and impose
13 reasonable penalties, including default, for delinquent
14 payments or for entering into the association on a fraudulent
15 basis.
16 (h) Procure insurance against any loss in connection
17 with the property, assets, and activities of the association
18 or the board.
19 (i) Contract for necessary goods and services; employ
20 necessary personnel; and engage the services of private
21 consultants, actuaries, managers, legal counsel, and
22 independent certified public accountants for administrative or
23 technical assistance.
24 (6) The department shall examine and investigate the
25 association in the manner provided in part II of chapter 624.
26 Section 10. Paragraph (b) of subsection (3) of section
27 627.649, Florida Statutes, is amended to read:
28 627.649 Administrator.--
29 (3) The administrator shall:
30 (b) Pay an agent's referral fee as established by the
31 board to each insurance agent who refers an applicant to the
29
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SENATE AMENDMENT
Bill No. CS/HB 1253, 2nd Eng.
Amendment No. ___ Barcode 800658
1 plan, if the applicant's application is accepted. The selling
2 or marketing of plans shall not be limited to the
3 administrator or its agents. Any agent must be licensed by the
4 department to sell health insurance in this state. The
5 referral fees shall be paid by the administrator from moneys
6 received as premiums for the plan.
7 Section 11. Section 627.6492, Florida Statutes, is
8 amended to read:
9 627.6492 Participation of insurers.--
10 (1)(a) As a condition of doing business in this state
11 an insurer shall pay an assessment to the board, in the amount
12 prescribed by this section. Subsections (1), (2), and (3)
13 apply only to the costs and expenses associated with
14 policyholders insured with the association prior to January 1,
15 2002, including renewal of coverage for such policyholders
16 after that date. For operating losses incurred in any
17 calendar year on July 1, 1991, and thereafter, each insurer
18 shall annually be assessed by the board in the following
19 calendar year a portion of such incurred operating losses of
20 the plan; such portion shall be determined by multiplying such
21 operating losses by a fraction, the numerator of which equals
22 the insurer's earned premium pertaining to direct writings of
23 health insurance in the state during the calendar year
24 preceding that for which the assessment is levied, and the
25 denominator of which equals the total of all such premiums
26 earned by participating insurers in the state during such
27 calendar year.
28 (b) For operating losses incurred from July 1, 1991,
29 through December 31, 1991, the total of all assessments upon a
30 participating insurer shall not exceed .375 percent of such
31 insurer's health insurance premiums earned in this state
30
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SENATE AMENDMENT
Bill No. CS/HB 1253, 2nd Eng.
Amendment No. ___ Barcode 800658
1 during 1990. For operating losses incurred in 1992 and
2 thereafter, The total of all assessments upon a participating
3 insurer shall not exceed 1 percent of such insurer's health
4 insurance premium earned in this state during the calendar
5 year preceding the year for which the assessments were levied.
6 (c) For operating losses incurred from October 1,
7 1990, through June 30, 1991, the board shall assess each
8 insurer in the amount and manner prescribed by chapter 90-334,
9 Laws of Florida. The maximum assessment against an insurer, as
10 provided in such act, shall apply separately to the claims
11 incurred in 1990 (October 1 through December 31) and the
12 claims incurred in 1991 (January 1 through June 30). For
13 operating losses incurred on January 1, 1991, through June 30,
14 1991, the maximum assessment against an insurer shall be
15 one-half of the amount of the maximum assessment specified for
16 such insurer in former s. 627.6492(1)(b), 1990 Supplement, as
17 amended by chapter 90-334, Laws of Florida.
18 (c)(d) All rights, title, and interest in the
19 assessment funds collected shall vest in this state. However,
20 all of such funds and interest earned shall be used by the
21 association to pay claims and administrative expenses.
22 (2) If assessments and other receipts by the
23 association, board, or administrator exceed the actual losses
24 and administrative expenses of the plan, the excess shall be
25 held at interest and used by the board to offset future
26 losses. As used in this subsection, the term "future losses"
27 includes reserves for claims incurred but not reported.
28 (3) Each insurer's assessment shall be determined
29 annually by the association based on annual statements and
30 other reports deemed necessary by the association and filed
31 with it by the insurer. Any deficit incurred under the plan
31
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SENATE AMENDMENT
Bill No. CS/HB 1253, 2nd Eng.
Amendment No. ___ Barcode 800658
1 shall be recouped by assessments against participating
2 insurers by the board in the manner provided in subsection
3 (1); and the insurers may recover the assessment in the normal
4 course of their respective businesses without time limitation.
5 (4)(a) The costs and expenses of the association
6 related to persons whose coverage begins after January 1,
7 2002, shall be funded by appropriations provided by law.
