Senate Bill sb1796c1
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Florida Senate - 2003 CS for SB 1796
By the Committee on Banking and Insurance; and Senator
Campbell
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1 A bill to be entitled
2 An act relating to health insurance; amending
3 s. 395.301, F.S.; requiring certain licensed
4 facilities to make certain information public
5 electronically; requiring notice; providing
6 requirements; requiring health care providers
7 and facilities to provide prospective patients
8 with reasonable estimates of prospective
9 charges; requiring certain licensed facilities
10 to make available to payors certain records;
11 providing that the facility may not charge for
12 making records available but may charge a
13 specified amount for providing copies; amending
14 s. 408.909, F.S.; revising the definition of
15 the term "health flex plans"; authorizing plans
16 to limit the term of coverage; extending the
17 expiration date for the program; amending s.
18 624.406, F.S.; providing for reinsurance under
19 a workers' compensation insurance policy;
20 amending s. 624.603, F.S.; providing an
21 exception in which health insurance includes
22 workers' compensation coverages; amending s.
23 627.410, F.S.; exempting individuals and
24 certain groups from laws restricting or
25 limiting coinsurance, copayments, or annual or
26 lifetime maximum payments; creating s.
27 627.6042, F.S.; requiring policies of insurers
28 offering coverage of dependent children to
29 maintain such coverage until the child reaches
30 age 25, under certain circumstances; providing
31 application; creating s. 627.60425, F.S.;
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1 providing for limitations to the requirement
2 for binding arbitration; amending s. 627.6044,
3 F.S.; providing for the payment of claims to
4 non-network providers under specified
5 conditions; requiring that the method used for
6 determining payment of claims be included in
7 filings; providing for disclosure; amending s.
8 627.6415, F.S.; deleting an age limitation on
9 application of certain dependent coverage
10 requirements; amending s. 627.6475, F.S.;
11 revising risk-assuming carrier election
12 requirements and procedures; revising certain
13 criteria and limitations under the individual
14 health reinsurance program; amending s.
15 627.651, F.S., relating to group contracts and
16 plans; conforming a cross-reference to changes
17 made by the act; amending s. 627.6487, F.S.;
18 revising a definition of eligible individual
19 for purposes of availability of individual
20 health insurance coverage; authorizing insurers
21 to impose certain surcharges or premium charges
22 for creditable coverage earned in certain
23 states; amending s. 627.6561, F.S.; requiring
24 additional information in a certification
25 relating to certain creditable coverage for
26 purposes of eligibility for exclusion from
27 preexisting condition requirements; amending s.
28 627.662, F.S.; revising a list of provisions
29 applicable to group, blanket, or franchise
30 health insurance to include use of specific
31 methodology for payment of claims provisions;
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1 amending s. 627.667, F.S.; deleting a
2 limitation on application of certain extension
3 of benefits provisions; amending s. 627.6692,
4 F.S.; increasing a time period for payment of
5 premium to continue coverage under a group
6 health plan; amending s. 627.6699, F.S.;
7 revising certain definitions; revising certain
8 coverage enrollment eligibility criteria for
9 small employers; revising small employer
10 carrier election requirements and procedures;
11 revising certain criteria and limitations under
12 the small employer health reinsurance program;
13 requiring small employers to provide certain
14 health benefit plan information to employees;
15 providing a limitation; revising certain rate
16 adjustment criteria; authorizing separation of
17 experience of certain small employer groups for
18 certain purposes; amending ss. 627.911 and
19 627.9175, F.S.; applying certain information
20 reporting requirements to health maintenance
21 organizations; revising health insurance
22 information requirements and criteria;
23 authorizing the Financial Services Commission
24 to adopt rules; deleting an annual report
25 requirement; amending s. 627.9403, F.S.;
26 exempting limited benefit policies relating to
27 nursing home care from certain requirements for
28 long-term care insurance; amending s. 641.31,
29 F.S.; specifying nonapplication of certain
30 health maintenance contract filing requirements
31 to certain group health insurance policies,
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1 with exceptions; requiring prepaid limited
2 health service organizations and health
3 maintenance organizations offering coverage of
4 dependent children to maintain such coverage
5 until the child reaches age 25, under certain
6 circumstances; providing application; providing
7 requirements for contract termination and
8 denial of a claim related to limiting age
9 attainment; amending s. 641.3101, F.S.;
10 providing a compliance requirement for health
11 maintenance contracts using a specific payment
12 of claims methodology; creating s. 641.31025,
13 F.S.; requiring that specific reasons for
14 denial of coverage be provided; creating s.
15 641.31075, F.S.; imposing compliance
16 requirements upon health maintenance
17 organization replacements of other group health
18 coverage with organization coverage; amending
19 s. 641.3111, F.S.; deleting limitations on
20 certain extension of benefits provisions upon
21 group health maintenance contract termination;
22 imposing additional extension of benefits
23 requirements upon such termination; amending s.
24 641.2018 and 641.3107, F.S., relating to home
25 health care coverage and contracts; conforming
26 cross-references to changes made by the act;
27 amending s. 641.513, F.S.; conforming a
28 cross-reference to changes made by the act;
29 creating s. 627.6410, F.S.; requiring insurers
30 issuing individual health insurance policies to
31 offer coverage for speech, language, swallowing
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1 and hearing disorders; providing certain
2 exceptions and authorizing certain conditions;
3 creating s. 27.66912, F.S.; requiring group
4 health insurers to offer such coverage;
5 amending s. 641.31, F.S.; requiring health
6 maintenance organizations to offer such
7 coverage; providing an effective date.
8
9 Be It Enacted by the Legislature of the State of Florida:
10
11 Section 1. Subsection (7) is added to section 395.301,
12 Florida Statutes, to read:
13 395.301 Itemized patient bill; form and content
14 prescribed by the agency.--
15 (7)(a) Each licensed facility not operated by the
16 state shall make available to the public on its Internet
17 website or by other electronic means a list of charges and
18 codes and a description of services of the top 100
19 diagnosis-related groups discharged from the hospital for that
20 year using the CMS grouper applicable to that year and the top
21 100 outpatient occasions of diagnostic and therapeutic
22 procedures performed using the Healthcare Common Procedure
23 Coding System. For purposes of this paragraph, "CMS grouper"
24 means a system of classification used by the Centers for
25 Medicare and Medicaid Services to assign an inpatient
26 discharge into a diagnosis-related group based on diagnosis
27 codes, procedure codes, and demographic information. The
28 facility shall place a notice in the reception areas that such
29 information is available electronically. The facility's list
30 of charges and codes and the description of services shall be
31 consistent with federal electronic transmission uniform
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1 standards under the Health Insurance Portability and
2 Accountability Act (HIPAA). Changes to the data shall be
3 posted and updated electronically at least 30 days prior to
4 implementation.
5 (b) A health care facility shall, upon request,
6 furnish a patient, prior to provision of medical services, a
7 reasonable estimate of charges for such services. Such
8 estimate shall not preclude the health care provider or health
9 care facility from exceeding the estimate or making additional
10 charges based on changes in the patient's condition or
11 treatment needs.
12 (c) A licensed facility not operated by the state must
13 make available to a patient, or a payor acting on behalf of
14 the patient, the records that are necessary to verify the
15 accuracy of the patient's bill or payor's claim related to
16 such patient's bill within a reasonable time after a request.
