CODING: Words stricken are deletions; words underlined are additions.
c2374070
Senate
s1200-98
s1286
2002
AA
792028
Senator Rossin moved the following amendment to amendment
(792028):
On page 79, between lines 14 and 15,
On page 85, line 26,
SENATE AMENDMENT
Bill No. CS for CS for SB's 1286, 1134 & 1008
Amendment No. ___ Barcode 374070
CHAMBER ACTION
Senate House
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11 Senator Rossin moved the following amendment to amendment
12 (792028):
13
14 Senate Amendment (with title amendment)
15 On page 79, between lines 14 and 15,
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17 insert:
18 Section 27. Effective July 1, 2002, subsection (12) of
19 section 627.6482, Florida Statutes, is amended, and
20 subsections (15) and (16) are added to that section, to read:
21 627.6482 Definitions.--As used in ss.
22 627.648-627.6498, the term:
23 (12) "Premium" means the entire cost of an insurance
24 plan, including the administrative fee, the risk assumption
25 charge, and, in the instance of a minimum premium plan or
26 stop-loss coverage, the incurred claims whether or not such
27 claims are paid directly by the insurer. "Premium" shall not
28 include a health maintenance organization's annual earned
29 premium revenue for Medicare and Medicaid contracts for any
30 assessment due for calendar years 1990 and 1991. For
31 assessments due for calendar year 1992 and subsequent years, A
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1 health maintenance organization's annual earned premium
2 revenue for Medicare and Medicaid contracts is subject to
3 assessments unless the department determines that the health
4 maintenance organization has made a reasonable effort to amend
5 its Medicare or Medicaid government contract for 1992 and
6 subsequent years to provide reimbursement for any assessment
7 on Medicare or Medicaid premiums paid by the health
8 maintenance organization and the contract does not provide for
9 such reimbursement.
10 (15) "Federal poverty level" means the most current
11 federal poverty guidelines, as established by the federal
12 Department of Health and Human Services and published in the
13 Federal Register, and in effect on the date of the policy and
14 its annual renewal.
15 (16) "Family income" means the adjusted gross income,
16 as defined in s. 62 of the United States Internal Revenue
17 Code, of all members of a household.
18 Section 28. Effective July 1, 2002, section 627.6486,
19 Florida Statutes, is amended to read:
20 627.6486 Eligibility.--
21 (1) Except as provided in subsection (2), any person
22 who is a resident of this state and has been a resident of
23 this state for the previous 6 months is shall be eligible for
24 coverage under the plan, including:
25 (a) The insured's spouse.
26 (b) Any dependent unmarried child of the insured, from
27 the moment of birth. Subject to the provisions of ss. s.
28 627.6041 and 627.6562, such coverage shall terminate at the
29 end of the premium period in which the child marries, ceases
30 to be a dependent of the insured, or attains the age of 19,
31 whichever occurs first. However, if the child is a full-time
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1 student at an accredited institution of higher learning, the
2 coverage may continue while the child remains unmarried and a
3 full-time student, but not beyond the premium period in which
4 the child reaches age 23.
5 (c) The former spouse of the insured whose coverage
6 would otherwise terminate because of annulment or dissolution
7 of marriage, if the former spouse is dependent upon the
8 insured for financial support. The former spouse shall have
9 continued coverage and shall not be subject to waiting periods
10 because of the change in policyholder status.
11 (2)(a) The board or administrator shall require
12 verification of residency for the preceding 6 months and shall
13 require any additional information or documentation, or
14 statements under oath, when necessary to determine residency
15 upon initial application and for the entire term of the
16 policy. A person may demonstrate his or her residency by
17 maintaining his or her residence in this state for the
18 preceding 6 months, purchasing a home that has been occupied
19 by him or her as his or her primary residence for the previous
20 6 months, or having established a domicile in this state
21 pursuant to s. 222.17 for the preceding 6 months.
22 (b) No person who is currently eligible for health
23 care benefits under Florida's Medicaid program is eligible for
24 coverage under the plan unless:
25 1. He or she has an illness or disease which requires
26 supplies or medication which are covered by the association
27 but are not included in the benefits provided under Florida's
28 Medicaid program in any form or manner; and
29 2. He or she is not receiving health care benefits or
30 coverage under Florida's Medicaid program.
31 (c) No person who is covered under the plan and
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1 terminates the coverage is again eligible for coverage.
2 (d) No person on whose behalf the plan has paid out
3 the lifetime maximum benefit currently being offered by the
4 association of $500,000 in covered benefits is eligible for
5 coverage under the plan.
6 (e) The coverage of any person who ceases to meet the
7 eligibility requirements of this section may be terminated
8 immediately. If such person again becomes eligible for
9 subsequent coverage under the plan, any previous claims
10 payments shall be applied towards the $500,000 lifetime
11 maximum benefit and any limitation relating to preexisting
12 conditions in effect at the time such person again becomes
13 eligible shall apply to such person. However, no such person
14 may again become eligible for coverage after June 30, 1991.
15 (f) No person is eligible for coverage under the plan
16 unless such person has been rejected by two insurers for
17 coverage substantially similar to the plan coverage and no
18 insurer has been found through the market assistance plan
19 pursuant to s. 627.6484 that is willing to accept the
20 application. As used in this paragraph, "rejection" includes
21 an offer of coverage with a material underwriting restriction
22 or an offer of coverage at a rate greater than the association
23 plan rate.