8 Section 12. Section 627.6498, Florida Statutes, is
9 amended to read:
10 627.6498 Minimum benefits coverage; exclusions;
11 premiums; deductibles.--
12 (1) COVERAGE OFFERED.--
13 (a) The plan shall offer in an annually a semiannually
14 renewable policy the coverage specified in this section for
15 each eligible person. For applications accepted on or after
16 June 7, 1991, but before July 1, 1991, coverage shall be
17 effective on July 1, 1991, and shall be renewable on January
18 1, 1992, and every 6 months thereafter. Policies in existence
19 on June 7, 1991, shall, upon renewal, be for a term of less
20 than 6 months that terminates and becomes subject to
21 subsequent renewal on the next succeeding January 1 or July 1,
22 whichever is sooner.
23 (b) If an eligible person is also eligible for
24 Medicare coverage, the plan shall not pay or reimburse any
25 person for expenses paid by Medicare.
26 (c) Any person whose health insurance coverage is
27 involuntarily terminated for any reason other than nonpayment
28 of premium may apply for coverage under the plan. If such
29 coverage is applied for within 60 days after the involuntary
30 termination and if premiums are paid for the entire period of
31 coverage, the effective date of the coverage shall be the date
32
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SENATE AMENDMENT
Bill No. CS/HB 1253, 2nd Eng.
Amendment No. ___ Barcode 800658
1 of termination of the previous coverage.
2 (b)(d) The plan shall provide that, upon the death or
3 divorce of the individual in whose name the contract was
4 issued, every other person then covered in the contract may
5 elect within 60 days to continue under the same or a different
6 contract.
7 (c)(e) No coverage provided to a person who is
8 eligible for Medicare benefits shall be issued as a Medicare
9 supplement policy as defined in s. 627.672.
10 (2) BENEFITS.--
11 (a) The plan must offer coverage to every eligible
12 person subject to limitations set by the association. The
13 coverage offered must pay an eligible person's covered
14 expenses, subject to limits on the deductible and coinsurance
15 payments authorized under subsection (4). The lifetime
16 benefits limit for such coverage shall be $500,000. However,
17 policyholders of association policies issued prior to 1992 are
18 entitled to continued coverage at the benefit level
19 established prior to January 1, 2002. Only the premium,
20 deductible, and coinsurance amounts may be modified as
21 determined necessary by the board. The plan shall offer major
22 medical expense coverage similar to that provided by the state
23 group health insurance program as defined in s. 110.123 except
24 as specified in subsection (3) to every eligible person who is
25 not eligible for Medicare. Major medical expense coverage
26 offered under the plan shall pay an eligible person's covered
27 expenses, subject to limits on the deductible and coinsurance
28 payments authorized under subsection (4), up to a lifetime
29 limit of $500,000 per covered individual. The maximum limit
30 under this paragraph shall not be altered by the board, and no
31 actuarially equivalent benefit may be substituted by the
33
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SENATE AMENDMENT
Bill No. CS/HB 1253, 2nd Eng.
Amendment No. ___ Barcode 800658
1 board.
2 (b) The plan shall provide that any policy issued to a
3 person eligible for Medicare shall be separately rated to
4 reflect differences in experience reasonably expected to occur
5 as a result of Medicare payments.
6 (3) COVERED EXPENSES.--
7 (a) The board shall establish the coverage to be
8 issued by the association.
9 (b) If the coverage is being issued to an eligible
10 individual as defined in s. 627.6487, the individual shall be
11 offered, at the option of the individual, the basic and the
12 standard health benefit plan as established in s. 627.6699.
13 The coverage to be issued by the association shall be
14 patterned after the state group health insurance program as
15 defined in s. 110.123, including its benefits, exclusions, and
16 other limitations, except as otherwise provided in this act.
17 The plan may cover the cost of experimental drugs which have
18 been approved for use by the Food and Drug Administration on
19 an experimental basis if the cost is less than the usual and
20 customary treatment. Such coverage shall only apply to those
21 insureds who are in the case management system upon the
22 approval of the insured, the case manager, and the board.
23 (4) PREMIUMS AND, DEDUCTIBLES, AND COINSURANCE.--
24 (a) The plan shall provide for annual deductibles for
25 major medical expense coverage in the amount of $1,000 or any
26 higher amounts proposed by the board and approved by the
27 department, plus the benefits payable under any other type of
28 insurance coverage or workers' compensation. The schedule of
29 premiums and deductibles shall be established by the board
30 association. With regard to any preferred provider arrangement
31 utilized by the association, the deductibles provided in this
34
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SENATE AMENDMENT
Bill No. CS/HB 1253, 2nd Eng.
Amendment No. ___ Barcode 800658
1 paragraph shall be the minimum deductibles applicable to the
2 preferred providers and higher deductibles, as approved by the
3 department, may be applied to providers who are not preferred
4 providers.
5 1. Separate schedules of premium rates based on age
6 may apply for individual risks.
7 2. Rates are subject to approval by the department
8 pursuant to ss. 627.410 and 627.411, except as provided by
9 this section. The board shall revise premium schedules
10 annually, beginning January 2002.
11 3. Standard risk rates for coverages issued by the
12 association shall be established by the department, pursuant
13 to s. 627.6675(3).
