HB 1573 2003
1	A bill to be entitled
2	An act relating to health insurance; amending s. 395.301,
3	F.S.; requiring certain licensed facilities to make
4	certain information public electronically; requiring
5	notice; providing requirements; requiring health care
6	providers and facilities to provide patients with
7	reasonable estimates of prospective charges; amending s.
8	627.410, F.S.; exempting individuals and certain groups
9	from laws restricting or limiting coinsurance, copayments,
10	or annual or lifetime maximum payments; amending s.
11	627.6487, F.S.; revising a definition of eligible
12	individual for purposes of availability of individual
13	health insurance coverage; authorizing insurers to impose
14	certain surcharges or premium charges for creditable
15	coverage earned in certain states; amending s. 627.6561,
16	F.S.; requiring additional information in a certification
17	relating to certain creditable coverage for purposes of
18	eligibility for exclusion from preexisting condition
19	requirements; amending s. 627.667, F.S.; deleting a
20	limitation on certain application of extension of benefits
21	provisions; amending s. 627.6692, F.S.; extending a time
22	period for continuation of certain coverage under group
23	health plans; amending s. 627.6699, F.S.; revising certain
24	definitions; revising enrollment period criteria for
25	certain health benefit plans; requiring small employers to
26	provide certain health benefit plan information to
27	employees; providing a limitation; revising certain rate
28	adjustment criteria; authorizing separation of experience
29	of certain small employer groups for certain purposes;
30	amending s. 641.31, F.S.; specifying nonapplication of
31	certain health maintenance contract filing requirements to
32	certain group health insurance policies, with exceptions;
33	creating s. 641.31075, F.S.; providing compliance
34	requirements for health maintenance organizations
35	replacing certain coverages; amending s. 641.3111, F.S.;
36	providing additional requirements for extension of
37	benefits under group health maintenance contracts;
38	amending s. 641.513, F.S.; requiring a health maintenance
39	organization to compensate a hospital and noncontracted
40	hospital-based providers for certain treatment under
41	certain circumstances; specifying an additional
42	requirement for reimbursement of certain services;
43	providing an effective date.
44
45	Be It Enacted by the Legislature of the State of Florida:
46
47	Section 1. Subsection (7) is added to section 395.301,
48	Florida Statutes, to read:
49	395.301 Itemized patient bill; form and content prescribed
50	by the agency.--
51	(7)(a) Each licensed facility not operated by the state
52	shall make available to the public on its Internet website or by
53	other electronic means a list of charges and codes and a
54	description of services of the top 100 diagnosis-related groups
55	discharged from the hospital for that year using the CMS grouper
56	applicable to that year and the top 100 outpatient occasions of
57	diagnostic and therapeutic procedures performed using the
58	Healthcare Common Procedure Coding System. For purposes of this
59	paragraph, "CMS grouper" means a system of classification used
60	by the Centers for Medicare and Medicaid Services to assign an
61	inpatient discharge into a diagnosis-related group based on
62	diagnosis codes, procedure codes, and demographic information.
63	The facility shall place a notice in the reception areas that
64	such information is available electronically. The facility’s
65	list of charges and codes and the description of services shall
66	be consistent with federal electronic transmission uniform
67	standards under the Health Insurance Portability and
68	Accountability Act (HIPAA). Changes to the data shall be posted
69	and updated electronically on a quarterly basis.
70	(b) A health care provider or a health care facility
71	shall, upon request, furnish a patient, prior to provision of
72	medical services, a reasonable estimate of charges for such
73	services. Such estimate shall not preclude the health care
74	provider or health care facility from exceeding the estimate or
75	making additional charges based on changes in the patient’s
76	condition or treatment needs.
77	Section 2. Paragraph (b) of subsection (6) of section
78	627.410, Florida Statutes, is amended to read:
79	627.410 Filing, approval of forms.--
80	(6)
81	(b) The department may establish by rule, for each type of
82	health insurance form, procedures to be used in ascertaining the
83	reasonableness of benefits in relation to premium rates and may,
84	by rule, exempt from any requirement of paragraph (a) any health
85	insurance policy form or type thereof (as specified in such
86	rule) to which form or type such requirements may not be
87	practically applied or to which form or type the application of
88	such requirements is not desirable or necessary for the
89	protection of the public. A law restricting or limiting
90	deductibles, coinsurance, copayments, or annual or lifetime
91	maximum payments shall not apply to any health plan policy
92	offered or delivered to an individual or to a group of 51 or
93	more persons.With respect to any health insurance policy form
94	or type thereof which is exempted by rule from any requirement
95	of paragraph (a), premium rates filed pursuant to ss. 627.640
96	and 627.662 shall be for informational purposes.
