Senate Bill sb2358
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Florida Senate - 2002 SB 2358
By Senator Posey
15-1072A-02
1 A bill to be entitled
2 An act relating to health care coverage;
3 amending ss. 641.31072, 627.65615, 110.123,
4 F.S.; providing for special enrollment periods
5 for employees under specified circumstances
6 relating to termination of contracts between an
7 insurer and an employee's or dependent's
8 primary care physician; providing for
9 applicability; providing an effective date.
10
11 Be It Enacted by the Legislature of the State of Florida:
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13 Section 1. Subsection (1) of section 641.31072,
14 Florida Statutes, is amended to read:
15 641.31072 Special enrollment periods.--
16 (1) A health maintenance organization that issues a
17 group health insurance policy shall permit an employee who is
18 eligible, but not enrolled, for coverage under the terms of
19 the contract, or a dependent of such an employee if the
20 dependent is eligible but not enrolled for coverage under such
21 terms, to enroll for coverage under the terms of the contract
22 if:
23 (a) Each of the following conditions is met:
24 1.(a) The employee or dependent was covered under a
25 group health plan or had health insurance coverage at the time
26 coverage was previously offered to the employee or dependent.
27 For the purpose of this section, the terms "group health plan"
28 and "health insurance coverage" have the same meaning ascribed
29 in s. 2791 of the Public Health Service Act.
30 2.(b) The employee stated in writing at such time that
31 coverage under a group health plan or health insurance
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1 coverage was the reason for declining enrollment, but only if
2 the plan sponsor or health maintenance organization, if
3 applicable, required such a statement at such time and
4 provided the employee with notice of such requirement and the
5 consequences of such requirement at such time.
6 3.(c) The employee's or dependent's coverage described
7 in subparagraph 1. paragraph (a):
8 a.1. Was under a COBRA continuation provision or
9 continuation pursuant to s. 627.6692, and the coverage under
10 such provision was exhausted; or
11 b.2. Was not under such a provision and the coverage
12 was terminated as a result of loss of eligibility for the
13 coverage, including legal separation, divorce, death,
14 termination of employment, or reduction in the number of hours
15 of employment, or the coverage was terminated as a result of
16 the termination of employer contributions toward such
17 coverage.
18 4.(d) Under the terms of the contract, the employee
19 requests such enrollment not later than 30 days after the date
20 of exhaustion of coverage described in subparagraph (c)1., or
21 termination of or employer contribution described in
22 sub-subparagraph 3.b.; or subparagraph (c)2.
23 (b) The employee's or enrollee's dependent's
24 individual primary care physician's contract was terminated by
25 the health maintenance organization before the renewal date of
26 the group health plan; the employer or plan sponsor offers the
27 choice of two or more group health plans to each employee at
28 the time the employee's or dependent's individual primary care
29 physician's contract was terminated; and, under the terms of
30 the contract, the employee requests such enrollment not later
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1 than 30 days after the date of termination of the employee's
2 or dependent's individual primary care physician's contract.
3 Section 2. Subsection (1) of section 627.65615,
4 Florida Statutes, is amended to read:
5 627.65615 Special enrollment periods.--
6 (1) An insurer that issues a group health insurance
7 policy shall permit an employee who is eligible, but not
8 enrolled, for coverage under the terms of the policy, or a
9 dependent of such an employee if the dependent is eligible but
10 not enrolled for coverage under such terms, to enroll for
11 coverage under the terms of the policy if:
12 (a) Each of the following conditions is met:
13 1.(a) The employee or dependent was covered under a
14 group health plan or had health insurance coverage at the time
15 coverage was previously offered to the employee or dependent.
16 For the purpose of this section, the terms "group health plan"
17 and "health insurance coverage" have the same meaning ascribed
18 in s. 2791 of the Public Health Service Act.
19 2.(b) The employee stated in writing at such time that
20 coverage under a group health plan or health insurance
21 coverage was the reason for declining enrollment, but only if
22 the plan sponsor or insurer, if applicable, required such a
23 statement at such time and provided the employee with notice
24 of such requirement and the consequences of such requirement
25 at such time.
26 3.(c) The employee's or dependent's coverage described
27 in subparagraph 1. paragraph (a):
28 a.1. Was under a COBRA continuation provision or
29 continuation pursuant to s. 627.6692, and the coverage under
30 such provision was exhausted; or
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Florida Senate - 2002 SB 2358
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1 b.2. Was not under such a provision and the coverage
2 was terminated as a result of loss of eligibility for the
3 coverage, including legal separation, divorce, death,
4 termination of employment, or reduction in the number of hours
5 of employment, or the coverage was terminated as a result of
6 the termination of employer contributions toward such
7 coverage.
8 4.(d) Under the terms of the plan, the employee
9 requests such enrollment not later than 30 days after the date
10 of exhaustion of coverage described in subparagraph (c)1., or
11 termination of or employer contribution described in
12 sub-subparagraph 3.b.; or subparagraph (c)2.