14 3.4. The board shall establish three premium schedules
15 based upon an individual's family income:
16 a. Schedule A is applicable to an individual whose
17 family income exceeds the allowable amount for determining
18 eligibility under the Medicaid program, up to and including
19 200 percent of the Federal Poverty Level. Premiums for a
20 person under this schedule may not exceed 150 percent of the
21 standard risk rate.
22 b. Schedule B is applicable to an individual whose
23 family income exceeds 200 percent but is less than 300 percent
24 of the Federal Poverty Level. Premiums for a person under this
25 schedule may not exceed 250 percent of the standard risk rate.
26 c. Schedule C is applicable to an individual whose
27 family income is equal to or greater than 300 percent of the
28 Federal Poverty Level. Premiums for a person under this
29 schedule may not exceed 300 percent of the standard risk rate.
30 establish separate premium schedules for low-risk individuals,
31 medium-risk individuals, and high-risk individuals and shall
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SENATE AMENDMENT
Bill No. CS/HB 1253, 2nd Eng.
Amendment No. ___ Barcode 800658
1 revise premium schedules annually beginning January 1999.
2 4. The standard risk rate shall be determined by the
3 department pursuant to s. 627.6675(3). The rate shall be
4 adjusted for benefit differences. No rate shall exceed 200
5 percent of the standard risk rate for low-risk individuals,
6 225 percent of the standard risk rate for medium-risk
7 individuals, or 250 percent of the standard risk rate for
8 high-risk individuals. For the purpose of determining what
9 constitutes a low-risk individual, medium-risk individual, or
10 high-risk individual, the board shall consider the anticipated
11 claims payment for individuals based upon an individual's
12 health condition.
13 (b) If the covered costs incurred by the eligible
14 person exceed the deductible for major medical expense
15 coverage selected by the person in a policy year, the plan
16 shall pay in the following manner:
17 1. For individuals placed under case management, the
18 plan shall pay 90 percent of the additional covered costs
19 incurred by the person during the policy year for the first
20 $10,000, after which the plan shall pay 100 percent of the
21 covered costs incurred by the person during the policy year.
22 2. For individuals utilizing the preferred provider
23 network, the plan shall pay 80 percent of the additional
24 covered costs incurred by the person during the policy year
25 for the first $10,000, after which the plan shall pay 90
26 percent of covered costs incurred by the person during the
27 policy year.
28 3. If the person does not utilize either the case
29 management system or the preferred provider network, the plan
30 shall pay 60 percent of the additional covered costs incurred
31 by the person for the first $10,000, after which the plan
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SENATE AMENDMENT
Bill No. CS/HB 1253, 2nd Eng.
Amendment No. ___ Barcode 800658
1 shall pay 70 percent of the additional covered costs incurred
2 by the person during the policy year.
3 (5) PREEXISTING CONDITIONS.--An association policy
4 shall may contain provisions under which coverage is excluded
5 during a period of 12 months following the effective date of
6 coverage with respect to a given covered individual for any
7 preexisting condition, as long as:
8 (a) The condition manifested itself within a period of
9 6 months before the effective date of coverage; or
10 (b) Medical advice or treatment was recommended or
11 received within a period of 6 months before the effective date
12 of coverage.
13
14 This subsection does not apply to an eligible individual as
15 defined in s. 627.6487.
16 (6) OTHER SOURCES PRIMARY.--
17 (a) No amounts paid or payable by Medicare or any
18 other governmental program or any other insurance, or
19 self-insurance maintained in lieu of otherwise statutorily
20 required insurance, may be made or recognized as claims under
21 such policy or be recognized as or towards satisfaction of
22 applicable deductibles or out-of-pocket maximums or to reduce
23 the limits of benefits available.
24 (b) The association has a cause of action against a
25 participant for any benefits paid to the participant which
26 should not have been claimed or recognized as claims because
27 of the provisions of this subsection or because otherwise not
28 covered.
29 (7) NONENTITLEMENT.--The Florida Comprehensive Health
30 Association Act does not provide an individual with an
31 entitlement to health care services or health insurance. A
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SENATE AMENDMENT
Bill No. CS/HB 1253, 2nd Eng.
Amendment No. ___ Barcode 800658
1 cause of action does not arise against the state, the board,
2 or the association for failure to make health services or
3 health insurance available under the Florida Comprehensive
4 Health Association Act.
5 Section 13. The Legislature finds that the provisions
6 of this act fulfill an important state interest.
7 Section 14. The amendments in this act to section
8 627.6487(3), Florida Statutes, shall not take effect unless
9 the Health Care Financing Administration of the U.S.
10 Department of Health and Human Services approves this act as
11 providing an acceptable alternative mechanism, as provided in
12 the Public Health Service Act.
13 Section 15. Effective January 1, 2002, section
14 627.6484, Florida Statutes, is repealed.
15 Section 16. Subsection (9) is added to section
16 627.6515, Florida Statutes, to read:
17 627.6515 Out-of-state groups.--
18 (9) Notwithstanding any other provision of this
19 section, any group health insurance policy or group
20 certificate for health insurance, as described in s.
