CODING: Words stricken are deletions; words underlined are additions.
HOUSE AMENDMENT
Bill No. CS/HB 913, 1st Eng.
Amendment No. ___ (for drafter's use only)
CHAMBER ACTION
Senate House
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5 ORIGINAL STAMP BELOW
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11 Representative(s) Sobel offered the following:
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13 Amendment (with directory language and title
14 amendments)
15 On page 8, line 6, through page 12, line 16,
16 remove: all of said lines,
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18 and insert:
19 (b)1. Each small employer carrier issuing new health
20 benefit plans shall offer to any small employer, upon request,
21 a standard health benefit plan and a basic health benefit plan
22 that meets the criteria set forth in this section.
23 2. For purposes of this subsection, the terms
24 "standard health benefit plan" and "basic health benefit plan"
25 mean policies or contracts that a small employer carrier
26 offers to eligible small employers that contain:
27 a. An exclusion for services that are not medically
28 necessary or that are not covered preventive health services;
29 and
30 b. A procedure for preauthorization by the small
31 employer carrier, or its designees.
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HOUSE AMENDMENT
Bill No. CS/HB 913, 1st Eng.
Amendment No. ___ (for drafter's use only)
1 3. A small employer carrier may include the following
2 managed care provisions in the policy or contract to control
3 costs:
4 a. A preferred provider arrangement or exclusive
5 provider organization or any combination thereof, in which a
6 small employer carrier enters into a written agreement with
7 the provider to provide services at specified levels of
8 reimbursement or to provide reimbursement to specified
9 providers. Any such written agreement between a provider and a
10 small employer carrier must contain a provision under which
11 the parties agree that the insured individual or covered
12 member has no obligation to make payment for any medical
13 service rendered by the provider which is determined not to be
14 medically necessary. A carrier may use preferred provider
15 arrangements or exclusive provider arrangements to the same
16 extent as allowed in group products that are not issued to
17 small employers.
18 b. A procedure for utilization review by the small
19 employer carrier or its designees.
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21 This subparagraph does not prohibit a small employer carrier
22 from including in its policy or contract additional managed
23 care and cost containment provisions, subject to the approval
24 of the department, which have potential for controlling costs
25 in a manner that does not result in inequitable treatment of
26 insureds or subscribers. The carrier may use such provisions
27 to the same extent as authorized for group products that are
28 not issued to small employers.
29 4. The standard health benefit plan and any flexible
30 benefit policy or contract shall include:
31 a. Coverage for inpatient hospitalization;
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HOUSE AMENDMENT
Bill No. CS/HB 913, 1st Eng.
Amendment No. ___ (for drafter's use only)
1 b. Coverage for outpatient services;
2 c. Coverage for newborn children pursuant to s.
3 627.6575;
4 d. Coverage for child care supervision services
5 pursuant to s. 627.6579;
6 e. Coverage for adopted children upon placement in the
7 residence pursuant to s. 627.6578;
8 f. Coverage for mammograms pursuant to s. 627.6613;
9 g. Coverage for handicapped children pursuant to s.
10 627.6615;
11 h. Emergency or urgent care out of the geographic
12 service area; and
13 i. Coverage for services provided by a hospice
14 licensed under s. 400.602 in cases where such coverage would
15 be the most appropriate and the most cost-effective method for
16 treating a covered illness.
17 5. The standard health benefit plan and the basic
18 health benefit plan may include a schedule of benefit
19 limitations for specified services and procedures. If the
20 committee develops such a schedule of benefits limitation for
21 the standard health benefit plan or the basic health benefit
22 plan, a small employer carrier offering the plan must offer
23 the employer an option for increasing the benefit schedule
24 amounts by 4 percent annually.
25 6. The basic health benefit plan shall include all of
26 the benefits specified in subparagraph 4.; however, the basic
27 health benefit plan shall place additional restrictions on the
28 benefits and utilization and may also impose additional cost
29 containment measures.
30 7. Sections 627.419(2), (3), and (4), 627.6574,
31 627.6612, 627.66121, 627.66122, 627.6616, 627.6618, 627.668,
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hmo0011 12:56 pm 00913-0100-860017
HOUSE AMENDMENT
Bill No. CS/HB 913, 1st Eng.