17 The verification information must be made available in the
18 facility's offices. Such records shall be available to the
19 patient or payor prior to and after payment of the bill or
20 claim. The facility may not charge the patient or payor for
21 making such verification records available, except that the
22 facility may charge its usual charge for providing copies of
23 records as specified in s. 395.3025.
24 Section 2. Subsections (2), (3), and (10) of section
25 408.909, Florida Statutes, are amended to read:
26 408.909 Health flex plans.--
27 (2) DEFINITIONS.--As used in this section, the term:
28 (a) "Agency" means the Agency for Health Care
29 Administration.
30 (b) "Department" means the Department of Insurance.
31
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1 (c) "Enrollee" means an individual who has been
2 determined to be eligible for and is receiving health care
3 coverage under a health flex plan approved under this section.
4 (d) "Health care coverage" or "health flex plan
5 coverage" means health care services that are covered as
6 benefits under an approved health flex plan or that are
7 otherwise provided, either directly or through arrangements
8 with other persons, via a health flex plan on a prepaid per
9 capita basis or on a prepaid aggregate fixed-sum basis.
10 (e) "Health flex plan" means a health plan approved
11 under subsection (3) which guarantees payment for specified
12 health care coverage provided to the enrollee who purchases
13 coverage directly from the plan or through a small business
14 purchasing arrangement sponsored by a local government.
15 (f) "Health flex plan entity" means a health insurer,
16 health maintenance organization,
17 health-care-provider-sponsored organization, local government,
18 health care district, or other public or private
19 community-based organization that develops and implements an
20 approved health flex plan and is responsible for administering
21 the health flex plan and paying all claims for health flex
22 plan coverage by enrollees of the health flex plan.
23 (3) PILOT PROGRAM.--The agency and the department
24 shall each approve or disapprove health flex plans that
25 provide health care coverage for eligible participants who
26 reside in the three areas of the state that have the highest
27 number of uninsured persons, as identified in the Florida
28 Health Insurance Study conducted by the agency and in Indian
29 River County. A health flex plan may limit or exclude benefits
30 otherwise required by law for insurers offering coverage in
31 this state, may cap the total amount of claims paid per year
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1 per enrollee, may limit the number of enrollees or the term of
2 coverage, or may take any combination of those actions.
3 (a) The agency shall develop guidelines for the review
4 of applications for health flex plans and shall disapprove or
5 withdraw approval of plans that do not meet or no longer meet
6 minimum standards for quality of care and access to care.
7 (b) The department shall develop guidelines for the
8 review of health flex plan applications and shall disapprove
9 or shall withdraw approval of plans that:
10 1. Contain any ambiguous, inconsistent, or misleading
11 provisions or any exceptions or conditions that deceptively
12 affect or limit the benefits purported to be assumed in the
13 general coverage provided by the health flex plan;
14 2. Provide benefits that are unreasonable in relation
15 to the premium charged or contain provisions that are unfair
16 or inequitable or contrary to the public policy of this state,
17 that encourage misrepresentation, or that result in unfair
18 discrimination in sales practices; or
19 3. Cannot demonstrate that the health flex plan is
20 financially sound and that the applicant is able to underwrite
21 or finance the health care coverage provided.
22 (c) The agency and the department may adopt rules as
23 needed to administer this section.
24 (10) EXPIRATION.--This section expires July 1, 2008
25 2004.
26 Section 3. Subsection (4) of section 624.406, Florida
27 Statutes, is amended to read:
28 624.406 Combinations of insuring powers, one
29 insurer.--An insurer which otherwise qualifies therefor may be
30 authorized to transact any one kind or combination of kinds of
31 insurance as defined in part V except:
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1 (1) A life insurer may also grant annuities, but shall
2 not be authorized to transact any other kind of insurance
3 except health insurance, disability income insurance, excess
4 coverage for health maintenance organizations, or excess
5 insurance, specific and aggregate, for self-insurers of a plan
6 of health insurance and multiple-employer welfare
7 arrangements.
8 (2) A reciprocal insurer shall not transact life
9 insurance.
10 (3) Except as to domestic business trust title
11 insurers as referred to in s. 624.404(6), so authorized prior
12 to the effective date of this code, a title insurer shall be a
13 stock insurer.
14 (4) A health insurer may also transact excess
15 insurance, specific and aggregate, for self-insurers of a plan
16 of health insurance and multiple-employer welfare arrangements
17 and reinsurance for the medical and lost-wages benefits
18 provided under a workers' compensation policy.
19 Section 4. Section 624.603, Florida Statutes, is
20 amended to read:
21 624.603 "Health insurance" defined.--"Health
22 insurance," also known as "disability insurance," is insurance
23 of human beings against bodily injury, disablement, or death
24 by accident or accidental means, or the expense thereof, or
25 against disablement or expense resulting from sickness, and
26 every insurance appertaining thereto. Health insurance does
27 not include workers' compensation coverages, except as
28 provided in s. 624.406.
29 Section 5. Paragraph (b) of subsection (6) of section
30 627.410, Florida Statutes, is amended to read:
31 627.410 Filing, approval of forms.--
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1 (6)
2 (b) The department may establish by rule, for each
3 type of health insurance form, procedures to be used in
4 ascertaining the reasonableness of benefits in relation to
5 premium rates and may, by rule, exempt from any requirement of
6 paragraph (a) any health insurance policy form or type thereof
7 (as specified in such rule) to which form or type such
8 requirements may not be practically applied or to which form
9 or type the application of such requirements is not desirable
10 or necessary for the protection of the public. A law
11 restricting or limiting deductibles, coinsurance, copayments,
12 or annual or lifetime maximum payments shall not apply to any
13 health plan policy offered or delivered to an individual or to
14 a group of 51 or more persons which provides coverage as
15 described in s. 627.6561(5)(a)2. With respect to any health
16 insurance policy form or type thereof which is exempted by
17 rule from any requirement of paragraph (a), premium rates
18 filed pursuant to ss. 627.640 and 627.662 shall be for
19 informational purposes.
20 Section 6. Section 627.6042, Florida Statutes, is
21 created to read:
22 627.6042 Dependent coverage.--
23 (1) If an insurer offers coverage that insures
24 dependent children of the policyholder or certificateholder,
25 the policy must insure a dependent child of the policyholder
26 or certificateholder at least until the end of the calendar
27 year in which the child reaches the age of 25, if the child
28 meets all of the following:
29 (a) The child is dependent upon the policyholder or
30 certificateholder for support.
31
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1 (b) The child is living in the household of the
2 policyholder or certificateholder or the child is a full-time
3 or part-time student.
4 (2) Nothing in this section affects or preempts an
5 insurer's right to medically underwrite or charge the
6 appropriate premium.
7 Section 7. Section 627.60425, Florida Statutes, is
8 created to read:
9 627.60425 Binding arbitration requirement
10 limitations.--Notwithstanding any other provision of law
11 except s. 624.155, an individual, blanket, or group life or
12 group health insurance policy, individual or group health
13 maintenance organization subscriber contract, prepaid limited
14 health organization subscriber contract, or any life or health
15 insurance policy or certificate delivered or issued for
16 delivery, including out of state group plans pursuant to s.