21 627.6561(5)(a)2., which is issued to a resident of this state
22 and requires individual underwriting to determine coverage
23 eligibility for an individual or premium rates to be charged
24 to an individual shall be considered a policy issued on an
25 individual basis and is subject to and must comply with the
26 Florida Insurance Code in the same manner as individual
27 insurance policies issued in this state.
28 Section 17. Paragraphs (i), (m), and (n) of subsection
29 (3), paragraph (b) of subsection (6), paragraphs (a), (d), and
30 (e) of subsection (12), and paragraph (a) of subsection (15)
31 of section 627.6699, Florida Statutes, are amended to read:
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Bill No. CS/HB 1253, 2nd Eng.
Amendment No. ___ Barcode 800658
1 627.6699 Employee Health Care Access Act.--
2 (3) DEFINITIONS.--As used in this section, the term:
3 (i) "Established geographic area" means the county or
4 counties, or any portion of a county or counties, within which
5 the carrier provides or arranges for health care services to
6 be available to its insureds, members, or subscribers.
7 (m) "Limited benefit policy or contract" means a
8 policy or contract that provides coverage for each person
9 insured under the policy for a specifically named disease or
10 diseases or, a specifically named accident, or a specifically
11 named limited market that fulfills a an experimental or
12 reasonable need by providing more affordable health insurance,
13 such as the small group market.
14 (n) "Modified community rating" means a method used to
15 develop carrier premiums which spreads financial risk across a
16 large population; allows the use of separate rating factors
17 for age, gender, family composition, tobacco usage, and
18 geographic area as determined under paragraph (5)(j); and
19 allows adjustments for: claims experience, health status, or
20 credits based on the duration that the of coverage has been in
21 force as permitted under subparagraph (6)(b)6. subparagraph
22 (6)(b)5.; and administrative and acquisition expenses as
23 permitted under subparagraph (6)(b)5. A carrier may separate
24 the experience of small employer groups with less than two
25 eligible employees from the experience of small employer
26 groups with two through 50 eligible employees.
27 (6) RESTRICTIONS RELATING TO PREMIUM RATES.--
28 (b) For all small employer health benefit plans that
29 are subject to this section and are issued by small employer
30 carriers on or after January 1, 1994, premium rates for health
31 benefit plans subject to this section are subject to the
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SENATE AMENDMENT
Bill No. CS/HB 1253, 2nd Eng.
Amendment No. ___ Barcode 800658
1 following:
2 1. Small employer carriers must use a modified
3 community rating methodology in which the premium for each
4 small employer must be determined solely on the basis of the
5 eligible employee's and eligible dependent's gender, age,
6 family composition, tobacco use, or geographic area as
7 determined under paragraph (5)(j) and in which the premium may
8 be adjusted as permitted by subparagraphs 5., and 6., and 7.
9 2. Rating factors related to age, gender, family
10 composition, tobacco use, or geographic location may be
11 developed by each carrier to reflect the carrier's experience.
12 The factors used by carriers are subject to department review
13 and approval.
14 3. If the modified community rate is determined from
15 two experience pools as authorized by paragraph (5)(n), the
16 rate to be charged to small employer groups of less than two
17 eligible employees may not exceed 150 percent of the rate
18 determined for groups of two through 50 eligible employees;
19 however, the carrier may charge excess losses of the
20 less-than-two-eligible-employee experience pool to the
21 experience pool of the two through 50 eligible employees so
22 that all losses are allocated and the 150-percent rate limit
23 on the less-than-two-eligible-employee experience pool is
24 maintained. Notwithstanding the provisions of s.
25 627.411(1)(e)4. and (3), the rate to be charged to a small
26 employer group of fewer than 2 eligible employees insured as
27 of July 1, 2001, may be up to 125 percent of the rate
28 determined for groups of 2 through 50 eligible employees for
29 the first annual renewal and 150 percent for subsequent annual
30 renewals.
31 4.3. Small employer carriers may not modify the rate
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SENATE AMENDMENT
Bill No. CS/HB 1253, 2nd Eng.
Amendment No. ___ Barcode 800658
1 for a small employer for 12 months from the initial issue date
2 or renewal date, unless the composition of the group changes
3 or benefits are changed. However, a small employer carrier may
4 modify the rate one time prior to 12 months after the initial
5 issue date for a small employer who enrolls under a previously
6 issued group policy that has a common anniversary date for all
7 employers covered under the policy if:
8 a. The carrier discloses to the employer in a clear
9 and conspicuous manner the date of the first renewal and the
10 fact that the premium may increase on or after that date.
11 b. The insurer demonstrates to the department that
12 efficiencies in administration are achieved and reflected in
13 the rates charged to small employers covered under the policy.
14 5.4. A carrier may issue a group health insurance
15 policy to a small employer health alliance or other group
16 association with rates that reflect a premium credit for
17 expense savings attributable to administrative activities
18 being performed by the alliance or group association if such
19 expense savings are specifically documented in the insurer's
20 rate filing and are approved by the department. Any such
21 credit may not be based on different morbidity assumptions or
22 on any other factor related to the health status or claims
23 experience of any person covered under the policy. Nothing in
24 this subparagraph exempts an alliance or group association
25 from licensure for any activities that require licensure under
26 the insurance code. A carrier issuing a group health insurance
27 policy to a small employer health alliance or other group
28 association shall allow any properly licensed and appointed
29 agent of that carrier to market and sell the small employer
30 health alliance or other group association policy. Such agent
31 shall be paid the usual and customary commission paid to any
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SENATE AMENDMENT
Bill No. CS/HB 1253, 2nd Eng.