97	Section 3. Paragraph (b) of subsection (3) of section
98	627.6487, Florida Statutes, is amended, and paragraph (c) is
99	added to subsection (4) of said section, to read:
100	627.6487 Guaranteed availability of individual health
101	insurance coverage to eligible individuals.--
102	(3) For the purposes of this section, the term "eligible
103	individual" means an individual:
104	(b) Who is not eligible for coverage under:
105	1. A group health plan, as defined in s. 2791 of the
106	Public Health Service Act;
107	2. A conversion policy or contract issued by an authorized
108	insurer or health maintenance organization under s. 627.6675 or
109	s. 641.3921, respectively, offered to an individual who is no
110	longer eligible for coverage under either an insured or self-
111	insured group healthemployer plan or group health insurance
112	policy;
113	3. Part A or part B of Title XVIII of the Social Security
114	Act; or
115	4. A state plan under Title XIX of such act, or any
116	successor program, and does not have other health insurance
117	coverage;
118	(4)
119	(c) If the individual’s most recent period of creditable
120	coverage was earned in a state other than this state, an insurer
121	issuing a policy that complies with paragraph (a) may impose a
122	surcharge or charge a premium for such policy equal to that
123	permitted in the state in which such creditable coverage was
124	earned.
125	Section 4. Paragraph (c) of subsection (8) of section
126	627.6561, Florida Statutes, is amended to read:
127	627.6561 Preexisting conditions.--
128	(8)
129	(c) The certification described in this section is a
130	written certification that must include:
131	1. The period of creditable coverage of the individual
132	under the policy and the coverage, if any, under such COBRA
133	continuation provision or continuation pursuant to s. 627.6692.;
134	and
135	2. The waiting period, if any, imposed with respect to the
136	individual for any coverage under such policy.
137	3. A statement that the creditable coverage was provided
138	under a group health plan, a group or individual health
139	insurance policy, or a health maintenance organization contract,
140	the state in which such coverage was provided, and whether or
141	not such individual was eligible for a conversion policy under
142	such coverage.
143	Section 5. Subsection (6) of section 627.667, Florida
144	Statutes, is amended to read:
145	627.667 Extension of benefits.--
146	(6) This section also applies to holders of group
147	certificates which are renewed, delivered, or issued for
148	delivery to residents of this state under group policies
149	effectuated or delivered outside this state, unless a succeeding
150	carrier under a group policy has agreed to assume liability for
151	the benefits.
152	Section 6. Paragraph (e) of subsection (5) of section
153	627.6692, Florida Statutes, is amended to read:
154	627.6692 Florida Health Insurance Coverage Continuation
155	Act.--
156	(5) CONTINUATION OF COVERAGE UNDER GROUP HEALTH PLANS.--
157	(e)1. A covered employee or other qualified beneficiary
158	who wishes continuation of coverage must pay the initial premium
159	and elect such continuation in writing to the insurance carrier
160	issuing the employer's group health plan within 6330days after
161	receiving notice from the insurance carrier under paragraph (d).
162	Subsequent premiums are due by the grace period expiration date.
163	The insurance carrier or the insurance carrier's designee shall
164	process all elections promptly and provide coverage
165	retroactively to the date coverage would otherwise have
166	terminated. The premium due shall be for the period beginning on
167	the date coverage would have otherwise terminated due to the
168	qualifying event. The first premium payment must include the
169	coverage paid to the end of the month in which the first payment
170	is made. After the election, the insurance carrier must bill the
171	qualified beneficiary for premiums once each month, with a due
172	date on the first of the month of coverage and allowing a 30-day
173	grace period for payment.