17 627.5515 or 627.6515 covering residents of this state, to any
18 resident of this state, shall not require the submission of
19 disputes between the parties to the policy, contract, or plan
20 to binding arbitration unless the applicant has indicated that
21 the same policy, contract, or plan was offered and rejected
22 without arbitration and that the binding arbitration provision
23 was fully explained to the applicant and willingly accepted.
24 Section 8. Section 627.6044, Florida Statutes, is
25 amended to read:
26 627.6044 Use of a specific methodology for payment of
27 claims.--
28 (1) Each insurance policy that provides for payment of
29 claims to non-network providers which is less than the payment
30 of the provider's billed charges to the insured, excluding
31 deductible, coinsurance, and copay amounts, shall:
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1 (a) Provide benefits, prior to deductible,
2 coinsurance, and copay amounts, for using a non-network
3 provider which are at least equal to the amount that would
4 have been allowed had the insured used a network provider, but
5 not in excess of the actual billed charges.
6 (b) Where there are multiple network providers in the
7 geographical area in which the services were provided, or if
8 none, the closest geographic area, the carrier may use an
9 averaging method of the contracted amounts, but not less than
10 the 80th percentile of all network contracted amounts in the
11 geographic area.
12
13 For purposes of this subsection, the term "network providers"
14 means those providers for which an insured will not be
15 responsible for any balance payment for services provided by
16 such provider, excluding deductible, coinsurance, and copay
17 amounts. based on a specific methodology, including, but not
18 limited to, usual and customary charges, reasonable and
19 customary charges, or charges based upon the prevailing rate
20 in the community, shall specify the formula or criteria used
21 by the insurer in determining the amount to be paid.
22 (2) Each insurer issuing a policy that provides for
23 payment of claims based on a specific methodology shall
24 provide to an insured, upon her or his written request, an
25 estimate of the amount the insurer will pay for a particular
26 medical procedure or service. The estimate may be in the form
27 of a range of payments or an average payment and may specify
28 that the estimate is based on the assumption of a particular
29 service code. The insurer may require the insured to provide
30 detailed information regarding the procedure or service to be
31 performed, including the procedure or service code number
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1 provided by the health care provider and the health care
2 provider's estimated charge. An insurer that provides an
3 insured with a good faith estimate is not bound by the
4 estimate. However, a pattern of providing estimates that vary
5 significantly from the ultimate insurance payment constitutes
6 a violation of this code.
7 (3) The method used for determining the payment of
8 claims shall be included in filings made pursuant to s.
9 627.410(6), and may not be changed unless such change is filed
10 under s. 627.410(6).
11 (4) Any policy that provides that the insured is
12 responsible for the balance of a claim amount, excluding
13 deductible, coinsurance, and copay amounts, must disclose such
14 feature on the face of the policy or certificate and such
15 feature must be included in any outline of coverage provided
16 to the insured.
17 Section 9. Subsections (1) and (4) of section
18 627.6415, Florida Statutes, are amended to read:
19 627.6415 Coverage for natural-born, adopted, and
20 foster children; children in insured's custodial care.--
21 (1) A health insurance policy that provides coverage
22 for a member of the family of the insured shall, as to the
23 family member's coverage, provide that the health insurance
24 benefits applicable to children of the insured also apply to
25 an adopted child or a foster child of the insured placed in
26 compliance with chapter 63, prior to the child's 18th
27 birthday, from the moment of placement in the residence of the
28 insured. Except in the case of a foster child, the policy may
29 not exclude coverage for any preexisting condition of the
30 child. In the case of a newborn child, coverage begins at the
31 moment of birth if a written agreement to adopt the child has
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1 been entered into by the insured prior to the birth of the
2 child, whether or not the agreement is enforceable. This
3 section does not require coverage for an adopted child who is
4 not ultimately placed in the residence of the insured in
5 compliance with chapter 63.
6 (4) In order to increase access to postnatal, infant,
7 and pediatric health care for all children placed in
8 court-ordered custody, including foster children, all health
9 insurance policies that provide coverage for a member of the
10 family of the insured shall, as to such family member's
11 coverage, also provide that the health insurance benefits
12 applicable for children shall be payable with respect to a
13 foster child or other child in court-ordered temporary or
14 other custody of the insured, prior to the child's 18th
15 birthday.
16 Section 10. Paragraph (a) of subsection (5), paragraph
17 (c) of subsection (6), and paragraphs (b), (c), and (e) of
18 subsection (7) of section 627.6475, Florida Statutes, are
19 amended to read:
20 627.6475 Individual reinsurance pool.--
21 (5) ISSUER'S ELECTION TO BECOME A RISK-ASSUMING
22 CARRIER.--
23 (a) Each health insurance issuer that offers
24 individual health insurance must elect to become a
25 risk-assuming carrier or a reinsuring carrier for purposes of
26 this section. Each such issuer must make an initial election,
27 binding through December 31, 1999. The issuer's initial
28 election must be made no later than October 31, 1997. By
29 October 31, 1997, all issuers must file a final election,
30 which is binding for 2 years, from January 1, 1998, through
31 December 31, 1999, after which an election which shall be
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1 binding indefinitely or until modified or withdrawn for a
2 period of 5 years. The department may permit an issuer to
3 modify its election at any time for good cause shown, after a
4 hearing.
5 (6) ELECTION PROCESS TO BECOME A RISK-ASSUMING
6 CARRIER.--
7 (c) The department shall provide public notice of an
8 issuer's filing a designation of election under this
9 subsection to become a risk-assuming carrier and shall provide
10 at least a 21-day period for public comment upon receipt of
11 such filing prior to making a decision on the election. The
12 department shall hold a hearing on the election at the request
13 of the issuer.
14 (7) INDIVIDUAL HEALTH REINSURANCE PROGRAM.--
15 (b) A reinsuring carrier may reinsure with the program
16 coverage of an eligible individual, subject to each of the
17 following provisions:
18 1. A reinsuring carrier may reinsure an eligible
19 individual within 90 60 days after commencement of the
20 coverage of the eligible individual.
21 2. The program may not reimburse a participating
22 carrier with respect to the claims of a reinsured eligible
23 individual until the carrier has paid incurred claims of an
24 amount equal to the participating carrier's selected
25 deductible level at least $5,000 in a calendar year for
26 benefits covered by the program. In addition, the reinsuring
27 carrier is responsible for 10 percent of the next $50,000 and
28 5 percent of the next $100,000 of incurred claims during a
29 calendar year, and the program shall reinsure the remainder.
30 3. The board shall annually adjust the initial level
31 of claims and the maximum limit to be retained by the carrier
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1 to reflect increases in costs and utilization within the
2 standard market for health benefit plans within the state. The
3 adjustment may not be less than the annual change in the
4 medical component of the "Commerce Price Index for All Urban
5 Consumers" of the Bureau of Labor Statistics of the United
6 States Department of Labor, unless the board proposes and the
7 department approves a lower adjustment factor.
8 4. A reinsuring carrier may terminate reinsurance for
9 all reinsured eligible individuals on any plan anniversary.