Amendment No. ___ Barcode 800658
1 agent selling the policy.
2 6.5. Any adjustments in rates for claims experience,
3 health status, or credits based on the duration of coverage
4 may not be charged to individual employees or dependents. For
5 a small employer's policy, such adjustments may not result in
6 a rate for the small employer which deviates more than 15
7 percent from the carrier's approved rate. Any such adjustment
8 must be applied uniformly to the rates charged for all
9 employees and dependents of the small employer. A small
10 employer carrier may make an adjustment to a small employer's
11 renewal premium, not to exceed 10 percent annually, due to the
12 claims experience, health status, or credits based on the
13 duration of coverage of the employees or dependents of the
14 small employer. Semiannually, small group carriers shall
15 report information on forms adopted by rule by the department,
16 to enable the department to monitor the relationship of
17 aggregate adjusted premiums actually charged policyholders by
18 each carrier to the premiums that would have been charged by
19 application of the carrier's approved modified community
20 rates. If the aggregate resulting from the application of such
21 adjustment exceeds the premium that would have been charged by
22 application of the approved modified community rate by 5
23 percent for the current reporting period, the carrier shall
24 limit the application of such adjustments only to minus
25 adjustments beginning not more than 60 days after the report
26 is sent to the department. For any subsequent reporting
27 period, if the total aggregate adjusted premium actually
28 charged does not exceed the premium that would have been
29 charged by application of the approved modified community rate
30 by 5 percent, the carrier may apply both plus and minus
31 adjustments. A small employer carrier may provide a credit to
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SENATE AMENDMENT
Bill No. CS/HB 1253, 2nd Eng.
Amendment No. ___ Barcode 800658
1 a small employer's premium based on administrative and
2 acquisition expense differences resulting from the size of the
3 group. Group size administrative and acquisition expense
4 factors may be developed by each carrier to reflect the
5 carrier's experience and are subject to department review and
6 approval.
7 7.6. A small employer carrier rating methodology may
8 include separate rating categories for one dependent child,
9 for two dependent children, and for three or more dependent
10 children for family coverage of employees having a spouse and
11 dependent children or employees having dependent children
12 only. A small employer carrier may have fewer, but not
13 greater, numbers of categories for dependent children than
14 those specified in this subparagraph.
15 8.7. Small employer carriers may not use a composite
16 rating methodology to rate a small employer with fewer than 10
17 employees. For the purposes of this subparagraph, a "composite
18 rating methodology" means a rating methodology that averages
19 the impact of the rating factors for age and gender in the
20 premiums charged to all of the employees of a small employer.
21 (12) STANDARD, BASIC, AND LIMITED HEALTH BENEFIT
22 PLANS.--
23 (a)1. By May 15, 1993, the commissioner shall appoint
24 a health benefit plan committee composed of four
25 representatives of carriers which shall include at least two
26 representatives of HMOs, at least one of which is a staff
27 model HMO, two representatives of agents, four representatives
28 of small employers, and one employee of a small employer. The
29 carrier members shall be selected from a list of individuals
30 recommended by the board. The commissioner may require the
31 board to submit additional recommendations of individuals for
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SENATE AMENDMENT
Bill No. CS/HB 1253, 2nd Eng.
Amendment No. ___ Barcode 800658
1 appointment.
2 2. The plans shall comply with all of the requirements
3 of this subsection.
4 3. The plans must be filed with and approved by the
5 department prior to issuance or delivery by any small employer
6 carrier.
7 4. Before October 1, 2001, and in every 4th year
8 thereafter, the commissioner shall appoint a new health
9 benefit plan committee in the manner provided in subparagraph
10 1. to determine whether modifications to a plan might be
11 appropriate and to submit recommended modifications to the
12 department for approval. Such determination shall be based
13 upon prevailing industry standards regarding managed care and
14 cost-containment provisions and shall be for the purpose of
15 ensuring that the benefit plans offered to small employers on
16 a guaranteed-issue basis are consistent with the low to
17 mid-priced benefit plans offered in the large-group market.
18 This determination shall be included in a report submitted to
19 the President of the Senate and the Speaker of the House of
20 Representatives annually by October 1. After approval of the
21 revised health benefit plans, if the department determines
22 that modifications to a plan might be appropriate, the
23 commissioner shall appoint a new health benefit plan committee
24 in the manner provided in subparagraph 1. to submit
25 recommended modifications to the department for approval.
26 (d)1. Upon offering coverage under a standard health
27 benefit plan, a basic health benefit plan, or a limited
28 benefit policy or contract for any small employer, the small
29 employer carrier shall disclose in writing to the employer
30 provide such employer group with a written statement that
31 contains, at a minimum:
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SENATE AMENDMENT
Bill No. CS/HB 1253, 2nd Eng.
