House Bill hb1253e1
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CS/HB 1253, First Engrossed
1 A bill to be entitled
2 An act relating to health care; making
3 legislative findings and providing legislative
4 intent; providing definitions; providing for a
5 pilot program for health flex plans for certain
6 uninsured persons; providing criteria;
7 exempting approved health flex plans from
8 certain licensing requirements; providing
9 criteria for eligibility to enroll in a health
10 flex plan; requiring health flex plan providers
11 to maintain certain records; providing
12 requirements for denial, nonrenewal, or
13 cancellation of coverage; specifying coverage
14 under an approved health flex plan is not an
15 entitlement; providing for civil actions
16 against health plan entities by the Agency for
17 Health Care Administration under certain
18 circumstances; amending s. 627.6699, F.S.;
19 revising a definition; requiring the Insurance
20 Commissioner to appoint a health benefit plan
21 committee to modify the standard, basic, and
22 limited health benefit plans; revising the
23 disclosure that a carrier must make to a small
24 employer upon offering certain policies;
25 prohibiting small employer carriers from using
26 certain policies, contracts, forms, or rates
27 unless filed with and approved by the
28 Department of Insurance pursuant to certain
29 provisions; restricting application of certain
30 laws to limited benefit policies under certain
31 circumstances; authorizing offering or
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CS/HB 1253, First Engrossed
1 delivering limited benefit policies or
2 contracts to certain employers; providing
3 requirements for benefits in limited benefit
4 policies or contracts for small employers;
5 providing an effective date.
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7 WHEREAS, the Legislature recognizes that the increasing
8 number of uninsured Floridians is due in part to small
9 employers' and their employees' inability to afford
10 comprehensive health insurance coverage, and
11 WHEREAS, the Legislature recognizes the need for small
12 employers and their employees to have the opportunity to
13 choose more affordable and flexible health insurance plans,
14 and
15 WHEREAS, it is the intent of the Legislature that
16 insurers and health maintenance organizations have maximum
17 flexibility in health plan design or in developing a health
18 plan design to complement a medical savings account program
19 established by a small employer for the benefit of its
20 employees, NOW, THEREFORE,
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22 Be It Enacted by the Legislature of the State of Florida:
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24 Section 1. Health flex plans.--
25 (1) INTENT.--The Legislature finds that a significant
26 portion of the residents of this state are not able to obtain
27 affordable health insurance coverage. Therefore it is the
28 intent of the Legislature to expand the availability of health
29 care options for lower income uninsured state residents by
30 encouraging health insurers, health maintenance organizations,
31 health care provider-sponsored organizations, local
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CS/HB 1253, First Engrossed
1 governments, health care districts, or other public or private
2 community-based organizations to develop alternative
3 approaches to traditional health insurance which emphasize
4 coverage for basic and preventive health care services. To
5 the maximum extent possible, such options should be
6 coordinated with existing governmental or community-based
7 health services programs in a manner which is consistent with
8 the objectives and requirements of such programs.
9 (2) DEFINITIONS.--As used in this section:
10 (a) "Agency" means the Agency for Health Care
11 Administration.
12 (b) "Approved plan" means a health flex plan approved
13 under subsection (3) which guarantees payment by the health
14 plan entity for specified health care services provided to the
15 enrollee.
16 (c) "Enrollee" means an individual who has been
17 determined eligible for and is receiving health benefits under
18 a health flex plan approved under this section.
19 (d) "Health care coverage" means payment for health
20 care services covered as benefits under an approved plan or
21 that otherwise provides, either directly or through
22 arrangements with other persons, covered health care services
23 on a prepaid per capita basis or on a prepaid aggregate
24 fixed-sum basis.
25 (e) "Health plan entity" means a health insurer,
26 health maintenance organization, health care
27 provider-sponsored organization, local government, health care
28 districts, or other public or private community-based
29 organization which develops and implements an approved plan,
30 and is responsible for financing and paying all claims by
31 enrollees of the plan.
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CS/HB 1253, First Engrossed
1 (3) PILOT PROGRAM.--The agency and the Department of
2 Insurance shall jointly approve or disapprove health flex
3 plans which provide health care coverage for eligible
4 participants residing in the three areas of the state having
5 the highest number of uninsured residents as determined by the
6 agency. A plan may limit or exclude benefits otherwise
7 required by law for insurers offering coverage in this state,
8 cap the total amount of claims paid in 1 year per enrollee, or
9 limit the number of enrollees covered. The agency and the
10 Department of Insurance shall not approve or shall withdraw
11 approval of a plan which:
12 (a) Contains any ambiguous, inconsistent, or
13 misleading provisions, or exceptions or conditions that
14 deceptively affect or limit the benefits purported to be
15 assumed in the general coverage provided by the plan;
16 (b) Provides benefits that are unreasonable in
17 relation to the premium charged, contains provisions that are
18 unfair or inequitable or contrary to the public policy of this
19 state or that encourage misrepresentation, or result in unfair
20 discrimination in sales practices; or
21 (c) Cannot demonstrate that the plan is financially
22 sound and the applicant has the ability to underwrite or
23 finance the benefits provided.