10 5. The premium rate charged for reinsurance by the
11 program to a health maintenance organization that is approved
12 by the Secretary of Health and Human Services as a federally
13 qualified health maintenance organization pursuant to 42
14 U.S.C. s. 300e(c)(2)(A) and that, as such, is subject to
15 requirements that limit the amount of risk that may be ceded
16 to the program, which requirements are more restrictive than
17 subparagraph 2., shall be reduced by an amount equal to that
18 portion of the risk, if any, which exceeds the amount set
19 forth in subparagraph 2., which may not be ceded to the
20 program.
21 6. The board may consider adjustments to the premium
22 rates charged for reinsurance by the program or carriers that
23 use effective cost-containment measures, including high-cost
24 case management, as defined by the board.
25 7. A reinsuring carrier shall apply its
26 case-management and claims-handling techniques, including, but
27 not limited to, utilization review, individual case
28 management, preferred provider provisions, other managed-care
29 provisions, or methods of operation consistently with both
30 reinsured business and nonreinsured business.
31
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1 (c)1. The board, as part of the plan of operation,
2 shall establish a methodology for determining premium rates to
3 be charged by the program for reinsuring eligible individuals
4 pursuant to this section. The methodology must include a
5 system for classifying individuals which reflects the types of
6 case characteristics commonly used by carriers in this state.
7 The methodology must provide for the development of basic
8 reinsurance premium rates, which shall be multiplied by the
9 factors set for them in this paragraph to determine the
10 premium rates for the program. The basic reinsurance premium
11 rates shall be established by the board, subject to the
12 approval of the department, and shall be set at levels that
13 reasonably approximate gross premiums charged to eligible
14 individuals for individual health insurance by health
15 insurance issuers. The premium rates set by the board may vary
16 by geographical area, as determined under this section, to
17 reflect differences in cost. An eligible individual may be
18 reinsured for a rate that is five times the rate established
19 by the board.
20 2. The board shall periodically review the methodology
21 established, including the system of classification and any
22 rating factors, to ensure that it reasonably reflects the
23 claims experience of the program. The board may propose
24 changes to the rates that are subject to the approval of the
25 department.
26 (e)1. Before September March 1 of each calendar year,
27 the board shall determine and report to the department the
28 program net loss in the individual account for the previous
29 year, including administrative expenses for that year and the
30 incurred losses for that year, taking into account investment
31 income and other appropriate gains and losses.
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1 2. Any net loss in the individual account for the year
2 shall be recouped by assessing the carriers as follows:
3 a. The operating losses of the program shall be
4 assessed in the following order subject to the specified
5 limitations. The first tier of assessments shall be made
6 against reinsuring carriers in an amount that may not exceed 5
7 percent of each reinsuring carrier's premiums for individual
8 health insurance. If such assessments have been collected and
9 additional moneys are needed, the board shall make a second
10 tier of assessments in an amount that may not exceed 0.5
11 percent of each carrier' s health benefit plan premiums.
12 b. Except as provided in paragraph (f), risk-assuming
13 carriers are exempt from all assessments authorized pursuant
14 to this section. The amount paid by a reinsuring carrier for
15 the first tier of assessments shall be credited against any
16 additional assessments made.
17 c. The board shall equitably assess reinsuring
18 carriers for operating losses of the individual account based
19 on market share. The board shall annually assess each carrier
20 a portion of the operating losses of the individual account.
21 The first tier of assessments shall be determined by
22 multiplying the operating losses by a fraction, the numerator
23 of which equals the reinsuring carrier's earned premium
24 pertaining to direct writings of individual health insurance
25 in the state during the calendar year for which the assessment
26 is levied, and the denominator of which equals the total of
27 all such premiums earned by reinsuring carriers in the state
28 during that calendar year. The second tier of assessments
29 shall be based on the premiums that all carriers, except
30 risk-assuming carriers, earned on all health benefit plans
31 written in this state. The board may levy interim assessments
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1 against reinsuring carriers to ensure the financial ability of
2 the plan to cover claims expenses and administrative expenses
3 paid or estimated to be paid in the operation of the plan for
4 the calendar year prior to the association's anticipated
5 receipt of annual assessments for that calendar year. Any
6 interim assessment is due and payable within 30 days after
7 receipt by a carrier of the interim assessment notice. Interim
8 assessment payments shall be credited against the carrier's
9 annual assessment. Health benefit plan premiums and benefits
10 paid by a carrier that are less than an amount determined by
11 the board to justify the cost of collection may not be
12 considered for purposes of determining assessments.
13 d. Subject to the approval of the department, the
14 board shall adjust the assessment formula for reinsuring
15 carriers that are approved as federally qualified health
16 maintenance organizations by the Secretary of Health and Human
17 Services pursuant to 42 U.S.C. s. 300e(c)(2)(A) to the extent,
18 if any, that restrictions are placed on them which are not
19 imposed on other carriers.
20 3. Before September March 1 of each year, the board
21 shall determine and file with the department an estimate of
22 the assessments needed to fund the losses incurred by the
23 program in the individual account for the previous calendar
24 year.
25 4. If the board determines that the assessments needed
26 to fund the losses incurred by the program in the individual
27 account for the previous calendar year will exceed the amount
28 specified in subparagraph 2., the board shall evaluate the
29 operation of the program and report its findings and
30 recommendations to the department in the format established in
31
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1 s. 627.6699(11) for the comparable report for the small
2 employer reinsurance program.
3 Section 11. Subsection (4) of section 627.651, Florida
4 Statutes, is amended to read:
5 627.651 Group contracts and plans of self-insurance
6 must meet group requirements.--
7 (4) This section does not apply to any plan which is
8 established or maintained by an individual employer in
9 accordance with the Employee Retirement Income Security Act of
10 1974, Pub. L. No. 93-406, or to a multiple-employer welfare
11 arrangement as defined in s. 624.437(1), except that a
12 multiple-employer welfare arrangement shall comply with ss.
13 627.419, 627.657, 627.6575, 627.6578, 627.6579, 627.6612,
14 627.66121, 627.66122, 627.6615, 627.6616, and 627.662(8)(7).
15 This subsection does not allow an authorized insurer to issue
16 a group health insurance policy or certificate which does not
17 comply with this part.
18 Section 12. Paragraph (b) of subsection (3) of section
19 627.6487, Florida Statutes, is amended, and paragraph (c) is
20 added to subsection (4) of that section, to read:
21 627.6487 Guaranteed availability of individual health
22 insurance coverage to eligible individuals.--
23 (3) For the purposes of this section, the term
24 "eligible individual" means an individual:
25 (b) Who is not eligible for coverage under:
26 1. A group health plan, as defined in s. 2791 of the
27 Public Health Service Act;
28 2. A conversion policy or contract issued by an
29 authorized insurer or health maintenance organization under s.
30 627.6675 or s. 641.3921, respectively, offered to an
31 individual who is no longer eligible for coverage under either
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1 an insured or self-insured group health employer plan or group
2 health insurance policy;
3 3. Part A or part B of Title XVIII of the Social
4 Security Act; or
5 4. A state plan under Title XIX of such act, or any
6 successor program, and does not have other health insurance
7 coverage;
8 (4)
9 (c) If the individual's most recent period of
10 creditable coverage was earned in a state other than this
11 state, an insurer issuing a policy that complies with
12 paragraph (a) may impose a surcharge or charge a premium for
13 such policy equal to that permitted in the state in which such
14 creditable coverage was earned.