174	2. Except as otherwise specified in an election, any
175	election by a qualified beneficiary shall be deemed to include
176	an election of continuation of coverage on behalf of any other
177	qualified beneficiary residing in the same household who would
178	lose coverage under the group health plan by reason of a
179	qualifying event. This subparagraph does not preclude a
180	qualified beneficiary from electing continuation of coverage on
181	behalf of any other qualified beneficiary.
182	Section 7. Paragraphs (h) and (u) of subsection (3),
183	paragraph (c) of subsection (5), and paragraph (b) of subsection
184	(6) of section 627.6699, Florida Statutes, are amended, and
185	paragraph (k) is added to subsection (5) of said section, to
186	read:
187	627.6699 Employee Health Care Access Act.--
188	(3) DEFINITIONS.--As used in this section, the term:
189	(h) "Eligible employee" means an employee who works full
190	time, having a normal workweek of 25 or more hours and is paid
191	wages or a salary at least equal to the federal minimum hourly
192	wage applicable to such employee, and who has met any applicable
193	waiting-period requirements or other requirements of this act.
194	The term includes a self-employed individual, a sole proprietor,
195	a partner of a partnership, or an independent contractor, if the
196	sole proprietor, partner, or independent contractor is included
197	as an employee under a health benefit plan of a small employer,
198	but does not include a part-time, temporary, or substitute
199	employee.
200	(u) "Self-employed individual" means an individual or sole
201	proprietor who derives his or her income from a trade or
202	business carried on by the individual or sole proprietor which
203	necessitates that the individual file federal income tax forms,
204	with supporting schedules and accompanying income reporting
205	forms, or federal income tax extensions of time to file forms
206	with the Internal Revenue Service for the most recent tax year
207	results in taxable income as indicated on IRS Form 1040,
208	schedule C or F, and which generated taxable income in one of
209	the 2 previous years.
210	(5) AVAILABILITY OF COVERAGE.--
211	(c) Every small employer carrier must, as a condition of
212	transacting business in this state:
213	1. Beginning July 1, 2000, offer and issue all small
214	employer health benefit plans on a guaranteed-issue basis to
215	every eligible small employer, with 2 to 50 eligible employees,
216	that elects to be covered under such plan, agrees to make the
217	required premium payments, and satisfies the other provisions of
218	the plan. A rider for additional or increased benefits may be
219	medically underwritten and may only be added to the standard
220	health benefit plan. The increased rate charged for the
221	additional or increased benefit must be rated in accordance with
222	this section.
223	2. Beginning July 1, 2000, and until July 31, 2001, offer
224	and issue basic and standard small employer health benefit plans
225	on a guaranteed-issue basis to every eligible small employer
226	which is eligible for guaranteed renewal, has less than two
227	eligible employees, is not formed primarily for the purpose of
228	buying health insurance, elects to be covered under such plan,
229	agrees to make the required premium payments, and satisfies the
230	other provisions of the plan. A rider for additional or
231	increased benefits may be medically underwritten and may be
232	added only to the standard benefit plan. The increased rate
233	charged for the additional or increased benefit must be rated in
234	accordance with this section. For purposes of this subparagraph,
235	a person, his or her spouse, and his or her dependent children
236	shall constitute a single eligible employee if that person and
237	spouse are employed by the same small employer and either one
238	has a normal work week of less than 25 hours.
239	3. Beginning June 1, 2004August 1, 2001, offer and issue
240	basic and standard small employer health benefit plans on a
241	guaranteed-issue basis, during a 30-day open enrollment period
242	of June 1 through June 30 and during a31-day open enrollment
243	period of DecemberAugust 1 through DecemberAugust31 of each
244	year, to every eligible small employer, with fewer than two
245	eligible employees, which small employer is not formed primarily
246	for the purpose of buying health insurance and which elects to
247	be covered under such plan, agrees to make the required premium
248	payments, and satisfies the other provisions of the plan.
249	Coverage provided under this subparagraph shall begin 60 days
250	afteron October 1 of the same year asthe date of enrollment,
251	unless the small employer carrier and the small employer agree
252	to a different date. A rider for additional or increased
253	benefits may be medically underwritten and may only be added to
254	the standard health benefit plan. The increased rate charged for
255	the additional or increased benefit must be rated in accordance
256	with this section. For purposes of this subparagraph, a person,
257	his or her spouse, and his or her dependent children constitute
258	a single eligible employee if that person and spouse are
259	employed by the same small employer and either that person or
260	his or her spouse has a normal work week of less than 25 hours.