24 (g) No person is eligible for coverage under the plan
25 if such person has, or is eligible for, on the date of issue
26 of coverage under the plan, substantially similar coverage
27 under another contract or policy, unless such coverage is
28 provided pursuant to the Consolidated Omnibus Budget
29 Reconciliation Act of 1985, Pub. L. No. 99-272, 100 Stat. 82
30 (1986) (COBRA), as amended, or such coverage is provided
31 pursuant to s. 627.6692 and such coverage is scheduled to end
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1 at a time certain and the person meets all other requirements
2 of eligibility. Coverage provided by the association shall be
3 secondary to any coverage provided by an insurer pursuant to
4 COBRA or pursuant to s. 627.6692.
5 (h) A person is ineligible for coverage under the plan
6 if such person is currently eligible for health care benefits
7 under the Medicare program, except for a person who is insured
8 by the Florida Comprehensive Health Association and enrolled
9 under Medicare on July 1, 2002. All eligible persons who are
10 classified as high-risk individuals pursuant to s.
11 627.6498(4)(a)4. shall, upon application or renewal, agree to
12 be placed in a case management system when it is determined by
13 the board and the plan case manager that such system will be
14 cost-effective and provide quality care to the individual.
15 (i) A person is ineligible for coverage under the plan
16 if such person's premiums are paid for or reimbursed under any
17 government-sponsored program or by any government agency or
18 health care provider.
19 (j) An eligible individual, as defined in s. 627.6487,
20 and his or her dependents, as described in subsection (1), are
21 automatically eligible for coverage in the association unless
22 the association has ceased accepting new enrollees under s.
23 627.6488. If the association has ceased accepting new
24 enrollees, the eligible individual is subject to the coverage
25 rights set forth in s. 627.6487.
26 (3) A person's coverage ceases:
27 (a) On the date a person is no longer a resident of
28 this state;
29 (b) On the date a person requests coverage to end;
30 (c) Upon the date of death of the covered person;
31 (d) On the date state law requires cancellation of the
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1 policy; or
2 (e) Sixty days after the person receives notice from
3 the association making any inquiry concerning the person's
4 eligibility or place or residence to which the person does not
5 reply.
6 (4) All eligible persons must, upon application or
7 renewal, agree to be placed in a case-management system when
8 the association and case manager find that such system will be
9 cost-effective and provide quality care to the individual.
10 (5) Except for persons who are insured by the
11 association on December 31, 2002, and who renew such coverage,
12 persons may apply for coverage beginning January 1, 2003, and
13 coverage for such persons shall begin on or after April 1,
14 2003, as determined by the board pursuant to s.
15 627.6488(4)(n).
16 Section 29. Effective July 1, 2002, subsection (3) of
17 section 627.6487, Florida Statutes, is amended to read:
18 627.6487 Guaranteed availability of individual health
19 insurance coverage to eligible individuals.--
20 (3) For the purposes of this section, the term
21 "eligible individual" means an individual:
22 (a)1. For whom, as of the date on which the individual
23 seeks coverage under this section, the aggregate of the
24 periods of creditable coverage, as defined in s. 627.6561(5)
25 and (6), is 18 or more months; and
26 2.a. Whose most recent prior creditable coverage was
27 under a group health plan, governmental plan, or church plan,
28 or health insurance coverage offered in connection with any
29 such plan; or
30 b. Whose most recent prior creditable coverage was
31 under an individual plan issued in this state by a health
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1 insurer or health maintenance organization, which coverage is
2 terminated due to the insurer or health maintenance
3 organization becoming insolvent or discontinuing the offering
4 of all individual coverage in the State of Florida, or due to
5 the insured no longer living in the service area in the State
6 of Florida of the insurer or health maintenance organization
7 that provides coverage through a network plan in the State of
8 Florida;
9 (b) Who is not eligible for coverage under:
10 1. A group health plan, as defined in s. 2791 of the
11 Public Health Service Act;
12 2. A conversion policy or contract issued by an
13 authorized insurer or health maintenance organization under s.
14 627.6675 or s. 641.3921, respectively, offered to an
15 individual who is no longer eligible for coverage under either
16 an insured or self-insured employer plan;
17 3. Part A or part B of Title XVIII of the Social
18 Security Act; or
19 4. A state plan under Title XIX of such act, or any
20 successor program, and does not have other health insurance
21 coverage; or
22 5. The Florida Comprehensive Health Association, if
23 the association is accepting and issuing coverage to new
24 enrollees, provided that the 63-day period specified in s.
25 627.6561(6) shall be tolled from the time the association
26 receives an application from an individual until the
27 association notifies the individual that it is not accepting
28 and issuing coverage to that individual;
29 (c) With respect to whom the most recent coverage
30 within the coverage period described in paragraph (a) was not
31 terminated based on a factor described in s. 627.6571(2)(a) or
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1 (b), relating to nonpayment of premiums or fraud, unless such
2 nonpayment of premiums or fraud was due to acts of an employer
3 or person other than the individual;
4 (d) Who, having been offered the option of
5 continuation coverage under a COBRA continuation provision or
6 under s. 627.6692, elected such coverage; and
7 (e) Who, if the individual elected such continuation
8 provision, has exhausted such continuation coverage under such
9 provision or program.