Amendment No. ___ (for drafter's use only)
1 627.66911, 627.4239, 627.65755, 627.6691, 627.4232, 627.42395,
2 627.65745, and 627.6619 apply to the standard health benefit
3 plan, to any flexible benefit policy or contract, and to the
4 basic health benefit plan. However, notwithstanding said
5 provisions, the plans may specify limits on the number of
6 authorized treatments, if such limits are reasonable and do
7 not discriminate against any type of provider.
8 8. Each small employer carrier that provides for
9 inpatient and outpatient services by allopathic hospitals may
10 provide as an option of the insured similar inpatient and
11 outpatient services by hospitals accredited by the American
12 Osteopathic Association when such services are available and
13 the osteopathic hospital agrees to provide the service.
14 (c) If a small employer rejects, in writing, the
15 standard health benefit plan and the basic health benefit
16 plan, the small employer carrier may offer the small employer
17 a flexible limited benefit policy or contract.
18 (d)1. Upon offering coverage under a standard health
19 benefit plan, a basic health benefit plan, or a flexible
20 limited benefit policy or contract for any small employer, the
21 small employer carrier shall disclose in writing to the
22 provide such employer group with a written statement that
23 contains, at a minimum:
24 a. An explanation of those mandated benefits and
25 providers that are not covered by the policy or contract;
26 a.b. An outline of coverage together explanation of
27 the managed care and cost control features of the policy or
28 contract, along with all appropriate mailing addresses and
29 telephone numbers to be used by insureds in seeking
30 information or authorization.; and
31 b.c. An explanation of The primary and preventive care
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HOUSE AMENDMENT
Bill No. CS/HB 913, 1st Eng.
Amendment No. ___ (for drafter's use only)
1 features of the policy or contract.
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3 Such disclosure statement must be presented in a clear and
4 understandable form and format and must be separate from the
5 policy or certificate or evidence of coverage provided to the
6 employer group.
7 2. Before a small employer carrier issues a standard
8 health benefit plan, a basic health benefit plan, or a limited
9 benefit policy or contract, it must obtain from the
10 prospective policyholder a signed written statement in which
11 the prospective policyholder:
12 a. Certifies as to eligibility for coverage under the
13 standard health benefit plan, basic health benefit plan, or
14 limited benefit policy or contract;
15 c.b. Acknowledges The limited nature of the coverage
16 and an understanding of the managed care and cost control
17 features of the policy or contract.;
18 c. Acknowledges that if misrepresentations are made
19 regarding eligibility for coverage under a standard health
20 benefit plan, a basic health benefit plan, or a limited
21 benefit policy or contract, the person making such
22 misrepresentations forfeits coverage provided by the policy or
23 contract; and
24 2.d. If a flexible benefit policy or contract limited
25 plan is requested, the prospective policyholder must
26 acknowledge in writing acknowledges that he or she the
27 prospective policyholder had been offered, at the time of
28 application for the insurance policy or contract, the
29 opportunity to purchase any health benefit plan offered by the
30 carrier and that the prospective policyholder had rejected
31 that coverage.
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HOUSE AMENDMENT
Bill No. CS/HB 913, 1st Eng.
Amendment No. ___ (for drafter's use only)
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2 A copy of such written statement shall be provided to the
3 prospective policyholder no later than at the time of delivery
4 of the policy or contract, and the original of such written
5 statement shall be retained in the files of the small employer
6 carrier for the period of time that the policy or contract
7 remains in effect or for 5 years, whichever period is longer.
8 3. Any material statement made by an applicant for
9 coverage under a health benefit plan which falsely certifies
10 as to the applicant's eligibility for coverage serves as the
11 basis for terminating coverage under the policy or contract.
12 3.4. Each marketing communication that is intended to
13 be used in the marketing of a health benefit plan in this
14 state must be submitted for review by the department prior to
15 use and must contain the disclosures stated in this
16 subsection.
17 4. The contract, policy, and certificates evidencing
18 coverage under a flexible benefit policy or contract and the
19 application for coverage under such plans must state in not
20 less than 12-point bold type on the first page in contrasting
21 color the following: "The benefits provided by this health
22 plan are limited and may not cover all of your medical needs.
23 You should carefully review the benefits offered under this
24 health plan."