261	4. This paragraph does not limit a carrier's ability to
262	offer other health benefit plans to small employers if the
263	standard and basic health benefit plans are offered and
264	rejected.
265	(k) Beginning January 1, 2004, every small employer, as a
266	condition for conducting business in this state, shall provide,
267	on an annual basis, information on at least three different
268	group health benefit plans for employees. Nothing in this
269	paragraph shall be construed as requiring a small employer to
270	provide the health benefit plan or contribute to the cost of
271	such plan.
272	(6) RESTRICTIONS RELATING TO PREMIUM RATES.--
273	(b) For all small employer health benefit plans that are
274	subject to this section and are issued by small employer
275	carriers on or after January 1, 1994, premium rates for health
276	benefit plans subject to this section are subject to the
277	following:
278	1. Small employer carriers must use a modified community
279	rating methodology in which the premium for each small employer
280	must be determined solely on the basis of the eligible
281	employee's and eligible dependent's gender, age, family
282	composition, tobacco use, or geographic area as determined under
283	paragraph (5)(j) and in which the premium may be adjusted as
284	permitted by this paragraph.
285	2. Rating factors related to age, gender, family
286	composition, tobacco use, or geographic location may be
287	developed by each carrier to reflect the carrier's experience.
288	The factors used by carriers are subject to department review
289	and approval.
290	3. Small employer carriers may not modify the rate for a
291	small employer for 12 months from the initial issue date or
292	renewal date, unless the composition of the group changes or
293	benefits are changed. However, a small employer carrier may
294	modify the rate one time prior to 12 months after the initial
295	issue date for a small employer who enrolls under a previously
296	issued group policy that has a common anniversary date for all
297	employers covered under the policy if:
298	a. The carrier discloses to the employer in a clear and
299	conspicuous manner the date of the first renewal and the fact
300	that the premium may increase on or after that date.
301	b. The insurer demonstrates to the department that
302	efficiencies in administration are achieved and reflected in the
303	rates charged to small employers covered under the policy.
304	4. A carrier may issue a group health insurance policy to
305	a small employer health alliance or other group association with
306	rates that reflect a premium credit for expense savings
307	attributable to administrative activities being performed by the
308	alliance or group association if such expense savings are
309	specifically documented in the insurer's rate filing and are
310	approved by the department. Any such credit may not be based on
311	different morbidity assumptions or on any other factor related
312	to the health status or claims experience of any person covered
313	under the policy. Nothing in this subparagraph exempts an
314	alliance or group association from licensure for any activities
315	that require licensure under the insurance code. A carrier
316	issuing a group health insurance policy to a small employer
317	health alliance or other group association shall allow any
318	properly licensed and appointed agent of that carrier to market
319	and sell the small employer health alliance or other group
320	association policy. Such agent shall be paid the usual and
321	customary commission paid to any agent selling the policy.
322	5. Any adjustments in rates for claims experience, health
323	status, or duration of coverage may not be charged to individual
324	employees or dependents. For a small employer's policy, such
325	adjustments may not result in a rate for the small employer
326	which deviates more than 15 percent from the carrier's approved
327	rate. Any such adjustment must be applied uniformly to the rates
328	charged for all employees and dependents of the small employer.
329	A small employer carrier may make an adjustment to a small
330	employer's renewal premium, not to exceed 10 percent annually,
331	due to the claims experience, health status, or duration of
332	coverage of the employees or dependents of the small employer.