15 Section 13. Paragraph (c) of subsection (8) of section
16 627.6561, Florida Statutes, is amended to read:
17 627.6561 Preexisting conditions.--
18 (8)
19 (c) The certification described in this section is a
20 written certification that must include:
21 1. The period of creditable coverage of the individual
22 under the policy and the coverage, if any, under such COBRA
23 continuation provision or continuation pursuant to s.
24 627.6692.; and
25 2. The waiting period, if any, imposed with respect to
26 the individual for any coverage under such policy.
27 3. A statement that the creditable coverage was
28 provided under a group health plan, a group or individual
29 health insurance policy, or a health maintenance organization
30 contract, the state in which such coverage was provided, and
31
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1 whether or not such individual was eligible for a conversion
2 policy under such coverage.
3 Section 14. Section 627.662, Florida Statutes, is
4 amended to read:
5 627.662 Other provisions applicable.--The following
6 provisions apply to group health insurance, blanket health
7 insurance, and franchise health insurance:
8 (1) Section 627.569, relating to use of dividends,
9 refunds, rate reductions, commissions, and service fees.
10 (2) Section 627.602(1)(f) and (2), relating to
11 identification numbers and statement of deductible provisions.
12 (3) Section 627.6044, relating to the use of specific
13 methodology for payment of claims.
14 (4)(3) Section 627.635, relating to excess insurance.
15 (5)(4) Section 627.638, relating to direct payment for
16 hospital or medical services.
17 (6)(5) Section 627.640, relating to filing and
18 classification of rates.
19 (7)(6) Section 627.613, relating to timely payment of
20 claims, or s. 627.6131, relating to payment of claims,
21 whichever is applicable.
22 (8)(7) Section 627.645(1), relating to denial of
23 claims.
24 (9)(8) Section 627.6471, relating to preferred
25 provider organizations.
26 (10)(9) Section 627.6472, relating to exclusive
27 provider organizations.
28 (11)(10) Section 627.6473, relating to combined
29 preferred provider and exclusive provider policies.
30 (12)(11) Section 627.6474, relating to provider
31 contracts.
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1 Section 15. Subsection (6) of section 627.667, Florida
2 Statutes, is amended to read:
3 627.667 Extension of benefits.--
4 (6) This section also applies to holders of group
5 certificates which are renewed, delivered, or issued for
6 delivery to residents of this state under group policies
7 effectuated or delivered outside this state, unless a
8 succeeding carrier under a group policy has agreed to assume
9 liability for the benefits.
10 Section 16. Paragraph (e) of subsection (5) of section
11 627.6692, Florida Statutes, is amended to read:
12 627.6692 Florida Health Insurance Coverage
13 Continuation Act.--
14 (5) CONTINUATION OF COVERAGE UNDER GROUP HEALTH
15 PLANS.--
16 (e)1. A covered employee or other qualified
17 beneficiary who wishes continuation of coverage must pay the
18 initial premium and elect such continuation in writing to the
19 insurance carrier issuing the employer's group health plan
20 within 63 30 days after receiving notice from the insurance
21 carrier under paragraph (d). Subsequent premiums are due by
22 the grace period expiration date. The insurance carrier or the
23 insurance carrier's designee shall process all elections
24 promptly and provide coverage retroactively to the date
25 coverage would otherwise have terminated. The premium due
26 shall be for the period beginning on the date coverage would
27 have otherwise terminated due to the qualifying event. The
28 first premium payment must include the coverage paid to the
29 end of the month in which the first payment is made. After the
30 election, the insurance carrier must bill the qualified
31 beneficiary for premiums once each month, with a due date on
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1 the first of the month of coverage and allowing a 30-day grace
2 period for payment.
3 2. Except as otherwise specified in an election, any
4 election by a qualified beneficiary shall be deemed to include
5 an election of continuation of coverage on behalf of any other
6 qualified beneficiary residing in the same household who would
7 lose coverage under the group health plan by reason of a
8 qualifying event. This subparagraph does not preclude a
9 qualified beneficiary from electing continuation of coverage
10 on behalf of any other qualified beneficiary.
11 Section 17. Paragraphs (g), (h), (i), and (u) of
12 subsection (3), paragraph (c) of subsection (5), paragraph (b)
13 of subsection (6), paragraph (a) of subsection (9), paragraph
14 (d) of subsection (10), and paragraphs (f), (g), (h), and (j)
15 of subsection (11) of section 627.6699, Florida Statutes, are
16 amended, and paragraph (k) is added to subsection (5) of that
17 section, to read:
18 627.6699 Employee Health Care Access Act.--
19 (3) DEFINITIONS.--As used in this section, the term:
20 (g) "Dependent" means the spouse or child as described
21 in s. 627.6512 of an eligible employee, subject to the
22 applicable terms of the health benefit plan covering that
23 employee.
24 (h) "Eligible employee" means an employee who works
25 full time, having a normal workweek of 25 or more hours, who
26 is paid wages or a salary at least equal to the federal
27 minimum hourly wage applicable to such employee, and who has
28 met any applicable waiting-period requirements or other
29 requirements of this act. The term includes a self-employed
30 individual, a sole proprietor, a partner of a partnership, or
31 an independent contractor, if the sole proprietor, partner, or
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1 independent contractor is included as an employee under a
2 health benefit plan of a small employer, but does not include
3 a part-time, temporary, or substitute employee.
4 (i) "Established geographic area" means the county or
5 counties, or any portion of a county or counties, within which
6 the carrier provides or arranges for health care services to
7 be available to its insureds, members, or subscribers.
8 (u) "Self-employed individual" means an individual or
9 sole proprietor who derives his or her income from a trade or
10 business carried on by the individual or sole proprietor which
11 necessitates that the individual file with the Internal
12 Revenue Service for the most recent tax year federal income
13 tax forms with supporting schedules and accompanying income
14 reporting forms or federal income tax extensions of time to
15 file forms results in taxable income as indicated on IRS Form
16 1040, schedule C or F, and which generated taxable income in
17 one of the 2 previous years.
18 (5) AVAILABILITY OF COVERAGE.--
19 (c) Every small employer carrier must, as a condition
20 of transacting business in this state:
21 1. Beginning July 1, 2000, offer and issue all small
22 employer health benefit plans on a guaranteed-issue basis to
23 every eligible small employer, with 2 to 50 eligible
24 employees, that elects to be covered under such plan, agrees
25 to make the required premium payments, and satisfies the other
26 provisions of the plan. A rider for additional or increased
27 benefits may be medically underwritten and may only be added
28 to the standard health benefit plan. The increased rate
29 charged for the additional or increased benefit must be rated
30 in accordance with this section.
31
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1 2. Beginning July 1, 2000, and until July 31, 2001,
2 offer and issue basic and standard small employer health
3 benefit plans on a guaranteed-issue basis to every eligible
4 small employer which is eligible for guaranteed renewal, has
5 less than two eligible employees, is not formed primarily for
6 the purpose of buying health insurance, elects to be covered
7 under such plan, agrees to make the required premium payments,
8 and satisfies the other provisions of the plan. A rider for
9 additional or increased benefits may be medically underwritten
10 and may be added only to the standard benefit plan. The
11 increased rate charged for the additional or increased benefit
12 must be rated in accordance with this section. For purposes of
13 this subparagraph, a person, his or her spouse, and his or her
14 dependent children shall constitute a single eligible employee
15 if that person and spouse are employed by the same small
16 employer and either one has a normal work week of less than 25
17 hours.