25 (e) A small employer carrier may not use any policy,
26 contract, form, or rate under this section, including
27 applications, enrollment forms, policies, contracts,
28 certificates, evidences of coverage, riders, amendments,
29 endorsements, and disclosure forms, until the carrier insurer
30 has filed it with the department and the department has
31 approved it under ss. 627.410, and 627.411, and 641.31 and
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HOUSE AMENDMENT
Bill No. CS/HB 913, 1st Eng.
Amendment No. ___ (for drafter's use only)
1 this section.
2 (f) A flexible benefit policy or contract must have an
3 annual maximum benefit of $150,000 or greater and a lifetime
4 benefit of $500,000 or greater and such benefit shall be
5 disclosed in 12-point bold type in contrasting color.
6 (15) APPLICABILITY OF OTHER STATE LAWS.--
7 (a) Except as expressly provided in this section, a
8 law requiring coverage for a specific health care service or
9 benefit, or a law requiring reimbursement, utilization, or
10 consideration of a specific category of licensed health care
11 practitioner, does not apply to a standard or basic health
12 benefit plan policy or contract or a flexible limited benefit
13 policy or contract offered or delivered to a small employer
14 unless that law is made expressly applicable to such policies
15 or contracts. A law restricting or limiting deductibles,
16 coinsurance, copayments, or annual or lifetime maximum
17 payments does not apply to any health plan policy, including a
18 standard or basic health benefit plan policy or contract or a
19 flexible benefit policy or contract, offered or delivered to a
20 small employer unless such law is made expressly applicable to
21 such policy or contract. When any flexible benefit health
22 insurance policy or flexible benefit contract provides for the
23 payment for medical expense benefits or procedures, such
24 policy or contract shall be construed to include payment to a
25 licensed physician who provides the medical service benefits
26 or procedures which are within the scope of a licensed
27 physician's license. Any limitation or condition placed upon
28 payment to, or upon services, diagnosis, or treatment by, any
29 licensed physician shall apply equally to all licensed
30 physicians without unfair discrimination to the usual and
31 customary treatment procedures of any class of physicians.
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hmo0011 12:56 pm 00913-0100-860017
HOUSE AMENDMENT
Bill No. CS/HB 913, 1st Eng.
Amendment No. ___ (for drafter's use only)
1 (b) Except as provided in this section, a standard or
2 basic health benefit plan policy or contract or flexible
3 limited benefit policy or contract offered to a small employer
4 is not subject to any provision of this code which:
5 1. Inhibits a small employer carrier from contracting
6 with providers or groups of providers with respect to health
7 care services or benefits;
8 2. Imposes any restriction on a small employer
9 carrier's ability to negotiate with providers regarding the
10 level or method of reimbursing care or services provided under
11 a health benefit plan; or
12 3. Requires a small employer carrier to either include
13 a specific provider or class of providers when contracting for
14 health care services or benefits or to exclude any class of
15 providers that is generally authorized by statute to provide
16 such care.
17 (c) Any second tier assessment paid by a carrier
18 pursuant to paragraph (11)(j) may be credited against
19 assessments levied against the carrier pursuant to s.
20 627.6494.
21 (d) Notwithstanding chapter 641, a health maintenance
22 organization is authorized to issue contracts providing
23 benefits to a small employer equal to the standard health
24 benefit plan, the basic health benefit plan, and the flexible
25 limited benefit policy authorized by this section. Flexible
26 benefit policies shall contain all group health provisions
27 required under chapter 641.
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30 == D I R E C T O R Y L A N G U A G E A M E N D M E N T ==
31 And the directory language is amended as follows:
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hmo0011 12:56 pm 00913-0100-860017
HOUSE AMENDMENT
Bill No. CS/HB 913, 1st Eng.
Amendment No. ___ (for drafter's use only)
1 On page 2, lines 13-16,
2 remove: all of said lines,
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4 and insert: (b) of subsection (6), and subsections (12) and
5 (15) of section 627.6699, Florida Statutes, are amended to
6 read:
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9 ================ T I T L E A M E N D M E N T ===============
10 And the title is amended as follows:
11 On page 1, line 11, after the semicolon,
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13 insert:
14 revising certain disclosure requirements;
15 providing additional notice requirements;
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