24 (4) LICENSE NOT REQUIRED.--A health flex plan approved
25 under this section shall not be subject to the licensing
26 requirements of the Florida Insurance Code or chapter 641,
27 Florida Statutes, relating to health maintenance
28 organizations, unless expressly made applicable. However, for
29 the purposes of prohibiting unfair trade practices, health
30 flex plans shall be considered insurance subject to the
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CS/HB 1253, First Engrossed
1 applicable provisions of part IX of chapter 626, Florida
2 Statutes, except as otherwise provided in this section.
3 (5) ELIGIBILITY.--Eligibility to enroll in an approved
4 health flex plan is limited to residents of this state who:
5 (a) Are 64 years of age or younger.
6 (b) Have a family income equal to or less than 200
7 percent of the federal poverty level.
8 (c) Are not covered by a private insurance policy and
9 are not eligible for coverage through a public health
10 insurance program such as Medicare or Medicaid, or other
11 public health care program, including, but not limited to,
12 Kidcare, and have not been covered at any time during the past
13 6 months.
14 (d) Have applied for health care benefits through an
15 approved health flex plan and agree to make any payments
16 required for participation, including, but not limited to,
17 periodic payments and payments due at the time health care
18 services are provided.
19 (6) RECORDS.--Every health flex plan provider shall
20 maintain reasonable records of its loss, expense, and claims
21 experience and shall make such records reasonably available to
22 enable the agency and the Department of Insurance to monitor
23 and determine the financial viability of the plan, as
24 necessary.
25 (7) NOTICE.--The denial of coverage by the health plan
26 entity shall be accompanied by the specific reasons for
27 denial, nonrenewal, or cancellation. Notice of nonrenewal or
28 cancellation shall be provided at least 45 days in advance of
29 such nonrenewal or cancellation except that 10 days' written
30 notice shall be given for cancellation due to nonpayment of
31 premiums. If the health plan entity fails to give the
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CS/HB 1253, First Engrossed
1 required notice, the plan shall remain in effect until notice
2 is appropriately given.
3 (8) NONENTITLEMENT.--Coverage under an approved health
4 flex plan is not an entitlement and no cause of action shall
5 arise against the state, local governmental entity, or other
6 political subdivision of this state or the agency for failure
7 to make coverage available to eligible persons under this
8 section.
9 (9) CIVIL ACTIONS.--In addition to an administrative
10 action initiated under subsection (4), the agency may seek any
11 remedy provided by law, including, but not limited to, the
12 remedies provided in s. 812.035, Florida Statutes, if the
13 agency finds that a health plan entity has engaged in any act
14 resulting in injury to an enrollee covered by a plan approved
15 under this section.
16 Section 2. Paragraph (m) of subsection (3), paragraphs
17 (a), (d), and (e) of subsection (12), and paragraph (a) of
18 subsection (15) of section 627.6699, Florida Statutes, are
19 amended to read:
20 627.6699 Employee Health Care Access Act.--
21 (3) DEFINITIONS.--As used in this section, the term:
22 (m) "Limited benefit policy or contract" means a
23 policy or contract that provides coverage for each person
24 insured under the policy for a specifically named disease or
25 diseases, a specifically named accident, or a specifically
26 named limited market that fulfills a an experimental or
27 reasonable need by providing more affordable health insurance,
28 such as the small group market.
29 (12) STANDARD, BASIC, AND LIMITED HEALTH BENEFIT
30 PLANS.--
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CS/HB 1253, First Engrossed
1 (a)1. By May 15, 1993, the commissioner shall appoint
2 a health benefit plan committee composed of four
3 representatives of carriers which shall include at least two
4 representatives of HMOs, at least one of which is a staff
5 model HMO, two representatives of agents, four representatives
6 of small employers, and one employee of a small employer. The
7 carrier members shall be selected from a list of individuals
8 recommended by the board. The commissioner may require the
9 board to submit additional recommendations of individuals for
10 appointment.
11 2. The plans shall comply with all of the requirements
12 of this subsection.
13 3. The plans must be filed with and approved by the
14 department prior to issuance or delivery by any small employer
15 carrier.
16 4. Before October 1, 2001, and in every fourth year
17 thereafter, the commissioner shall appoint a new health
18 benefit plan committee in the manner provided in subparagraph
19 1. to determine if modifications to a plan might be
20 appropriate and to submit recommended modifications to the
21 department for approval. Such determination shall be based
22 upon prevailing industry standards regarding managed care and
23 cost containment provisions and shall be for the purpose of
24 ensuring that the benefit plans offered to small employers on
25 a guaranteed issue basis are consistent with the low-priced to
26 mid-priced benefit plans offered in the large group market.