333	Semiannually, small group carriers shall report information on
334	forms adopted by rule by the department, to enable the
335	department to monitor the relationship of aggregate adjusted
336	premiums actually charged policyholders by each carrier to the
337	premiums that would have been charged by application of the
338	carrier's approved modified community rates. If the aggregate
339	resulting from the application of such adjustment exceeds the
340	premium that would have been charged by application of the
341	approved modified community rate by 25percent for the current
342	reporting period, the carrier shall limit the application of
343	such adjustments only to minus adjustments beginning not more
344	than 60 days after the report is sent to the department. For any
345	subsequent reporting period, if the total aggregate adjusted
346	premium actually charged does not exceed the premium that would
347	have been charged by application of the approved modified
348	community rate by 25percent, the carrier may apply both plus
349	and minus adjustments. A small employer carrier may provide a
350	credit to a small employer's premium based on administrative and
351	acquisition expense differences resulting from the size of the
352	group. Group size administrative and acquisition expense factors
353	may be developed by each carrier to reflect the carrier's
354	experience and are subject to department review and approval.
355	6. A small employer carrier rating methodology may include
356	separate rating categories for one dependent child, for two
357	dependent children, and for three or more dependent children for
358	family coverage of employees having a spouse and dependent
359	children or employees having dependent children only. A small
360	employer carrier may have fewer, but not greater, numbers of
361	categories for dependent children than those specified in this
362	subparagraph.
363	7. Small employer carriers may not use a composite rating
364	methodology to rate a small employer with fewer than 10
365	employees. For the purposes of this subparagraph, a "composite
366	rating methodology" means a rating methodology that averages the
367	impact of the rating factors for age and gender in the premiums
368	charged to all of the employees of a small employer.
369	8.a. A carrier may separate the experience of small
370	employer groups with less than 2 eligible employees from the
371	experience of small employer groups with 2-50 eligible employees
372	for purposes of determining an alternative modified community
373	rating.
374	b. If a carrier separates the experience of small employer
375	groups as provided in sub-subparagraph a., the rate to be
376	charged to small employer groups of less than 2 eligible
377	employees may not exceed 150 percent of the rate determined for
378	small employer groups of 2-50 eligible employees. However, the
379	carrier may charge excess losses of the experience pool
380	consisting of small employer groups with less than 2 eligible
381	employees to the experience pool consisting of small employer
382	groups with 2-50 eligible employees so that all losses are
383	allocated and the 150-percent rate limit on the experience pool
384	consisting of small employer groups with less than 2 eligible
385	employees is maintained. Notwithstanding s. 627.411(1), the rate
386	to be charged to a small employer group of fewer than 2 eligible
387	employees, insured as of July 1, 2002, may be up to 125 percent
388	of the rate determined for small employer groups of 2-50
389	eligible employees for the first annual renewal and 150 percent
390	for subsequent annual renewals.
391	9. In addition to the separation allowed under sub-
392	subparagraph 8.a., a carrier may also separate the experience of
393	small employer groups of 1-50 eligible employees using a health
394	reimbursement arrangement, as defined in Internal Revenue
395	Service Notice 2002-45, 2002-28 Internal Revenue Bulletin 93,
396	and Revenue Ruling 2002-41, 2002-28 Internal Revenue Bulletin
397	75, from the experience of small employer groups of 1-50
398	eligible employees not using such a health reimbursement
399	arrangement for purposes of determining an alternative modified
400	community rating.
401	Section 8. Subsection (2) and paragraph (d) of subsection
402	(3) of section 641.31, Florida Statutes, are amended to read:
403	641.31 Health maintenance contracts.--
404	(2) The rates charged by any health maintenance
405	organization to its subscribers shall not be excessive,
406	inadequate, or unfairly discriminatory or follow a rating
407	methodology that is inconsistent, indeterminate, or ambiguous or
408	encourages misrepresentation or misunderstanding. A law
409	restricting or limiting deductibles, coinsurance, copayments, or
410	annual or lifetime maximum payments shall not apply to any
411	health maintenance organization contact offered or delivered to
412	an individual or a group of 51 or more persons.The department,
413	in accordance with generally accepted actuarial practice as
414	applied to health maintenance organizations, may define by rule
415	what constitutes excessive, inadequate, or unfairly
416	discriminatory rates and may require whatever information it
417	deems necessary to determine that a rate or proposed rate meets
418	the requirements of this subsection.