Amendment No. ___ Barcode 800658
1 a. An explanation of those mandated benefits and
2 providers that are not covered by the policy or contract;
3 a.b. An outline of coverage explanation of the managed
4 care and cost control features of the policy or contract,
5 along with all appropriate mailing addresses and telephone
6 numbers to be used by insureds in seeking information or
7 authorization; and
8 b.c. An explanation of The primary and preventive care
9 features of the policy or contract; and.
10
11 Such disclosure statement must be presented in a clear and
12 understandable form and format and must be separate from the
13 policy or certificate or evidence of coverage provided to the
14 employer group.
15 2. Before a small employer carrier issues a standard
16 health benefit plan, a basic health benefit plan, or a limited
17 benefit policy or contract, it must obtain from the
18 prospective policyholder a signed written statement in which
19 the prospective policyholder:
20 a. Certifies as to eligibility for coverage under the
21 standard health benefit plan, basic health benefit plan, or
22 limited benefit policy or contract;
23 c.b. Acknowledges The limited nature of the coverage
24 and the an understanding of the managed care and cost control
25 features of the policy or contract.;
26 c. Acknowledges that if misrepresentations are made
27 regarding eligibility for coverage under a standard health
28 benefit plan, a basic health benefit plan, or a limited
29 benefit policy or contract, the person making such
30 misrepresentations forfeits coverage provided by the policy or
31 contract; and
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SENATE AMENDMENT
Bill No. CS/HB 1253, 2nd Eng.
Amendment No. ___ Barcode 800658
1 2.d. If a limited plan is requested, the prospective
2 policyholder must acknowledge in writing acknowledges that he
3 or she the prospective policyholder had been offered, at the
4 time of application for the insurance policy or contract, the
5 opportunity to purchase any health benefit plan offered by the
6 carrier and that the prospective policyholder had rejected
7 that coverage.
8
9 A copy of such written statement shall be provided to the
10 prospective policyholder no later than at the time of delivery
11 of the policy or contract, and the original of such written
12 statement shall be retained in the files of the small employer
13 carrier for the period of time that the policy or contract
14 remains in effect or for 5 years, whichever period is longer.
15 3. Any material statement made by an applicant for
16 coverage under a health benefit plan which falsely certifies
17 as to the applicant's eligibility for coverage serves as the
18 basis for terminating coverage under the policy or contract.
19 3.4. Each marketing communication that is intended to
20 be used in the marketing of a health benefit plan in this
21 state must be submitted for review by the department prior to
22 use and must contain the disclosures stated in this
23 subsection.
24 4. The contract, policy, and certificates evidencing
25 coverage under a limited benefit policy or contract and the
26 application for coverage under such plans must state in not
27 less than 10-point type on the first page in contrasting color
28 the following: "The benefits provided by this health plan are
29 limited and may not cover all of your medical needs. You
30 should carefully review the benefits offered under this health
31 plan."
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SENATE AMENDMENT
Bill No. CS/HB 1253, 2nd Eng.
Amendment No. ___ Barcode 800658
1 (d)(e) A small employer carrier may not use any
2 policy, contract, form, or rate under this section, including
3 applications, enrollment forms, policies, contracts,
4 certificates, evidences of coverage, riders, amendments,
5 endorsements, and disclosure forms, until the insurer has
6 filed it with the department and the department has approved
7 it under ss. 627.31, 627.410, 627.4106, and 627.411.
8 (15) APPLICABILITY OF OTHER STATE LAWS.--
9 (a) Except as expressly provided in this section, a
10 law requiring coverage for a specific health care service or
11 benefit, or a law requiring reimbursement, utilization, or
12 consideration of a specific category of licensed health care
13 practitioner, does not apply to a standard or basic health
14 benefit plan policy or contract or a limited benefit policy or
15 contract offered or delivered to a small employer unless that
16 law is made expressly applicable to such policies or
17 contracts. A law restricting or limiting deductibles,
18 copayments, or annual or lifetime maximum payments does not
19 apply to a limited benefit policy or contract offered or
20 delivered to a small employer unless such law is made
21 expressly applicable to such policy or contract. A limited
22 benefit policy or contract that is offered or delivered to a
23 small employer may also be offered or delivered to an employer
24 having 51 or more eligible employees. Any covered disease or
25 condition may be treated by any physician, without
26 discrimination, licensed or certified to treat the disease or
27 condition.
28 Section 18. Section 627.9408, Florida Statutes, is
29 amended to read:
30 627.9408 Rules.--
31 (1) The department may has authority to adopt rules
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SENATE AMENDMENT
Bill No. CS/HB 1253, 2nd Eng.
Amendment No. ___ Barcode 800658
1 pursuant to ss. 120.536(1) and 120.54 to administer implement
2 the provisions of this part.