10 Section 30. Effective July 1, 2002, section 627.6488,
11 Florida Statutes, is amended to read:
12 627.6488 Florida Comprehensive Health Association.--
13 (1) There is created a nonprofit legal entity to be
14 known as the "Florida Comprehensive Health Association." All
15 insurers, as a condition of doing business, shall be members
16 of the association.
17 (2)(a) The association shall operate subject to the
18 supervision and approval of a five-member three-member board
19 of directors consisting of the Insurance Commissioner, or his
20 or her designee, who shall serve as chairperson of the board,
21 and four additional members who must be state residents. At
22 least one member must be a representative of an authorized
23 health insurer or health maintenance organization authorized
24 to transact business in this state. The board of directors
25 shall be appointed by the Insurance Commissioner as follows:
26 1. The chair of the board shall be the Insurance
27 Commissioner or his or her designee.
28 2. One representative of policyholders who is not
29 associated with the medical profession, a hospital, or an
30 insurer.
31 3. One representative of insurers.
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1
2 The administrator or his or her affiliate shall not be a
3 member of the board. Any board member appointed by the
4 commissioner may be removed and replaced by him or her at any
5 time without cause.
6 (b) All board members, including the chair, shall be
7 appointed to serve for staggered 3-year terms beginning on a
8 date as established in the plan of operation.
9 (c) The board of directors may shall have the power to
10 employ or retain such persons as are necessary to perform the
11 administrative and financial transactions and responsibilities
12 of the association and to perform other necessary and proper
13 functions not prohibited by law. Employees of the association
14 shall be reimbursed as provided in s. 112.061 from moneys of
15 the association for expenses incurred in carrying out their
16 responsibilities under this act.
17 (d) Board members may be reimbursed as provided in s.
18 112.061 from moneys of the association for actual and
19 necessary expenses incurred by them as members in carrying out
20 their responsibilities under the Florida Comprehensive Health
21 Association Act, but may not otherwise be compensated for
22 their services.
23 (e) There shall be no liability on the part of, and no
24 cause of action of any nature shall arise against, any member
25 insurer, or its agents or employees, agents or employees of
26 the association, members of the board of directors of the
27 association, or the departmental representatives for any act
28 or omission taken by them in the performance of their powers
29 and duties under this act, unless such act or omission by such
30 person is in intentional disregard of the rights of the
31 claimant.
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1 (f) Meetings of the board are subject to s. 286.011.
2 (3) The association shall adopt a plan pursuant to
3 this act and submit its articles, bylaws, and operating rules
4 to the department for approval. If the association fails to
5 adopt such plan and suitable articles, bylaws, and operating
6 rules within 180 days after the appointment of the board, the
7 department shall adopt rules to effectuate the provisions of
8 this act; and such rules shall remain in effect until
9 superseded by a plan and articles, bylaws, and operating rules
10 submitted by the association and approved by the department.
11 Such plan shall be reviewed, revised as necessary, and
12 annually submitted to the department for approval.
13 (4) The association shall:
14 (a) Establish administrative and accounting procedures
15 and internal controls for the operation of the association and
16 provide for an annual financial audit of the association by an
17 independent certified public accountant licensed pursuant to
18 chapter 473.
19 (b) Establish procedures under which applicants and
20 participants in the plan may have grievances reviewed by an
21 impartial body and reported to the board. Individuals
22 receiving care through the association under contract from a
23 health maintenance organization must follow the grievance
24 procedures established in ss. 408.7056 and 641.31(5).
25 (c) Select an administrator in accordance with s.
26 627.649.
27 (d) Collect assessments from all insurers to provide
28 for operating losses incurred or estimated to be incurred
29 during the period for which the assessment is made. The level
30 of payments shall be established by the board, as formulated
31 in s. 627.6492(1). Annual assessment of the insurers for each
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1 calendar year shall occur as soon thereafter as the operating
2 results of the plan for the calendar year and the earned
3 premiums of insurers being assessed for that year are known.
4 Annual assessments are due and payable within 30 days of
5 receipt of the assessment notice by the insurer.
6 (e) Require that all policy forms issued by the
7 association conform to standard forms developed by the
8 association. The forms shall be approved by the department.
9 (f) Develop and implement a program to publicize the
10 existence of the plan, the eligibility requirements for the
11 plan, and the procedures for enrollment in the plan and to
12 maintain public awareness of the plan.
13 (g) Design and employ cost containment measures and
14 requirements which may include preadmission certification,
15 home health care, hospice care, negotiated purchase of medical
16 and pharmaceutical supplies, and individual case management.
17 (h) Contract with preferred provider organizations and
18 health maintenance organizations giving due consideration to
19 the preferred provider organizations and health maintenance
20 organizations which have contracted with the state group
21 health insurance program pursuant to s. 110.123. If
22 cost-effective and available in the county where the
23 policyholder resides, the board, upon application or renewal
24 of a policy, shall place a high-risk individual, as
25 established under s. 627.6498(4)(a)4., with the plan case
26 manager who shall determine the most cost-effective quality
27 care system or health care provider and shall place the
28 individual in such system or with such health care provider.