27 This determination shall be included in a report submitted to
28 the President of the Senate and the Speaker of the House of
29 Representatives annually by October 1. After approval of the
30 revised health benefit plans, if the department determines
31 that modifications to a plan might be appropriate, the
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CS/HB 1253, First Engrossed
1 commissioner shall appoint a new health benefit plan committee
2 in the manner provided in subparagraph 1. to submit
3 recommended modifications to the department for approval.
4 (d)1. Upon offering coverage under a standard health
5 benefit plan, a basic health benefit plan, or a limited
6 benefit policy or contract for any small employer, the small
7 employer carrier shall disclose in writing to the employer
8 provide such employer group with a written statement that
9 contains, at a minimum:
10 a. An explanation of those mandated benefits and
11 providers that are not covered by the policy or contract;
12 a.b. An outline of coverage An explanation of the
13 managed care and cost control features of the policy or
14 contract, along with all appropriate mailing addresses and
15 telephone numbers to be used by insureds in seeking
16 information. or authorization; and
17 b.c. An explanation of The primary and preventive care
18 features of the policy or contract.
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20 Such disclosure statement must be presented in a clear and
21 understandable form and format and must be separate from the
22 policy or certificate or evidence of coverage provided to the
23 employer group.
24 2. Before a small employer carrier issues a standard
25 health benefit plan, a basic health benefit plan, or a limited
26 benefit policy or contract, it must obtain from the
27 prospective policyholder a signed written statement in which
28 the prospective policyholder:
29 a. Certifies as to eligibility for coverage under the
30 standard health benefit plan, basic health benefit plan, or
31 limited benefit policy or contract;
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CS/HB 1253, First Engrossed
1 c.b. Acknowledges The limited nature of the coverage
2 and an understanding of the managed care and the cost control
3 features of the policy or contract.;
4 c. Acknowledges that if misrepresentations are made
5 regarding eligibility for coverage under a standard health
6 benefit plan, a basic health benefit plan, or a limited
7 benefit policy or contract, the person making such
8 misrepresentations forfeits coverage provided by the policy or
9 contract; and
10 2.d. If a limited plan is requested, the prospective
11 policyholder must acknowledge in writing acknowledges that he
12 or she the prospective policyholder had been offered, at the
13 time of application for the insurance policy or contract, the
14 opportunity to purchase any health benefit plan offered by the
15 carrier and that the prospective policyholder had rejected
16 that coverage.
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18 A copy of such written statement shall be provided to the
19 prospective policyholder no later than at the time of delivery
20 of the policy or contract, and the original of such written
21 statement shall be retained in the files of the small employer
22 carrier for the period of time that the policy or contract
23 remains in effect or for 5 years, whichever period is longer.
24 3. Any material statement made by an applicant for
25 coverage under a health benefit plan which falsely certifies
26 as to the applicant's eligibility for coverage serves as the
27 basis for terminating coverage under the policy or contract.
28 3.4. Each marketing communication that is intended to
29 be used in the marketing of a health benefit plan in this
30 state must be submitted for review by the department prior to
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1 use and must contain the disclosures stated in this
2 subsection.
3 4. The contract, policy, and certificates evidencing
4 coverage under a limited benefit policy or contract and the
5 application for coverage under such plans must state in not
6 less than 10 point type on the first page in contrasting color
7 the following: "The benefits provided by this health plan are
8 limited and may not cover all of your medical needs. You
9 should carefully review the benefits offered under this health
10 plan."
11 (d)(e) A small employer carrier may not use any
12 policy, contract, form, or rate under this section, including
13 applications, enrollment forms, policies, contracts,
14 certificates, evidences of coverage, riders, amendments,
15 endorsements, and disclosure forms, until the insurer has
16 filed it with the department and the department has approved
17 it under ss. 627.410, 627.4106, and 627.411, and 641.31.
18 (15) APPLICABILITY OF OTHER STATE LAWS.--
19 (a) Except as expressly provided in this section, a
20 law requiring coverage for a specific health care service or
21 benefit, or a law requiring reimbursement, utilization, or
22 consideration of a specific category of licensed health care
23 practitioner, does not apply to a standard or basic health
24 benefit plan policy or contract or a limited benefit policy or
25 contract offered or delivered to a small employer unless that
26 law is made expressly applicable to such policies or
27 contracts. A law restricting or limiting deductibles,
28 copayments, or annual or lifetime maximum payments does not
29 apply to a limited benefit policy or contract offered or
30 delivered to a small employer unless such law is made
31 expressly applicable to such policy or contract. A limited
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CS/HB 1253, First Engrossed
1 benefit policy or contract which is offered or delivered to a
2 small employer may also be offered or delivered to an employer
3 with 51 or more eligible employees. Any covered disease or
4 condition may be treated by any physician, without
5 discrimination, licensed or certified to treat the disease or
6 condition.
7 Section 3. This act shall take effect October 1, 2001.
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