419	(3)
420	(d) Any change in rates charged for the contract must be
421	filed with the department not less than 30 days in advance of
422	the effective date. At the expiration of such 30 days, the rate
423	filing shall be deemed approved unless prior to such time the
424	filing has been affirmatively approved or disapproved by order
425	of the department. The approval of the filing by the department
426	constitutes a waiver of any unexpired portion of such waiting
427	period. The department may extend by not more than an additional
428	15 days the period within which it may so affirmatively approve
429	or disapprove any such filing, by giving notice of such
430	extension before expiration of the initial 30-day period. At the
431	expiration of any such period as so extended, and in the absence
432	of such prior affirmative approval or disapproval, any such
433	filing shall be deemed approved. This paragraph does not apply
434	to group health insurance policies effectuated and delivered in
435	this state insuring groups of 51 or more persons, except for
436	Medicare supplement insurance, long-term care insurance, and any
437	coverage under which the increase in claims costs over the
438	lifetime of the contract due to advancing age or duration is
439	refunded in the premium.
440	Section 9. Section 641.31075, Florida Statutes, is created
441	to read:
442	641.31075 Requirements for replacing health coverage.--
443	(1) Any health maintenance organization that is replacing
444	any other group health coverage with its group health
445	maintenance coverage shall comply with s. 627.666.
446	(2) Any health maintenance organization that is replacing
447	any other individual health coverage with its individual health
448	maintenance coverage shall comply with s. 627.6045.
449	Section 10. Subsection (1) of section 641.3111, Florida
450	Statutes, is amended to read:
451	641.3111 Extension of benefits.--
452	(1) Every group health maintenance contract shall provide
453	that termination of the contract shall be without prejudice to
454	any continuous loss which commenced while the contract was in
455	force, but any extension of benefits beyond the period the
456	contract was in force may be predicated upon the continuous
457	total disability of the subscriber and may be limited to payment
458	for the treatment of a specific accident or illness incurred
459	while the subscriber was a member. The extension is required
460	regardless of whether the group contract holder or other entity
461	secures replacement coverage from a new insurer or health
462	maintenance organization or foregoes the provision of coverage.
463	The required provision must provide for continuation of contract
464	benefits in connection with the treatment of a specific accident
465	or illness incurred while the contract was in effect.Such
466	extension of benefits may be limited to the occurrence of the
467	earliest of the following events:
468	(a) The expiration of 12 months.
469	(b) Such time as the member is no longer totally disabled.
470	(c) A succeeding carrier elects to provide replacement
471	coverage without limitation as to the disability condition.
472	(d) The maximum benefits payable under the contract have
473	been paid.
474	Section 11. Paragraph (c) of subsection (3) and subsection
475	(5) of section 641.513, Florida Statutes, are amended to read:
476	641.513 Requirements for providing emergency services and
477	care.--
478	(3)
479	(c) If the subscriber's primary care physician responds to
480	the notification, the hospital physician and the primary care
481	physician may discuss the appropriate care and treatment of the
482	subscriber. The health maintenance organization may have a
483	member of the hospital staff with whom it has a contract
484	participate in the treatment of the subscriber within the scope
485	of the physician's hospital staff privileges. The subscriber may
486	be transferred, in accordance with state and federal law, to a
487	hospital that has a contract with the health maintenance
488	organization and has the service capability to treat the
489	subscriber's emergency medical condition. If the subscriber is
490	treated, the health maintenance organization shall compensate
491	the hospital and the noncontracted hospital-based providers for
492	such treatment pursuant to subsection (5).Notwithstanding any
493	other state law, a hospital may request and collect insurance or
494	financial information from a patient in accordance with federal
495	law, which is necessary to determine if the patient is a
496	subscriber of a health maintenance organization, if emergency
497	services and care are not delayed.
498	(5) Reimbursement for services pursuant to this section by
499	a provider who does not have a contract with the health
500	maintenance organization shall be the lesser of:
501	(a) The provider's charges;
502	(b) The usual and customary provider charges for similar
503	services in the community where the services were provided; or
504	(c) The charge mutually agreed to by the health
505	maintenance organization and the provider within 60 days of the
506	submittal of the claim; or
507	(d) No more than 125 percent of the hospital’s average
508	contract price which the hospital contracts with health
509	maintenance organizations in the hospital’s geographic service
510	area.
511
512	Such reimbursement shall be net of any applicable copayment
513	authorized pursuant to subsection (4).
514	Section 12. This act shall take effect upon becoming a
515	law.