29 If cost-effective and available in the county where the
30 policyholder resides, the board, with the consent of the
31 policyholder, may place a low-risk or medium-risk individual,
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1 as established under s. 627.6498(4)(a)4., with the plan case
2 manager who may determine the most cost-effective quality care
3 system or health care provider and shall place the individual
4 in such system or with such health care provider. Prior to and
5 during the implementation of case management, the plan case
6 manager shall obtain input from the policyholder, parent, or
7 guardian.
8 (h)(i) Make a report to the Governor, the President of
9 the Senate, the Speaker of the House of Representatives, and
10 the Minority Leaders of the Senate and the House of
11 Representatives not later than March 1 October 1 of each year.
12 The report shall summarize the activities of the plan for the
13 prior fiscal 12-month period ending July 1 of that year,
14 including then-current data and estimates as to net written
15 and earned premiums, the expense of administration, and the
16 paid and incurred losses for the year. The report shall also
17 include analysis and recommendations for legislative changes
18 regarding utilization review, quality assurance, an evaluation
19 of the administrator of the plan, access to cost-effective
20 health care, and cost containment/case management policy and
21 recommendations concerning the opening of enrollment to new
22 entrants as of July 1, 1992.
23 (i)(j) Make a report to the Governor, the Insurance
24 Commissioner, the President of the Senate, the Speaker of the
25 House of Representatives, and the Minority Leaders of the
26 Senate and House of Representatives, not later than 45 days
27 after the close of each calendar quarter, which includes, for
28 the prior quarter, current data and estimates of net written
29 and earned premiums, the expenses of administration, and the
30 paid and incurred losses. The report shall identify any
31 statutorily mandated program that has not been fully
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1 implemented by the board.
2 (j)(k) To facilitate preparation of assessments and
3 for other purposes, the board shall engage an independent
4 certified public account licensed pursuant to chapter 473 to
5 conduct an annual financial audit of the association direct
6 preparation of annual audited financial statements for each
7 calendar year as soon as feasible following the conclusion of
8 that calendar year, and shall, within 30 days after the
9 issuance rendition of such statements, file with the
10 department the annual report containing such information as
11 required by the department to be filed on March 1 of each
12 year.
13 (k)(l) Employ a plan case manager or managers to
14 supervise and manage the medical care or coordinate the
15 supervision and management of the medical care, with the
16 administrator, of specified individuals. The plan case
17 manager, with the approval of the board, shall have final
18 approval over the case management for any specific individual.
19 If cost-effective and available in the county where the
20 policyholder resides, the association, upon application or
21 renewal of a policy, may place an individual with the plan
22 case manager, who shall determine the most cost-effective
23 quality care system or health care provider and shall place
24 the individual in such system or with such health care
25 provider. Prior to and during the implementation of case
26 management, the plan case manager shall obtain input from the
27 policyholder, parent or guardian, and the health care
28 providers.
29 (l) Administer the association in a fiscally
30 responsible manner that ensures that its expenditures are
31 reasonable in relation to the services provided and that the
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1 financial resources of the association are adequate to meet
2 its obligations.
3 (m) At least annually, but no more than quarterly,
4 evaluate or cause to be evaluated the actuarial soundness of
5 the association. The association shall contract with an
6 actuary to evaluate the pool of insureds in the association
7 and monitor the financial condition of the association. The
8 actuary shall determine the feasibility of enrolling new
9 members in the association, which must be based on the
10 projected revenues and expenses of the association.
11 (n) Restrict at any time the number of participants in
12 the association based on a determination by the board that the
13 revenues will be inadequate to fund new participants. However,
14 any person denied participation solely on the basis of such
15 restriction must be granted priority for participation in the
16 succeeding period in which the association is reopened for
17 participants. Effective April 1, 2003, the association may
18 provide coverage for up to 500 persons for the period ending
19 December 31, 2003. On or after January 1, 2004, the
20 association may enroll an additional 1,500 persons. At no time
21 may the association provide coverage for more than 2,000
22 persons. Except as provided in s. 627.6486(2)(j), applications
23 for enrollment must be processed on a first-in, first-out
24 basis.
25 (o) Establish procedures to maintain separate accounts
26 and recordkeeping for policyholders prior to January 1, 2003,
27 and policyholders issued coverage on and after January 1,
28 2003.
29 (p) Appoint an executive director to serve as the
30 chief administrative and operational officer of the
31 association and operate within the specifications of the plan
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1 of operation and perform other duties assigned to him or her
2 by the board.
3 (5) The association may:
4 (a) Exercise powers granted to insurers under the laws
5 of this state.
6 (b) Sue or be sued.
7 (c) In addition to imposing annual assessments under
8 paragraph (4)(d), levy interim assessments against insurers to
9 ensure the financial ability of the plan to cover claims
10 expenses and administrative expenses paid or estimated to be
11 paid in the operation of the plan for a calendar year prior to
12 the association's anticipated receipt of annual assessments
13 for that calendar year. Any interim assessment shall be due
14 and payable within 30 days after of receipt by an insurer of
15 an interim assessment notice. Interim assessment payments
16 shall be credited against the insurer's annual assessment.
17 Such assessments may be levied only for costs and expenses
18 associated with policyholders insured with the association
19 prior to January 1, 2003.
20 (d) Prepare or contract for a performance audit of the
21 administrator of the association.
22 (e) Appear in its own behalf before boards,
23 commissions, or other governmental agencies.