3 (2) The department may adopt by rule the provisions of
4 the Long-Term Care Insurance Model Regulation adopted by the
5 National Association of Insurance Commissioners in the second
6 quarter of the year 2000 which are not in conflict with the
7 Florida Insurance Code.
8 Section 19. Paragraphs (b) and (d) of subsection (3)
9 of section 641.31, Florida Statutes, are amended, and
10 paragraph (f) is added to that subsection, to read:
11 641.31 Health maintenance contracts.--
12 (3)
13 (b) Any change in the rate is subject to paragraph (d)
14 and requires at least 30 days' advance written notice to the
15 subscriber. In the case of a group member, there may be a
16 contractual agreement with the health maintenance organization
17 to have the employer provide the required notice to the
18 individual members of the group. This paragraph does not apply
19 to a group contract covering 51 or more persons unless the
20 rate is for any coverage under which the increase in claim
21 costs over the lifetime of the contract due to advancing age
22 or duration is prefunded in the premium.
23 (d) Any change in rates charged for the contract must
24 be filed with the department not less than 30 days in advance
25 of the effective date. At the expiration of such 30 days, the
26 rate filing shall be deemed approved unless prior to such time
27 the filing has been affirmatively approved or disapproved by
28 order of the department pursuant to s. 627.411. The approval
29 of the filing by the department constitutes a waiver of any
30 unexpired portion of such waiting period. The department may
31 extend by not more than an additional 15 days the period
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SENATE AMENDMENT
Bill No. CS/HB 1253, 2nd Eng.
Amendment No. ___ Barcode 800658
1 within which it may so affirmatively approve or disapprove any
2 such filing, by giving notice of such extension before
3 expiration of the initial 30-day period. At the expiration of
4 any such period as so extended, and in the absence of such
5 prior affirmative approval or disapproval, any such filing
6 shall be deemed approved.
7 (f) A health maintenance organization with fewer than
8 1,000 covered subscribers under all individual or group
9 contracts, at the time of a rate filing, may file for an
10 annual rate increase limited to annual medical trend, as
11 adopted by the department. The filing is in lieu of the
12 actuarial memorandum otherwise required for the rate filing.
13 The filing must include forms adopted by the department and a
14 certification by an officer of the company that the filing
15 includes all similar forms.
16 Section 20. Contingent upon the passage of CS/CS/SB
17 2214, or similar legislation, beginning July 1, 2001, $10
18 million of the funds collected from subscribing participating
19 manufacturers and the public health tobacco equity surcharge
20 imposed by s. 210.0221 shall be transferred from the Tobacco
21 Settlement Clearing Trust Fund to the Florida Comprehensive
22 Health Association created in s. 627.6488, for coverage of new
23 participants. Effective April 1, 2002, the association may
24 provide coverage for up to 500 persons for the period ending
25 December 31, 2002. On or after January 1, 2003, the
26 association may enroll an additional 1,500 persons. At no time
27 may the association provide coverage for more than 2,000
28 persons. The appropriation made by this section shall not be
29 made if the same appropriation is made by CS/CS/SB 2214 or
30 similar legislation.
31 Section 21. This act shall take effect October 1,
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SENATE AMENDMENT
Bill No. CS/HB 1253, 2nd Eng.
Amendment No. ___ Barcode 800658
1 2001.
2
3
4 ================ T I T L E A M E N D M E N T ===============
5 And the title is amended as follows:
6 Delete everything before the enacting clause
7
8 and insert:
9 A bill to be entitled
10 An act relating to health care; making
11 legislative findings and providing legislative
12 intent; providing definitions; providing for a
13 pilot program for health flex plans for certain
14 uninsured persons; providing criteria;
15 exempting approved health flex plans from
16 certain licensing requirements; providing
17 criteria for eligibility to enroll in a health
18 flex plan; requiring health flex plan providers
19 to maintain certain records; providing
20 requirements for denial, nonrenewal, or
21 cancellation of coverage; specifying that
22 coverage under an approved health flex plan is
23 not an entitlement; providing for civil actions
24 against health plan entities by the Agency for
25 Health Care Administration under certain
26 circumstances; amending s. 627.410, F.S.;
27 requiring certain group certificates for health
28 insurance coverage to be subject to the
29 requirements for individual health insurance
30 policies; exempting group health insurance
31 policies insuring groups of a certain size from
50
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SENATE AMENDMENT
Bill No. CS/HB 1253, 2nd Eng.
Amendment No. ___ Barcode 800658
1 rate filing requirements; providing alternative
2 rate filing requirements for insurers with less
3 than a specified number of nationwide
4 policyholders or members; amending s. 627.411,
5 F.S.; revising the grounds for the disapproval
6 of insurance policy forms; providing that a
7 health insurance policy form may be disapproved
8 if it results in certain rate increases;
9 specifying allowable new business rates and
10 renewal rates if rate increases exceed certain
11 levels; authorizing the Department of Insurance
12 to determine medical trend for purposes of
13 approving rate filings; amending s. 627.6487,
14 F.S.; revising the types of policies that
15 individual health insurers must offer to
16 persons eligible for guaranteed individual
17 health insurance coverage; prohibiting
18 individual health insurers from applying
19 discriminatory underwriting or rating practices
20 to eligible individuals; amending s. 627.6482,
21 F.S.; amending definitions used in the Florida
22 Comprehensive Health Association Act; amending
23 s. 627.6486, F.S.; revising the criteria for
24 eligibility for coverage from the association;
25 providing for cessation of coverage; requiring
26 all eligible persons to agree to be placed in a
27 case-management system; amending s. 627.6487,
28 F.S.; redefining the term "eligible individual"
29 for purposes of guaranteed availability of
30 individual health insurance coverage; providing
31 that a person is not eligible if the person is
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SENATE AMENDMENT
Bill No. CS/HB 1253, 2nd Eng.