13 (b) The employee's or enrollee's dependent's
14 individual primary care physician's contract was terminated by
15 the insurer before the renewal date of the group health plan;
16 the employer or plan sponsor offers the choice of two or more
17 group health plans to each employee at the time the employee's
18 or dependent's individual primary care physician's contract
19 was terminated; and, under the terms of the contract, the
20 employee requests such enrollment not later than 30 days after
21 the date of termination of the employee's or dependent's
22 individual primary care physician's contract.
23 Section 3. Paragraph (h) of subsection (3) of section
24 110.123, Florida Statutes, is amended to read:
25 110.123 State group insurance program.--
26 (3) STATE GROUP INSURANCE PROGRAM.--
27 (h)1. A person eligible to participate in the state
28 group insurance program may be authorized by rules adopted by
29 the department, in lieu of participating in the state group
30 health insurance plan, to exercise an option to elect
31 membership in a health maintenance organization plan which is
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1 under contract with the state in accordance with criteria
2 established by this section and by said rules. The offer of
3 optional membership in a health maintenance organization plan
4 permitted by this paragraph may be limited or conditioned by
5 rule as may be necessary to meet the requirements of state and
6 federal laws.
7 2. The department shall contract with health
8 maintenance organizations seeking to participate in the state
9 group insurance program through a request for proposal or
10 other procurement process, as developed by the Department of
11 Management Services and determined to be appropriate.
12 a. The department shall establish a schedule of
13 minimum benefits for health maintenance organization coverage,
14 and that schedule shall include: physician services; inpatient
15 and outpatient hospital services; emergency medical services,
16 including out-of-area emergency coverage; diagnostic
17 laboratory and diagnostic and therapeutic radiologic services;
18 mental health, alcohol, and chemical dependency treatment
19 services meeting the minimum requirements of state and federal
20 law; skilled nursing facilities and services; prescription
21 drugs; and other benefits as may be required by the
22 department. Additional services may be provided subject to
23 the contract between the department and the HMO.
24 b. The department may establish uniform deductibles,
25 copayments, or coinsurance schedules for all participating HMO
26 plans.
27 c. The department may require detailed information
28 from each health maintenance organization participating in the
29 procurement process, including information pertaining to
30 organizational status, experience in providing prepaid health
31 benefits, accessibility of services, financial stability of
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1 the plan, quality of management services, accreditation
2 status, quality of medical services, network access and
3 adequacy, performance measurement, ability to meet the
4 department's reporting requirements, and the actuarial basis
5 of the proposed rates and other data determined by the
6 director to be necessary for the evaluation and selection of
7 health maintenance organization plans and negotiation of
8 appropriate rates for these plans. Upon receipt of proposals
9 by health maintenance organization plans and the evaluation of
10 those proposals, the department may enter into negotiations
11 with all of the plans or a subset of the plans, as the
12 department determines appropriate. Nothing shall preclude the
13 department from negotiating regional or statewide contracts
14 with health maintenance organization plans when this is
15 cost-effective and when the department determines that the
16 plan offers high value to enrollees.
17 d. The department may limit the number of HMOs that it
18 contracts with in each service area based on the nature of the
19 bids the department receives, the number of state employees in
20 the service area, or any unique geographical characteristics
21 of the service area. The department shall establish by rule
22 service areas throughout the state.
23 e. All persons participating in the state group
24 insurance program who are required to contribute towards a
25 total state group health premium shall be subject to the same
26 dollar contribution regardless of whether the enrollee enrolls
27 in the state group health insurance plan or in an HMO plan.
28 3. The department is authorized to negotiate and to
29 contract with specialty psychiatric hospitals for mental
30 health benefits, on a regional basis, for alcohol, drug abuse,
31 and mental and nervous disorders. The department may
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1 establish, subject to the approval of the Legislature pursuant
2 to subsection (5), any such regional plan upon completion of
3 an actuarial study to determine any impact on plan benefits
4 and premiums.
5 4. In addition to contracting pursuant to subparagraph
6 2., the department shall enter into contract with any HMO to
7 participate in the state group insurance program which:
8 a. Serves greater than 5,000 recipients on a prepaid
9 basis under the Medicaid program;
10 b. Does not currently meet the 25-percent
11 non-Medicare/non-Medicaid enrollment composition requirement
12 established by the Department of Health excluding participants
13 enrolled in the state group insurance program;
14 c. Meets the minimum benefit package and copayments
15 and deductibles contained in sub-subparagraphs 2.a. and b.;
16 d. Is willing to participate in the state group
17 insurance program at a cost of premiums that is not greater
18 than 95 percent of the cost of HMO premiums accepted by the
19 department in each service area; and
20 e. Meets the minimum surplus requirements of s.
21 641.225.