24 (f) Solicit and accept gifts, grants, loans, and other
25 aid from any source or participate in any way in any
26 government program to carry out the purposes of the Florida
27 Comprehensive Health Association Act.
28 (g) Require and collect administrative fees and
29 charges in connection with any transaction and impose
30 reasonable penalties, including default, for delinquent
31 payments or for entering into the association on a fraudulent
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1 basis.
2 (h) Procure insurance against any loss in connection
3 with the property, assets, and activities of the association
4 or the board.
5 (i) Contract for necessary goods and services; employ
6 necessary personnel; and engage the services of private
7 consultants, actuaries, managers, legal counsel, and
8 independent certified public accountants for administrative or
9 technical assistance.
10 (6) The department shall examine and investigate the
11 association in the manner provided in part II of chapter 624.
12 Section 31. Effective July 1, 2002, paragraph (b) of
13 subsection (3) of section 627.649, Florida Statutes, is
14 amended to read:
15 627.649 Administrator.--
16 (3) The administrator shall:
17 (b) Pay an agent's referral fee as established by the
18 board to each insurance agent who refers an applicant to the
19 plan, if the applicant's application is accepted. The selling
20 or marketing of plans shall not be limited to the
21 administrator or its agents. Any agent must be licensed by the
22 department to sell health insurance in this state. The
23 referral fees shall be paid by the administrator from moneys
24 received as premiums for the plan.
25 Section 32. Effective July 1, 2002, section 627.6492,
26 Florida Statutes, is amended to read:
27 627.6492 Participation of insurers.--
28 (1)(a) As a condition of doing business in this state
29 an insurer shall pay an assessment to the board, in the amount
30 prescribed by this section. This subsection and subsections
31 (2) and (3) apply only to the costs and expenses associated
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1 with policyholders insured with the association prior to
2 January 1, 2003, including renewal of coverage for such
3 policyholders after that date. For operating losses incurred
4 in any calendar year on July 1, 1991, and thereafter, each
5 insurer shall annually be assessed by the board in the
6 following calendar year a portion of such incurred operating
7 losses of the plan; such portion shall be determined by
8 multiplying such operating losses by a fraction, the numerator
9 of which equals the insurer's earned premium pertaining to
10 direct writings of health insurance in the state during the
11 calendar year preceding that for which the assessment is
12 levied, and the denominator of which equals the total of all
13 such premiums earned by participating insurers in the state
14 during such calendar year.
15 (b) For operating losses incurred from July 1, 1991,
16 through December 31, 1991, the total of all assessments upon a
17 participating insurer shall not exceed .375 percent of such
18 insurer's health insurance premiums earned in this state
19 during 1990. For operating losses incurred in 1992 and
20 thereafter, The total of all assessments upon a participating
21 insurer shall not exceed 1 percent of such insurer's health
22 insurance premium earned in this state during the calendar
23 year preceding the year for which the assessments were levied.
24 (c) For operating losses incurred from October 1,
25 1990, through June 30, 1991, the board shall assess each
26 insurer in the amount and manner prescribed by chapter 90-334,
27 Laws of Florida. The maximum assessment against an insurer, as
28 provided in such act, shall apply separately to the claims
29 incurred in 1990 (October 1 through December 31) and the
30 claims incurred in 1991 (January 1 through June 30). For
31 operating losses incurred on January 1, 1991, through June 30,
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SENATE AMENDMENT
Bill No. CS for CS for SB's 1286, 1134 & 1008
Amendment No. ___ Barcode 374070
1 1991, the maximum assessment against an insurer shall be
2 one-half of the amount of the maximum assessment specified for
3 such insurer in former s. 627.6492(1)(b), 1990 Supplement, as
4 amended by chapter 90-334, Laws of Florida.
5 (c)(d) All rights, title, and interest in the
6 assessment funds collected shall vest in this state. However,
7 all of such funds and interest earned shall be used by the
8 association to pay claims and administrative expenses.
9 (2) If assessments and other receipts by the
10 association, board, or administrator exceed the actual losses
11 and administrative expenses of the plan, the excess shall be
12 held at interest and used by the board to offset future
13 losses. As used in this subsection, the term "future losses"
14 includes reserves for claims incurred but not reported.
15 (3) Each insurer's assessment shall be determined
16 annually by the association based on annual statements and
17 other reports deemed necessary by the association and filed
18 with it by the insurer. Any deficit incurred under the plan
19 shall be recouped by assessments against participating
20 insurers by the board in the manner provided in subsection
21 (1); and the insurers may recover the assessment in the normal
22 course of their respective businesses without time limitation.
23 (4)(a) This subsection applies only to those costs and
24 expenses of the association related to persons whose coverage
25 begins after January 1, 2003. As a condition of doing business
26 in this state, every insurer shall pay an amount determined by
27 the board of up to 25 cents per month for each individual
28 policy or covered group subscriber insured in this state, not
29 including covered dependents, under a health insurance policy,
30 certificate, or other evidence of coverage that is issued for
31 a resident of this state and shall file the information with
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Bill No. CS for CS for SB's 1286, 1134 & 1008
Amendment No. ___ Barcode 374070
1 the association as required pursuant to paragraph (d). Any
2 insurer who neglects, fails, or refuses to collect the fee
3 shall be liable for and pay the fee. The fee shall not be
4 subject to the provisions of s. 624.509.