Amendment No. ___ Barcode 800658
1 eligible for coverage under the Florida
2 Comprehensive Health Association; amending s.
3 627.6488, F.S.; revising the membership of the
4 board of directors of the association; revising
5 the reimbursement of board members and
6 employees; requiring that the plan of the
7 association be submitted to the department for
8 approval on an annual basis; revising the
9 duties of the association related to
10 administrative and accounting procedures;
11 requiring an annual financial audit; specifying
12 grievance procedures; establishing a premium
13 schedule based upon an individual's family
14 income; deleting requirements for categorizing
15 insureds as low-risk, medium-risk, and
16 high-risk; authorizing the association to place
17 an individual with a case manager who
18 determines the health care system or provider;
19 requiring an annual review of the actuarial
20 soundness of the association and the
21 feasibility of enrolling new members; requiring
22 a separate account for policyholders insured
23 prior to a specified date; requiring
24 appointment of an executive director with
25 specified duties; authorizing the board to
26 restrict the number of participants based on
27 inadequate funding; limiting enrollment;
28 specifying other powers of the board; amending
29 s. 627.649, F.S.; revising the requirements for
30 the association to use in selecting an
31 administrator; amending s. 627.6492, F.S.;
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SENATE AMENDMENT
Bill No. CS/HB 1253, 2nd Eng.
Amendment No. ___ Barcode 800658
1 requiring insurers to be members of the
2 association and to be subject to assessments
3 for operating expenses; limiting assessments to
4 specified maximum amounts; specifying when
5 assessments are calculated and paid; providing
6 that funding for coverage for certain persons
7 shall be provided by appropriations as provided
8 by law; amending s. 627.6498, F.S.; revising
9 the coverage, benefits, covered expenses,
10 premiums, and deductibles of the association;
11 requiring preexisting condition limitations;
12 providing that the act does not provide an
13 entitlement to health care services or health
14 insurance and does not create a cause of
15 action; limiting enrollment in the association;
16 repealing s. 627.6484, F.S., relating to a
17 prohibition on the Florida Comprehensive Health
18 Association from accepting applications for
19 coverage after a certain date; making a
20 legislative finding that the provisions of this
21 act fulfill an important state interest;
22 providing that the amendments to s.
23 627.6487(3), F.S., do not take effect unless
24 approved by the U.S. Health Care Financing
25 Administration; amending s. 627.6515, F.S.;
26 requiring that coverage issued to a state
27 resident under certain group health insurance
28 policies issued outside the state be subject to
29 the requirements for individual health
30 insurance policies; amending s. 627.6699, F.S.;
31 revising definitions used in the Employee
53
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SENATE AMENDMENT
Bill No. CS/HB 1253, 2nd Eng.
Amendment No. ___ Barcode 800658
1 Health Care Access Act; allowing carriers to
2 separate the experience of small employer
3 groups with fewer than two employees; revising
4 the rating factors that may be used by small
5 employer carriers; requiring the Insurance
6 Commissioner to appoint a health benefit plan
7 committee to modify the standard, basic, and
8 limited health benefit plans; revising the
9 disclosure that a carrier must make to a small
10 employer upon offering certain policies;
11 prohibiting small employer carriers from using
12 certain policies, contracts, forms, or rates
13 unless filed with and approved by the
14 Department of Insurance pursuant to certain
15 provisions; restricting application of certain
16 laws to limited benefit policies under certain
17 circumstances; authorizing offering or
18 delivering limited benefit policies or
19 contracts to certain employers; providing
20 requirements for benefits in limited benefit
21 policies or contracts for small employers;
22 amending s. 627.9408, F.S.; authorizing the
23 department to adopt by rule certain provisions
24 of the Long-Term Care Insurance Model
25 Regulation, as adopted by the National
26 Association of Insurance Commissioners;
27 amending s. 641.31, F.S.; exempting contracts
28 of group health maintenance organizations
29 covering a specified number of persons from the
30 requirements of filing with the department;
31 specifying the standards for department
54
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SENATE AMENDMENT
Bill No. CS/HB 1253, 2nd Eng.
Amendment No. ___ Barcode 800658
1 approval and disapproval of a change in rates
2 by a health maintenance organization; providing
3 alternative rate filing requirements for
4 organizations with less than a specified number
5 of subscribers; providing an appropriation
6 contingent upon passage of other legislation;
7 providing an effective date.
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