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23 The department is authorized to contract with HMOs that meet
24 the requirements of sub-subparagraphs a.-d. prior to the open
25 enrollment period for state employees. The department is not
26 required to renew the contract with the HMOs as set forth in
27 this paragraph more than twice. Thereafter, the HMOs shall be
28 eligible to participate in the state group insurance program
29 only through the request for proposal process described in
30 subparagraph 2.
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1 5. All enrollees in the state group health insurance
2 plan or any health maintenance organization plan shall have
3 the option of changing to any other health plan which is
4 offered by the state within any open enrollment period
5 designated by the department. Open enrollment shall be held at
6 least once each calendar year. In addition to other events
7 that constitute an open enrollment period, the enrollee shall
8 be granted a special open enrollment period if the enrollee's
9 or the enrollee's dependent's individual primary care
10 physician's contract is terminated by the health maintenance
11 organization.
12 6. When a contract between a treating provider and the
13 state-contracted health maintenance organization is terminated
14 for any reason other than for cause, each party shall allow
15 any enrollee for whom treatment was active to continue
16 coverage and care when medically necessary, through completion
17 of treatment of a condition for which the enrollee was
18 receiving care at the time of the termination, until the
19 enrollee selects another treating provider, or until the next
20 open enrollment period offered, whichever is longer, but no
21 longer than 6 months after termination of the contract. Each
22 party to the terminated contract shall allow an enrollee who
23 has initiated a course of prenatal care, regardless of the
24 trimester in which care was initiated, to continue care and
25 coverage until completion of postpartum care. This does not
26 prevent a provider from refusing to continue to provide care
27 to an enrollee who is abusive, noncompliant, or in arrears in
28 payments for services provided. For care continued under this
29 subparagraph, the program and the provider shall continue to
30 be bound by the terms of the terminated contract. Changes made
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1 within 30 days before termination of a contract are effective
2 only if agreed to by both parties.
3 7. Any HMO participating in the state group insurance
4 program shall submit health care utilization and cost data to
5 the department, in such form and in such manner as the
6 department shall require, as a condition of participating in
7 the program. The department shall enter into negotiations
8 with its contracting HMOs to determine the nature and scope of
9 the data submission and the final requirements, format,
10 penalties associated with noncompliance, and timetables for
11 submission. These determinations shall be adopted by rule.
12 8. The department may establish and direct, with
13 respect to collective bargaining issues, a comprehensive
14 package of insurance benefits that may include supplemental
15 health and life coverage, dental care, long-term care, vision
16 care, and other benefits it determines necessary to enable
17 state employees to select from among benefit options that best
18 suit their individual and family needs.
19 a. Based upon a desired benefit package, the
20 department shall issue a request for proposal for health
21 insurance providers interested in participating in the state
22 group insurance program, and the department shall issue a
23 request for proposal for insurance providers interested in
24 participating in the non-health-related components of the
25 state group insurance program. Upon receipt of all proposals,
26 the department may enter into contract negotiations with
27 insurance providers submitting bids or negotiate a specially
28 designed benefit package. Insurance providers offering or
29 providing supplemental coverage as of May 30, 1991, which
30 qualify for pretax benefit treatment pursuant to s. 125 of the
31 Internal Revenue Code of 1986, with 5,500 or more state
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1 employees currently enrolled may be included by the department
2 in the supplemental insurance benefit plan established by the
3 department without participating in a request for proposal,
4 submitting bids, negotiating contracts, or negotiating a
5 specially designed benefit package. These contracts shall
6 provide state employees with the most cost-effective and
7 comprehensive coverage available; however, no state or agency
8 funds shall be contributed toward the cost of any part of the
9 premium of such supplemental benefit plans. With respect to
10 dental coverage, the division shall include in any
11 solicitation or contract for any state group dental program
12 made after July 1, 2001, a comprehensive indemnity dental plan
13 option which offers enrollees a completely unrestricted choice
14 of dentists. If a dental plan is endorsed, or in some manner
15 recognized as the preferred product, such plan shall include a
16 comprehensive indemnity dental plan option which provides
17 enrollees with a completely unrestricted choice of dentists.
18 b. Pursuant to the applicable provisions of s.
19 110.161, and s. 125 of the Internal Revenue Code of 1986, the
20 department shall enroll in the pretax benefit program those
21 state employees who voluntarily elect coverage in any of the
22 supplemental insurance benefit plans as provided by
23 sub-subparagraph a.
24 c. Nothing herein contained shall be construed to
25 prohibit insurance providers from continuing to provide or
26 offer supplemental benefit coverage to state employees as
27 provided under existing agency plans.
28 Section 4. This act shall take effect July 1, 2002,
29 and apply to insurance and managed care contracts issued,
30 renewed, or amended on or after October 1, 2002.
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2 SENATE SUMMARY
3 Requires a health maintenance organization, a group
health insurer, and the state to offer an open enrollment
4 period to an enrollee if the enrollee or enrollee's
dependent's primary care physician's contract with the
5 provider has been terminated.
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