5 (b) For purposes of this subsection, health insurance
6 does not include accident only, specified disease, individual
7 hospital indemnity, credit, dental-only, vision-only, Medicare
8 supplement, long-term care, nursing home care, home health
9 care, community-based care, or disability income insurance;
10 similar supplemental plans provided under a separate policy,
11 certificate, or contract of insurance, which cannot duplicate
12 coverage under an underlying health plan and are specifically
13 designed to fill gaps in the underlying health plan,
14 coinsurance, or deductibles; any policy covering
15 medical-payment coverage or personal injury protection
16 coverage in a motor vehicle policy; coverage issued as a
17 supplement to liability insurance; or workers' compensation
18 insurance. For the purposes of this subsection, the term
19 "insurer" as defined in s. 627.6482(7) also includes
20 administrators licensed pursuant to s. 626.8805, and any
21 insurer defined in s. 627.6482(7) from whom any person
22 providing health insurance to Florida residents procures
23 insurance for itself in the insurer, with respect to all or
24 part of the health insurance risk of the person, or provides
25 administrative services only. This definition of insurer
26 excludes self-insured, employee welfare benefit plans that are
27 not regulated by the Florida Insurance Code pursuant to the
28 Employee Retirement Income Security Act of 1974, Pub. L. No.
29 93-406, as amended. However, this definition of insurer
30 includes multiple employer welfare arrangements as provided
31 for in the Employee Retirement Income Security Act of 1974,
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Bill No. CS for CS for SB's 1286, 1134 & 1008
Amendment No. ___ Barcode 374070
1 Pub. L. No. 93-406, as amended. Each covered group subscriber,
2 without regard to covered dependents of the subscriber, shall
3 be counted only once with respect to any assessment. For that
4 purpose, the board shall allow an insurer as defined by this
5 subsection to exclude from its number of covered group
6 subscribers those who have been counted by any primary insurer
7 providing health insurance coverage pursuant to s. 624.603.
8 (c) The calculation shall be determined as of December
9 31 of each year and shall include all policies and covered
10 subscribers, not including covered dependents of the
11 subscribers, insured at any time during the year, calculated
12 for each month of coverage. The payment is payable to the
13 association no later than April 1 of the subsequent year. The
14 first payment shall be forwarded to the association no later
15 than April 1, 2003, covering the period of October 1, 2002,
16 through December 31, 2002.
17 (d) The payment of such funds shall be submitted to
18 the association accompanied by a form prescribed by the
19 association and adopted in the plan of operation. The form
20 shall identify the number of covered lives for different types
21 of health insurance products and the number of months of
22 coverage.
23 (e) Beginning October 1, 2002, the fee paid to the
24 association may be charged by the health insurer directly to
25 each policyholder, insured member, or subscriber and is not
26 part of the premium subject to the department's review and
27 approval. Nonpayment of the fee shall be considered nonpayment
28 of premium for purposes of s. 627.6043.
29 Section 33. Effective July 1, 2002, section 627.6498,
30 Florida Statutes, is amended to read:
31 627.6498 Minimum benefits coverage; exclusions;
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Bill No. CS for CS for SB's 1286, 1134 & 1008
Amendment No. ___ Barcode 374070
1 premiums; deductibles.--
2 (1) COVERAGE OFFERED.--
3 (a) The plan shall offer in an annually a semiannually
4 renewable policy the coverage specified in this section for
5 each eligible person. For applications accepted on or after
6 June 7, 1991, but before July 1, 1991, coverage shall be
7 effective on July 1, 1991, and shall be renewable on January
8 1, 1992, and every 6 months thereafter. Policies in existence
9 on June 7, 1991, shall, upon renewal, be for a term of less
10 than 6 months that terminates and becomes subject to
11 subsequent renewal on the next succeeding January 1 or July 1,
12 whichever is sooner.
13 (b) If an eligible person is also eligible for
14 Medicare coverage, the plan shall not pay or reimburse any
15 person for expenses paid by Medicare.
16 (c) Any person whose health insurance coverage is
17 involuntarily terminated for any reason other than nonpayment
18 of premium may apply for coverage under the plan. If such
19 coverage is applied for within 60 days after the involuntary
20 termination and if premiums are paid for the entire period of
21 coverage, the effective date of the coverage shall be the date
22 of termination of the previous coverage.
23 (b)(d) The plan shall provide that, upon the death or
24 divorce of the individual in whose name the contract was
25 issued, every other person then covered in the contract may
26 elect within 60 days to continue under the same or a different
27 contract.
28 (c)(e) No coverage provided to a person who is
29 eligible for Medicare benefits shall be issued as a Medicare
30 supplement policy as defined in s. 627.672.
31 (2) BENEFITS.--
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Bill No. CS for CS for SB's 1286, 1134 & 1008
Amendment No. ___ Barcode 374070
1 (a) The plan must offer coverage to every eligible
2 person subject to limitations set by the association. The
3 coverage offered must pay an eligible person's covered
4 expenses, subject to limits on the deductible and coinsurance
5 payments authorized under subsection (4). The lifetime
6 benefits limit for such coverage shall be $500,000. However,
7 policyholders of association policies issued prior to 1993 are
8 entitled to continued coverage at the benefit level
9 established prior to January 1, 2003. Only the premium,
10 deductible, and coinsurance amounts may be modified as
11 determined necessary by the board. The plan shall offer major
12 medical expense coverage similar to that provided by the state
13 group health insurance program as defined in s. 110.123 except
14 as specified in subsection (3) to every eligible person who is
15 not eligible for Medicare. Major medical expense coverage
16 offered under the plan shall pay an eligible person's covered
17 expenses, subject to limits on the deductible and coinsurance
18 payments authorized under subsection (4), up to a lifetime
19 limit of $500,000 per covered individual. The maximum limit
20 under this paragraph shall not be altered by the board, and no
21 actuarially equivalent benefit may be substituted by the
22 board.