18 3.a. Beginning August 1, 2001, offer and issue basic
19 and standard small employer health benefit plans on a
20 guaranteed-issue basis, during a 31-day open enrollment period
21 of August 1 through August 31 of each year, to every eligible
22 small employer, with fewer than two eligible employees, which
23 small employer is not formed primarily for the purpose of
24 buying health insurance and which elects to be covered under
25 such plan, agrees to make the required premium payments, and
26 satisfies the other provisions of the plan. Coverage provided
27 under this sub-subparagraph subparagraph shall begin on
28 October 1 of the same year as the date of enrollment, unless
29 the small employer carrier and the small employer agree to a
30 different date. A rider for additional or increased benefits
31 may be medically underwritten and may only be added to the
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1 standard health benefit plan. The increased rate charged for
2 the additional or increased benefit must be rated in
3 accordance with this section. For purposes of this
4 sub-subparagraph subparagraph, a person, his or her spouse,
5 and his or her dependent children constitute a single eligible
6 employee if that person and spouse are employed by the same
7 small employer and either that person or his or her spouse has
8 a normal work week of less than 25 hours.
9 b. Notwithstanding the restrictions set forth in
10 sub-subparagraph a., when a small employer group is losing
11 coverage because a carrier is exercising the provisions of s.
12 627.6571(3)(b) or s. 641.31074(3)(b), the eligible small
13 employer, as defined in sub-subparagraph a., shall be entitled
14 to enroll with another carrier offering small employer
15 coverage within 63 days after the notice of termination or the
16 termination date of the prior coverage, whichever is later.
17 Coverage provided under this sub-subparagraph shall begin
18 immediately upon enrollment unless the small employer carrier
19 and the small employer agree to a different date.
20 4. This paragraph does not limit a carrier's ability
21 to offer other health benefit plans to small employers if the
22 standard and basic health benefit plans are offered and
23 rejected.
24 (k) Beginning January 1, 2004, every small employer
25 shall provide, on an annual basis, information on at least
26 three different health benefit plans for employees. Nothing in
27 this paragraph shall be construed as requiring a small
28 employer to provide the health benefit plan or contribute to
29 the cost of such plan.
30 (6) RESTRICTIONS RELATING TO PREMIUM RATES.--
31
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1 (b) For all small employer health benefit plans that
2 are subject to this section and are issued by small employer
3 carriers on or after January 1, 1994, premium rates for health
4 benefit plans subject to this section are subject to the
5 following:
6 1. Small employer carriers must use a modified
7 community rating methodology in which the premium for each
8 small employer must be determined solely on the basis of the
9 eligible employee's and eligible dependent's gender, age,
10 family composition, tobacco use, or geographic area as
11 determined under paragraph (5)(j) and in which the premium may
12 be adjusted as permitted by this paragraph.
13 2. Rating factors related to age, gender, family
14 composition, tobacco use, or geographic location may be
15 developed by each carrier to reflect the carrier's experience.
16 The factors used by carriers are subject to department review
17 and approval.
18 3. Small employer carriers may not modify the rate for
19 a small employer for 12 months from the initial issue date or
20 renewal date, unless the composition of the group changes or
21 benefits are changed. However, a small employer carrier may
22 modify the rate one time prior to 12 months after the initial
23 issue date for a small employer who enrolls under a previously
24 issued group policy that has a common anniversary date for all
25 employers covered under the policy if:
26 a. The carrier discloses to the employer in a clear
27 and conspicuous manner the date of the first renewal and the
28 fact that the premium may increase on or after that date.
29 b. The insurer demonstrates to the department that
30 efficiencies in administration are achieved and reflected in
31 the rates charged to small employers covered under the policy.
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1 4. A carrier may issue a group health insurance policy
2 to a small employer health alliance or other group association
3 with rates that reflect a premium credit for expense savings
4 attributable to administrative activities being performed by
5 the alliance or group association if such expense savings are
6 specifically documented in the insurer's rate filing and are
7 approved by the department. Any such credit may not be based
8 on different morbidity assumptions or on any other factor
9 related to the health status or claims experience of any
10 person covered under the policy. Nothing in this subparagraph
11 exempts an alliance or group association from licensure for
12 any activities that require licensure under the insurance
13 code. A carrier issuing a group health insurance policy to a
14 small employer health alliance or other group association
15 shall allow any properly licensed and appointed agent of that
16 carrier to market and sell the small employer health alliance
17 or other group association policy. Such agent shall be paid
18 the usual and customary commission paid to any agent selling
19 the policy.
20 5. Any adjustments in rates for claims experience,
21 health status, or duration of coverage may not be charged to
22 individual employees or dependents. For a small employer's
23 policy, such adjustments may not result in a rate for the
24 small employer which deviates more than 15 percent from the
25 carrier's approved rate. Any such adjustment must be applied
26 uniformly to the rates charged for all employees and
27 dependents of the small employer. A small employer carrier may
28 make an adjustment to a small employer's renewal premium, not
29 to exceed 10 percent annually, due to the claims experience,
30 health status, or duration of coverage of the employees or
31 dependents of the small employer. Semiannually, small group
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1 carriers shall report information on forms adopted by rule by
2 the department, to enable the department to monitor the
3 relationship of aggregate adjusted premiums actually charged
4 policyholders by each carrier to the premiums that would have
5 been charged by application of the carrier's approved modified
6 community rates. If the aggregate resulting from the
7 application of such adjustment exceeds the premium that would
8 have been charged by application of the approved modified
9 community rate by 3 5 percent for the current reporting
10 period, the carrier shall limit the application of such
11 adjustments only to minus adjustments beginning not more than
12 60 days after the report is sent to the department. For any
13 subsequent reporting period, if the total aggregate adjusted
14 premium actually charged does not exceed the premium that
15 would have been charged by application of the approved
16 modified community rate by 3 5 percent, the carrier may apply
17 both plus and minus adjustments. A small employer carrier may
18 provide a credit to a small employer's premium based on
19 administrative and acquisition expense differences resulting
20 from the size of the group. Group size administrative and
21 acquisition expense factors may be developed by each carrier
22 to reflect the carrier's experience and are subject to
23 department review and approval.
24 6. A small employer carrier rating methodology may
25 include separate rating categories for one dependent child,
26 for two dependent children, and for three or more dependent
27 children for family coverage of employees having a spouse and
28 dependent children or employees having dependent children
29 only. A small employer carrier may have fewer, but not
30 greater, numbers of categories for dependent children than
31 those specified in this subparagraph.
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1 7. Small employer carriers may not use a composite
2 rating methodology to rate a small employer with fewer than 10
3 employees. For the purposes of this subparagraph, a "composite
4 rating methodology" means a rating methodology that averages
5 the impact of the rating factors for age and gender in the
6 premiums charged to all of the employees of a small employer.
7 8.a. A carrier may separate the experience of small
8 employer groups with less than 2 eligible employees from the
9 experience of small employer groups with 2-50 eligible
10 employees for purposes of determining an alternative modified
11 community rating.
