CODING: Words stricken are deletions; words underlined are additions.
e2211444
House
h0900-99
h0913
2002
AA
913362
Senator Rossin moved the following amendment to amendment
(913362):
On page 79, between lines 14 and 15,
On page 85, line 26,




                                                  SENATE AMENDMENT

    Bill No. CS/HB 913, 2nd Eng.

    Amendment No. ___   Barcode 211444

                            CHAMBER ACTION
              Senate                               House
                                   .
                                   .
  1                                .
                                   .
  2                                .
                                   .
  3                                .
                                   .
  4  ______________________________________________________________

  5

  6

  7

  8

  9

10  ______________________________________________________________

11  Senator Rossin moved the following amendment to amendment

12  (913362):

13

14         Senate Amendment (with title amendment) 

15         On page 79, between lines 14 and 15,

16

17  insert:

18         Section 27.   Effective July 1, 2002, subsection (12)

19  of 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

                                  1
    8:51 PM   03/20/02                              h0913c1c-351ie




                                                  SENATE AMENDMENT

    Bill No. CS/HB 913, 2nd Eng.

    Amendment No. ___   Barcode 211444





  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

                                  2
    8:51 PM   03/20/02                              h0913c1c-351ie




                                                  SENATE AMENDMENT

    Bill No. CS/HB 913, 2nd Eng.

    Amendment No. ___   Barcode 211444





  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

                                  3
    8:51 PM   03/20/02                              h0913c1c-351ie




                                                  SENATE AMENDMENT

    Bill No. CS/HB 913, 2nd Eng.

    Amendment No. ___   Barcode 211444





  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

                                  4
    8:51 PM   03/20/02                              h0913c1c-351ie




                                                  SENATE AMENDMENT

    Bill No. CS/HB 913, 2nd Eng.

    Amendment No. ___   Barcode 211444





  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

                                  5
    8:51 PM   03/20/02                              h0913c1c-351ie




                                                  SENATE AMENDMENT

    Bill No. CS/HB 913, 2nd Eng.

    Amendment No. ___   Barcode 211444





  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

                                  6
    8:51 PM   03/20/02                              h0913c1c-351ie




                                                  SENATE AMENDMENT

    Bill No. CS/HB 913, 2nd Eng.

    Amendment No. ___   Barcode 211444





  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

                                  7
    8:51 PM   03/20/02                              h0913c1c-351ie




                                                  SENATE AMENDMENT

    Bill No. CS/HB 913, 2nd Eng.

    Amendment No. ___   Barcode 211444





  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.

                                  8
    8:51 PM   03/20/02                              h0913c1c-351ie




                                                  SENATE AMENDMENT

    Bill No. CS/HB 913, 2nd Eng.

    Amendment No. ___   Barcode 211444





  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.

                                  9
    8:51 PM   03/20/02                              h0913c1c-351ie




                                                  SENATE AMENDMENT

    Bill No. CS/HB 913, 2nd Eng.

    Amendment No. ___   Barcode 211444





  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

                                  10
    8:51 PM   03/20/02                              h0913c1c-351ie




                                                  SENATE AMENDMENT

    Bill No. CS/HB 913, 2nd Eng.

    Amendment No. ___   Barcode 211444





  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,

                                  11
    8:51 PM   03/20/02                              h0913c1c-351ie




                                                  SENATE AMENDMENT

    Bill No. CS/HB 913, 2nd Eng.

    Amendment No. ___   Barcode 211444





  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

                                  12
    8:51 PM   03/20/02                              h0913c1c-351ie




                                                  SENATE AMENDMENT

    Bill No. CS/HB 913, 2nd Eng.

    Amendment No. ___   Barcode 211444





  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

                                  13
    8:51 PM   03/20/02                              h0913c1c-351ie




                                                  SENATE AMENDMENT

    Bill No. CS/HB 913, 2nd Eng.

    Amendment No. ___   Barcode 211444





  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

                                  14
    8:51 PM   03/20/02                              h0913c1c-351ie




                                                  SENATE AMENDMENT

    Bill No. CS/HB 913, 2nd Eng.

    Amendment No. ___   Barcode 211444





  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

                                  15
    8:51 PM   03/20/02                              h0913c1c-351ie




                                                  SENATE AMENDMENT

    Bill No. CS/HB 913, 2nd Eng.

    Amendment No. ___   Barcode 211444





  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

                                  16
    8:51 PM   03/20/02                              h0913c1c-351ie




                                                  SENATE AMENDMENT

    Bill No. CS/HB 913, 2nd Eng.

    Amendment No. ___   Barcode 211444





  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,

                                  17
    8:51 PM   03/20/02                              h0913c1c-351ie




                                                  SENATE AMENDMENT

    Bill No. CS/HB 913, 2nd Eng.

    Amendment No. ___   Barcode 211444





  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

                                  18
    8:51 PM   03/20/02                              h0913c1c-351ie




                                                  SENATE AMENDMENT

    Bill No. CS/HB 913, 2nd Eng.

    Amendment No. ___   Barcode 211444





  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,

                                  19
    8:51 PM   03/20/02                              h0913c1c-351ie




                                                  SENATE AMENDMENT

    Bill No. CS/HB 913, 2nd Eng.

    Amendment No. ___   Barcode 211444





  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;

                                  20
    8:51 PM   03/20/02                              h0913c1c-351ie




                                                  SENATE AMENDMENT

    Bill No. CS/HB 913, 2nd Eng.

    Amendment No. ___   Barcode 211444





  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.--

                                  21
    8:51 PM   03/20/02                              h0913c1c-351ie




                                                  SENATE AMENDMENT

    Bill No. CS/HB 913, 2nd Eng.

    Amendment No. ___   Barcode 211444





  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

                                  22
    8:51 PM   03/20/02                              h0913c1c-351ie




                                                  SENATE AMENDMENT

    Bill No. CS/HB 913, 2nd Eng.

    Amendment No. ___   Barcode 211444





  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.

                                  23
    8:51 PM   03/20/02                              h0913c1c-351ie




                                                  SENATE AMENDMENT

    Bill No. CS/HB 913, 2nd Eng.

    Amendment No. ___   Barcode 211444





  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

                                  24
    8:51 PM   03/20/02                              h0913c1c-351ie




                                                  SENATE AMENDMENT

    Bill No. CS/HB 913, 2nd Eng.

    Amendment No. ___   Barcode 211444





  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

                                  25
    8:51 PM   03/20/02                              h0913c1c-351ie




                                                  SENATE AMENDMENT

    Bill No. CS/HB 913, 2nd Eng.

    Amendment No. ___   Barcode 211444





  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

                                  26
    8:51 PM   03/20/02                              h0913c1c-351ie




                                                  SENATE AMENDMENT

    Bill No. CS/HB 913, 2nd Eng.

    Amendment No. ___   Barcode 211444





  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

                                  27
    8:51 PM   03/20/02                              h0913c1c-351ie




                                                  SENATE AMENDMENT

    Bill No. CS/HB 913, 2nd Eng.

    Amendment No. ___   Barcode 211444





  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

                                  28
    8:51 PM   03/20/02                              h0913c1c-351ie




                                                  SENATE AMENDMENT

    Bill No. CS/HB 913, 2nd Eng.

    Amendment No. ___   Barcode 211444





  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;

19

20

21

22

23

24

25

26

27

28

29

30

31

                                  29
    8:51 PM   03/20/02                              h0913c1c-351ie