23 (b) The plan shall provide that any policy issued to a
24 person eligible for Medicare shall be separately rated to
25 reflect differences in experience reasonably expected to occur
26 as a result of Medicare payments.
27 (3) COVERED EXPENSES.--
28 (a) The board shall establish the coverage to be
29 issued by the association.
30 (b) If the coverage is being issued to an eligible
31 individual as defined in s. 627.6487, the individual shall be
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Bill No. CS for CS for SB's 1286, 1134 & 1008
Amendment No. ___ Barcode 374070
1 offered, at the option of the individual, the basic and the
2 standard health benefit plan as established in s. 627.6699.
3 The coverage to be issued by the association shall be
4 patterned after the state group health insurance program as
5 defined in s. 110.123, including its benefits, exclusions, and
6 other limitations, except as otherwise provided in this act.
7 The plan may cover the cost of experimental drugs which have
8 been approved for use by the Food and Drug Administration on
9 an experimental basis if the cost is less than the usual and
10 customary treatment. Such coverage shall only apply to those
11 insureds who are in the case management system upon the
12 approval of the insured, the case manager, and the board.
13 (4) PREMIUMS AND, DEDUCTIBLES, AND COINSURANCE.--
14 (a) The plan shall provide for annual deductibles for
15 major medical expense coverage in the amount of $1,000 or any
16 higher amounts proposed by the board and approved by the
17 department, plus the benefits payable under any other type of
18 insurance coverage or workers' compensation. The schedule of
19 premiums and deductibles shall be established by the board
20 association. With regard to any preferred provider arrangement
21 utilized by the association, the deductibles provided in this
22 paragraph shall be the minimum deductibles applicable to the
23 preferred providers and higher deductibles, as approved by the
24 department, may be applied to providers who are not preferred
25 providers.
26 1. Separate schedules of premium rates based on age
27 may apply for individual risks.
28 2. Rates are subject to approval by the department
29 pursuant to ss. 627.410 and 627.411, except as provided by
30 this section. The board shall revise premium schedules
31 annually, beginning January 2003.
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Bill No. CS for CS for SB's 1286, 1134 & 1008
Amendment No. ___ Barcode 374070
1 3. Standard risk rates for coverages issued by the
2 association shall be established by the department, pursuant
3 to s. 627.6675(3).
4 3.4. The board shall establish three premium schedules
5 based upon an individual's family income:
6 a. Schedule A is applicable to an individual whose
7 family income exceeds the allowable amount for determining
8 eligibility under the Medicaid program, up to and including
9 200 percent of the Federal Poverty Level. Premiums for a
10 person under this schedule may not exceed 150 percent of the
11 standard risk rate.
12 b. Schedule B is applicable to an individual whose
13 family income exceeds 200 percent but is less than 300 percent
14 of the Federal Poverty Level. Premiums for a person under this
15 schedule may not exceed 250 percent of the standard risk rate.
16 c. Schedule C is applicable to an individual whose
17 family income is equal to or greater than 300 percent of the
18 Federal Poverty Level. Premiums for a person under this
19 schedule may not exceed 300 percent of the standard risk rate.
20 establish separate premium schedules for low-risk individuals,
21 medium-risk individuals, and high-risk individuals and shall
22 revise premium schedules annually beginning January 1999.
23 4. The standard risk rate shall be determined by the
24 department pursuant to s. 627.6675(3). The rate shall be
25 adjusted for benefit differences. No rate shall exceed 200
26 percent of the standard risk rate for low-risk individuals,
27 225 percent of the standard risk rate for medium-risk
28 individuals, or 250 percent of the standard risk rate for
29 high-risk individuals. For the purpose of determining what
30 constitutes a low-risk individual, medium-risk individual, or
31 high-risk individual, the board shall consider the anticipated
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Bill No. CS for CS for SB's 1286, 1134 & 1008
Amendment No. ___ Barcode 374070
1 claims payment for individuals based upon an individual's
2 health condition.
3 (b) If the covered costs incurred by the eligible
4 person exceed the deductible for major medical expense
5 coverage selected by the person in a policy year, the plan
6 shall pay in the following manner:
7 1. For individuals placed under case management, the
8 plan shall pay 90 percent of the additional covered costs
9 incurred by the person during the policy year for the first
10 $10,000, after which the plan shall pay 100 percent of the
11 covered costs incurred by the person during the policy year.
12 2. For individuals utilizing the preferred provider
13 network, the plan shall pay 80 percent of the additional
14 covered costs incurred by the person during the policy year
15 for the first $10,000, after which the plan shall pay 90
16 percent of covered costs incurred by the person during the
17 policy year.
18 3. If the person does not utilize either the case
19 management system or the preferred provider network, the plan
20 shall pay 60 percent of the additional covered costs incurred
21 by the person for the first $10,000, after which the plan
22 shall pay 70 percent of the additional covered costs incurred
23 by the person during the policy year.