12 b. If a carrier separates the experience of small
13 employer groups as provided in sub-subparagraph a., the rate
14 to be charged to small employer groups of less than 2 eligible
15 employees may not exceed 150 percent of the rate determined
16 for small employer groups of 2-50 eligible employees. However,
17 the carrier may charge excess losses of the experience pool
18 consisting of small employer groups with less than 2 eligible
19 employees to the experience pool consisting of small employer
20 groups with 2-50 eligible employees so that all losses are
21 allocated and the 150-percent rate limit on the experience
22 pool consisting of small employer groups with less than 2
23 eligible employees is maintained. Notwithstanding s.
24 627.411(1), the rate to be charged to a small employer group
25 of fewer than 2 eligible employees, insured as of July 1,
26 2002, may be up to 125 percent of the rate determined for
27 small employer groups of 2-50 eligible employees for the first
28 annual renewal and 150 percent for subsequent annual renewals.
29 9. In addition to the separation allowed under
30 sub-subparagraph 8.a., a carrier may also separate the
31 experience of small employer groups of 1-50 eligible employees
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1 using a health reimbursement arrangement, as defined in
2 Internal Revenue Service Notice 2002-45, 2002-28 Internal
3 Revenue Bulletin 93, and Revenue Ruling 2002-41, 2002-28
4 Internal Revenue Bulletin 75, from the experience of small
5 employer groups of 1-50 eligible employees not using such a
6 health reimbursement arrangement for purposes of determining
7 an alternative modified community rating.
8 (9) SMALL EMPLOYER CARRIER'S ELECTION TO BECOME A
9 RISK-ASSUMING CARRIER OR A REINSURING CARRIER.--
10 (a) A small employer carrier must elect to become
11 either a risk-assuming carrier or a reinsuring carrier. Each
12 small employer carrier must make an initial election, binding
13 through January 1, 1994. The carrier's initial election must
14 be made no later than October 31, 1992. By October 31, 1993,
15 all small employer carriers must file a final election, which
16 is binding for 2 years, from January 1, 1994, through December
17 31, 1995, after which an election shall be binding for a
18 period of 5 years. Any carrier that is not a small employer
19 carrier on October 31, 1992, and intends to become a small
20 employer carrier after October 31, 1992, must file its
21 designation when it files the forms and rates it intends to
22 use for small employer group health insurance; such
23 designation shall be binding indefinitely or until modified or
24 withdrawn for 2 years after the date of approval of the forms
25 and rates, and any subsequent designation is binding for 5
26 years. The department may permit a carrier to modify its
27 election at any time for good cause shown, after a hearing.
28 (10) ELECTION PROCESS TO BECOME A RISK-ASSUMING
29 CARRIER.--
30 (d) The department shall provide public notice of a
31 small employer carrier's filing a designation of election
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1 under subsection (9) to become a risk-assuming carrier and
2 shall provide at least a 21-day period for public comment upon
3 receipt of such filing prior to making a decision on the
4 election. The department shall hold a hearing on the election
5 at the request of the carrier.
6 (11) SMALL EMPLOYER HEALTH REINSURANCE PROGRAM.--
7 (f) The program has the general powers and authority
8 granted under the laws of this state to insurance companies
9 and health maintenance organizations licensed to transact
10 business, except the power to issue health benefit plans
11 directly to groups or individuals. In addition thereto, the
12 program has specific authority to:
13 1. Enter into contracts as necessary or proper to
14 carry out the provisions and purposes of this act, including
15 the authority to enter into contracts with similar programs of
16 other states for the joint performance of common functions or
17 with persons or other organizations for the performance of
18 administrative functions.
19 2. Sue or be sued, including taking any legal action
20 necessary or proper for recovering any assessments and
21 penalties for, on behalf of, or against the program or any
22 carrier.
23 3. Take any legal action necessary to avoid the
24 payment of improper claims against the program.
25 4. Issue reinsurance policies, in accordance with the
26 requirements of this act.
27 5. Establish rules, conditions, and procedures for
28 reinsurance risks under the program participation.
29 6. Establish actuarial functions as appropriate for
30 the operation of the program.
31
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1 7. Assess participating carriers in accordance with
2 paragraph (j), and make advance interim assessments as may be
3 reasonable and necessary for organizational and interim
4 operating expenses. Interim assessments shall be credited as
5 offsets against any regular assessments due following the
6 close of the calendar year.
7 8. Appoint appropriate legal, actuarial, and other
8 committees as necessary to provide technical assistance in the
9 operation of the program, and in any other function within the
10 authority of the program.
11 9. Borrow money to effect the purposes of the program.
12 Any notes or other evidences of indebtedness of the program
13 which are not in default constitute legal investments for
14 carriers and may be carried as admitted assets.
15 10. To the extent necessary, increase the $5,000
16 deductible reinsurance requirement to adjust for the effects
17 of inflation. The program may evaluate the desirability of
18 establishing different levels of deductibles. If different
19 levels of deductibles are established, such levels and the
20 resulting premiums shall be approved by the office.
21 (g) A reinsuring carrier may reinsure with the program
22 coverage of an eligible employee of a small employer, or any
23 dependent of such an employee, subject to each of the
24 following provisions:
25 1. With respect to a standard and basic health care
26 plan, the program may must reinsure the level of coverage
27 provided; and, with respect to any other plan, the program may
28 must reinsure the coverage up to, but not exceeding, the level
29 of coverage provided under the standard and basic health care
30 plan. As an alternative to reinsuring the level of coverage
31 provided under the standard and basic health care plan, the
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1 program may develop alternate levels of reinsurance designed
2 to coordinate with a reinsuring carrier's existing
3 reinsurance. The levels of reinsurance and resulting premiums
4 must be approved by the office.
5 2. Except in the case of a late enrollee, a reinsuring
6 carrier may reinsure an eligible employee or dependent within
7 60 days after the commencement of the coverage of the small
8 employer. A newly employed eligible employee or dependent of a
9 small employer may be reinsured within 60 days after the
10 commencement of his or her coverage.
11 3. A small employer carrier may reinsure an entire
12 employer group within 60 days after the commencement of the
13 group's coverage under the plan. The carrier may choose to
14 reinsure newly eligible employees and dependents of the
15 reinsured group pursuant to subparagraph 1.
16 4. The program may evaluate the option of allowing a
17 small employer carrier to reinsure an entire employer group or
18 an eligible employee at the first or subsequent renewal date.
19 Any such option and the resulting premium must be approved by
20 the office.
21 5.4. The program may not reimburse a participating
22 carrier with respect to the claims of a reinsured employee or
23 dependent until the carrier has paid incurred claims of an
24 amount equal to the participating carrier's selected
25 deductible level at least $5,000 in a calendar year for
26 benefits covered by the program. In addition, the reinsuring
27 carrier shall be responsible for 10 percent of the next
28 $50,000 and 5 percent of the next $100,000 of incurred claims
29 during a calendar year and the program shall reinsure the
30 remainder.
31
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1 6.5. The board annually shall adjust the initial level
2 of claims and the maximum limit to be retained by the carrier
3 to reflect increases in costs and utilization within the
4 standard market for health benefit plans within the state. The
5 adjustment shall not be less than the annual change in the
6 medical component of the "Consumer Price Index for All Urban
7 Consumers" of the Bureau of Labor Statistics of the Department
8 of Labor, unless the board proposes and the department
9 approves a lower adjustment factor.
