House Bill hb0111e1

                                           HB 111, First Engrossed



  1                      A bill to be entitled

  2         An act relating to health flex plans; providing

  3         legislative findings and intent; providing

  4         definitions; providing for a pilot program for

  5         health flex plans for certain uninsured

  6         persons; providing criteria for approval of

  7         health flex plans; delineating the

  8         responsibilities of the Agency for Health Care

  9         Administration and the Department of Insurance;

10         exempting approved health flex plans from

11         certain regulatory requirements; providing

12         criteria for eligibility to enroll in a health

13         flex plan; requiring health flex plan entities

14         to maintain certain records; providing

15         requirements for denial, nonrenewal, or

16         cancellation of coverage; specifying that

17         coverage under an approved health flex plan is

18         not an entitlement; requiring an evaluation and

19         report; providing for subsequent repeal;

20         providing an effective date.

21

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

23

24         Section 1.  Health Flex plans.--

25         (1)  INTENT.--The Legislature finds that a significant

26  proportion of state residents 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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                                           HB 111, 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 these 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, the term:

10         (a)  "Agency" means the Agency for Health Care

11  Administration.

12         (b)  "Department" means the Department of Insurance.

13         (c)  "Enrollee" means an individual who has been

14  determined eligible for and is receiving health care coverage

15  under a health flex plan approved under this section.

16         (d)  "Health care coverage" or "health flex plan

17  coverage" means health care services covered as benefits under

18  an approved health flex plan or that are otherwise provided,

19  either directly or through arrangements with other persons,

20  via health flex plan health care services on a prepaid per

21  capita basis or on a prepaid aggregate fixed-sum basis.

22         (e)  "Health flex plan" means a health plan approved

23  under subsection (3) which guarantees payment for specified

24  health care coverage provided to the enrollee.

25         (f)  "Health flex plan entity" means a health insurer,

26  health maintenance organization, health care

27  provider-sponsored organization, local government, health care

28  district, or other public or private community-based

29  organization which develops and implements an approved health

30  flex plan and is responsible for administering the health flex

31


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                                           HB 111, First Engrossed



  1  plan and paying all claims for health flex plan coverage by

  2  enrollees of the health flex plan.

  3         (3)  PILOT PROGRAM.--The agency and the department

  4  shall each approve or disapprove health flex plans which

  5  provide health care coverage for eligible participants

  6  residing in the 3 service areas of the state with the highest

  7  number of uninsured as identified in the Florida Health

  8  Insurance Study conducted by the agency.  A health flex plan

  9  may limit or exclude benefits otherwise required by law for

10  insurers offering coverage in this state, cap the total amount

11  of claims paid per year per enrollee, limit the number of

12  enrollees, or any combination of the foregoing.

13         (a)  The agency shall develop guidelines for the review

14  of health flex plan applications and shall not approve or

15  shall withdraw approval of plans which do not or no longer

16  meet minimum quality of care and access to care standards.

17         (b)  The department shall develop guidelines for the

18  review of health flex plan applications and shall not approve

19  or shall withdraw approval of plans which:

20         1.  Contain any ambiguous, inconsistent or misleading

21  provisions, or exceptions or conditions that deceptively

22  affect or limit the benefits purported to be assumed in the

23  general coverage provided by the health flex plan;

24         2.  Provide benefits that are unreasonable in relation

25  to the premium charged, contain provisions that are unfair or

26  inequitable or contrary to the public policy of this state,

27  that encourage misrepresentation, or that result in unfair

28  discrimination in sales practices; or

29         3.  Cannot demonstrate that the health flex plan is

30  financially sound and that the applicant has the ability to

31  underwrite or finance the health care coverage provided.


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                                           HB 111, First Engrossed



  1         (c)  The agency and the department are each authorized

  2  to adopt rules as needed to implement this section.

  3         (4)  LICENSE NOT REQUIRED.--A health flex plan approved

  4  under this section shall not be 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 flex

  9  plans shall be considered insurance subject to the applicable

10  provisions of part IX of chapter 626, Florida Statutes, except

11  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, such as KidCare, and have not been

21  covered at any time during the past 6 months; and

22         (d)  Have applied for health care coverage through an

23  approved health flex plan and agree to make any payments

24  required for participation, including periodic payments or

25  payments due at the time health care services are provided.

26         (6)  RECORDS.--Every health flex plan shall maintain

27  enrollment data, reasonable records of its loss, expense, and

28  claims experience, and shall make such records reasonably

29  available to enable the department to monitor and determine

30  the financial viability of the health flex plan, as necessary.

31  Provider networks and total enrollment by area shall be


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                                           HB 111, First Engrossed



  1  reported to the agency biannually to enable the agency to

  2  monitor access to care.

  3          (7)  NOTICE.--The denial of coverage by a health flex

  4  plan, or nonrenewal or cancellation of coverage, must be

  5  accompanied by the specific reasons for denial, nonrenewal, or

  6  cancellation.  Notice of nonrenewal or cancellation must be

  7  provided at least 45 days in advance of such nonrenewal or

  8  cancellation, except that 10 days' written notice shall be

  9  given for cancellation due to nonpayment of premiums.  If the

10  health flex plan fails to give the required notice, the health

11  flex plan coverage shall remain in effect until notice is

12  appropriately given.

13         (8)  NONENTITLEMENT.--Coverage under an approved health

14  flex plan is not an entitlement, and no cause of action shall

15  arise against the state, local government entity or other

16  political subdivision of this state, or the agency for failure

17  to make coverage available to eligible persons under this

18  section.

19         (9)  PROGRAM EVALUATION.--The agency and the department

20  shall evaluate the pilot program and its impact on the

21  entities that seek approval as health flex plans, the number

22  of enrollees, the scope of health care coverage offered under

23  a health flex plan, and an assessment of the health flex plans

24  and their potential applicability in other settings, and

25  jointly submit a report to the Governor, the President of the

26  Senate, and the Speaker of the House of Representatives, no

27  later than January 1, 2004.

28         (10)  REPEAL.--Unless specifically reenacted by the

29  Legislature, this section shall stand repealed on July 1,

30  2004.

31         Section 2.  This act shall take effect July 1, 2002.


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