24 (5) PREEXISTING CONDITIONS.--An association policy
25 shall may contain provisions under which coverage is excluded
26 during a period of 12 months following the effective date of
27 coverage with respect to a given covered individual for any
28 preexisting condition, as long as:
29 (a) The condition manifested itself within a period of
30 6 months before the effective date of coverage; or
31 (b) Medical advice or treatment was recommended or
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Bill No. CS for CS for SB's 1286, 1134 & 1008
Amendment No. ___ Barcode 374070
1 received within a period of 6 months before the effective date
2 of coverage.
3
4 This subsection does not apply to an eligible individual as
5 defined in s. 627.6487.
6 (6) OTHER SOURCES PRIMARY.--
7 (a) No amounts paid or payable by Medicare or any
8 other governmental program or any other insurance, or
9 self-insurance maintained in lieu of otherwise statutorily
10 required insurance, may be made or recognized as claims under
11 such policy or be recognized as or towards satisfaction of
12 applicable deductibles or out-of-pocket maximums or to reduce
13 the limits of benefits available.
14 (b) The association has a cause of action against a
15 participant for any benefits paid to the participant which
16 should not have been claimed or recognized as claims because
17 of the provisions of this subsection or because otherwise not
18 covered.
19 (7) NONENTITLEMENT.--The Florida Comprehensive Health
20 Association Act does not provide an individual with an
21 entitlement to health care services or health insurance. A
22 cause of action does not arise against the state, the board,
23 or the association for failure to make health services or
24 health insurance available under the Florida Comprehensive
25 Health Association Act.
26 Section 34. The Legislature finds that the provisions
27 of this act fulfill an important state interest.
28 Section 35. The amendments in this act to section
29 627.6487, Florida Statutes, shall not take effect unless the
30 Health Care Financing Administration of the U.S. Department of
31 Health and Human Services approves this act as providing an
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Bill No. CS for CS for SB's 1286, 1134 & 1008
Amendment No. ___ Barcode 374070
1 acceptable alternative mechanism, as provided in the Public
2 Health Service Act.
3 Section 36. Effective January 1, 2003, section
4 627.6484, Florida Statutes, is repealed.
5
6
7 ================ T I T L E A M E N D M E N T ===============
8 And the title is amended as follows:
9 On page 85, line 26, after the semicolon
10
11 insert:
12 amending s. 627.6482, F.S.; amending
13 definitions used in the Florida Comprehensive
14 Health Association Act; amending s. 627.6486,
15 F.S.; revising the criteria for eligibility for
16 coverage from the association; providing for
17 cessation of coverage; requiring all eligible
18 persons to agree to be placed in a
19 case-management system; amending s. 627.6487,
20 F.S.; redefining the term "eligible individual"
21 for purposes of guaranteed availability of
22 individual health insurance coverage; providing
23 that a person is not eligible if the person is
24 eligible for coverage under the Florida
25 Comprehensive Health Association; amending s.
26 627.6488, F.S.; revising the membership of the
27 board of directors of the association; revising
28 the reimbursement of board members and
29 employees; requiring that the plan of the
30 association be submitted to the department for
31 approval on an annual basis; revising the
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Bill No. CS for CS for SB's 1286, 1134 & 1008
Amendment No. ___ Barcode 374070
1 duties of the association related to
2 administrative and accounting procedures;
3 requiring an annual financial audit; specifying
4 grievance procedures; establishing a premium
5 schedule based upon an individual's family
6 income; deleting requirements for categorizing
7 insureds as low-risk, medium-risk, and
8 high-risk; authorizing the association to place
9 an individual with a case manager who
10 determines the health care system or provider;
11 requiring an annual review of the actuarial
12 soundness of the association and the
13 feasibility of enrolling new members; requiring
14 a separate account for policyholders insured
15 prior to a specified date; requiring
16 appointment of an executive director with
17 specified duties; authorizing the board to
18 restrict the number of participants based on
19 inadequate funding; limiting enrollment;
20 specifying other powers of the board; amending
21 s. 627.649, F.S.; revising the requirements for
22 the association to use in selecting an
23 administrator; amending s. 627.6492, F.S.;
24 requiring insurers to be members of the
25 association and to be subject to assessments
26 for operating expenses; limiting assessments to
27 specified maximum amounts; specifying when
28 assessments are calculated and paid; allowing
29 certain assessments to be charged by the health
30 insurer directly to each insured, member, or
31 subscriber and to not be subject to department
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Bill No. CS for CS for SB's 1286, 1134 & 1008
Amendment No. ___ Barcode 374070
1 review or approval; amending s. 627.6498, F.S.;
2 revising the coverage, benefits, covered
3 expenses, premiums, and deductibles of the
4 association; requiring preexisting condition
5 limitations; providing that the act does not
6 provide an entitlement to health care services
7 or health insurance and does not create a cause
8 of action; limiting enrollment in the
9 association; repealing s. 627.6484, F.S.,
10 relating to a prohibition on the Florida
11 Comprehensive Health Association from accepting
12 applications for coverage after a certain date;
13 making a legislative finding that the
14 provisions of this act fulfill an important
15 state interest; providing that the amendments
16 to s. 627.6487, F.S., do not take effect unless
17 approved by the U.S. Health Care Financing
18 Administration;
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