10 7.6. A small employer carrier may terminate
11 reinsurance for all reinsured employees or dependents on any
12 plan anniversary.
13 8.7. The premium rate charged for reinsurance by the
14 program to a health maintenance organization that is approved
15 by the Secretary of Health and Human Services as a federally
16 qualified health maintenance organization pursuant to 42
17 U.S.C. s. 300e(c)(2)(A) and that, as such, is subject to
18 requirements that limit the amount of risk that may be ceded
19 to the program, which requirements are more restrictive than
20 subparagraph 5. 4., shall be reduced by an amount equal to
21 that portion of the risk, if any, which exceeds the amount set
22 forth in subparagraph 5. 4. which may not be ceded to the
23 program.
24 9.8. The board may consider adjustments to the premium
25 rates charged for reinsurance by the program for carriers that
26 use effective cost containment measures, including high-cost
27 case management, as defined by the board.
28 10.9. A reinsuring carrier shall apply its
29 case-management and claims-handling techniques, including, but
30 not limited to, utilization review, individual case
31 management, preferred provider provisions, other managed care
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1 provisions or methods of operation, consistently with both
2 reinsured business and nonreinsured business.
3 (h)1. The board, as part of the plan of operation,
4 shall establish a methodology for determining premium rates to
5 be charged by the program for reinsuring small employers and
6 individuals pursuant to this section. The methodology shall
7 include a system for classification of small employers that
8 reflects the types of case characteristics commonly used by
9 small employer carriers in the state. The methodology shall
10 provide for the development of basic reinsurance premium
11 rates, which shall be multiplied by the factors set for them
12 in this paragraph to determine the premium rates for the
13 program. The basic reinsurance premium rates shall be
14 established by the board, subject to the approval of the
15 department, and shall be set at levels which reasonably
16 approximate gross premiums charged to small employers by small
17 employer carriers for health benefit plans with benefits
18 similar to the standard and basic health benefit plan. The
19 premium rates set by the board may vary by geographical area,
20 as determined under this section, to reflect differences in
21 cost. The multiplying factors must be established as follows:
22 a. The entire group may be reinsured for a rate that
23 is 1.5 times the rate established by the board.
24 b. An eligible employee or dependent may be reinsured
25 for a rate that is 5 times the rate established by the board.
26 2. The board periodically shall review the methodology
27 established, including the system of classification and any
28 rating factors, to assure that it reasonably reflects the
29 claims experience of the program. The board may propose
30 changes to the rates which shall be subject to the approval of
31 the department.
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1 (j)1. Before September March 1 of each calendar year,
2 the board shall determine and report to the department the
3 program net loss for the previous year, including
4 administrative expenses for that year, and the incurred losses
5 for the year, taking into account investment income and other
6 appropriate gains and losses.
7 2. Any net loss for the year shall be recouped by
8 assessment of the carriers, as follows:
9 a. The operating losses of the program shall be
10 assessed in the following order subject to the specified
11 limitations. The first tier of assessments shall be made
12 against reinsuring carriers in an amount which shall not
13 exceed 5 percent of each reinsuring carrier's premiums from
14 health benefit plans covering small employers. If such
15 assessments have been collected and additional moneys are
16 needed, the board shall make a second tier of assessments in
17 an amount which shall not exceed 0.5 percent of each carrier's
18 health benefit plan premiums. Except as provided in paragraph
19 (n), risk-assuming carriers are exempt from all assessments
20 authorized pursuant to this section. The amount paid by a
21 reinsuring carrier for the first tier of assessments shall be
22 credited against any additional assessments made.
23 b. The board shall equitably assess carriers for
24 operating losses of the plan based on market share. The board
25 shall annually assess each carrier a portion of the operating
26 losses of the plan. The first tier of assessments shall be
27 determined by multiplying the operating losses by a fraction,
28 the numerator of which equals the reinsuring carrier's earned
29 premium pertaining to direct writings of small employer health
30 benefit plans in the state during the calendar year for which
31 the assessment is levied, and the denominator of which equals
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1 the total of all such premiums earned by reinsuring carriers
2 in the state during that calendar year. The second tier of
3 assessments shall be based on the premiums that all carriers,
4 except risk-assuming carriers, earned on all health benefit
5 plans written in this state. The board may levy interim
6 assessments against carriers to ensure the financial ability
7 of the plan to cover claims expenses and administrative
8 expenses paid or estimated to be paid in the operation of the
9 plan for the calendar year prior to the association' s
10 anticipated receipt of annual assessments for that calendar
11 year. Any interim assessment is due and payable within 30 days
12 after receipt by a carrier of the interim assessment notice.
13 Interim assessment payments shall be credited against the
14 carrier's annual assessment. Health benefit plan premiums and
15 benefits paid by a carrier that are less than an amount
16 determined by the board to justify the cost of collection may
17 not be considered for purposes of determining assessments.
18 c. Subject to the approval of the department, the
19 board shall make an adjustment to the assessment formula for
20 reinsuring carriers that are approved as federally qualified
21 health maintenance organizations by the Secretary of Health
22 and Human Services pursuant to 42 U.S.C. s. 300e(c)(2)(A) to
23 the extent, if any, that restrictions are placed on them that
24 are not imposed on other small employer carriers.
25 3. Before September March 1 of each year, the board
26 shall determine and file with the department an estimate of
27 the assessments needed to fund the losses incurred by the
28 program in the previous calendar year.
29 4. If the board determines that the assessments needed
30 to fund the losses incurred by the program in the previous
31 calendar year will exceed the amount specified in subparagraph
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1 2., the board shall evaluate the operation of the program and
2 report its findings, including any recommendations for changes
3 to the plan of operation, to the department within 240 90 days
4 following the end of the calendar year in which the losses
5 were incurred. The evaluation shall include an estimate of
6 future assessments, the administrative costs of the program,
7 the appropriateness of the premiums charged and the level of
8 carrier retention under the program, and the costs of coverage
9 for small employers. If the board fails to file a report with
10 the department within 240 90 days following the end of the
11 applicable calendar year, the department may evaluate the
12 operations of the program and implement such amendments to the
13 plan of operation the department deems necessary to reduce
14 future losses and assessments.
15 5. If assessments exceed the amount of the actual
16 losses and administrative expenses of the program, the excess
17 shall be held as interest and used by the board to offset
18 future losses or to reduce program premiums. As used in this
19 paragraph, the term "future losses" includes reserves for
20 incurred but not reported claims.
21 6. Each carrier's proportion of the assessment shall
22 be determined annually by the board, based on annual
23 statements and other reports considered necessary by the board
24 and filed by the carriers with the board.
25 7. Provision shall be made in the plan of operation
26 for the imposition of an interest penalty for late payment of
27 an assessment.
28 8. A carrier may seek, from the commissioner, a
29 deferment, in whole or in part, from any assessment made by
30 the board. The department may defer, in whole or in part, the
31 assessment of a carrier if, in the opinion of the department,
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1 the payment of the assessment would place the carrier in a
2 financially impaired condition. If an assessment against a
3 carrier is deferred, in whole or in part, the amount by which
4 the assessment is deferred may be assessed against the other
5 carriers in a manner consistent with the basis for assessment
6 set forth in this section. The carrier receiving such
7 deferment remains liable to the program for the amount
8 deferred and is prohibited from reinsuring any individuals or
9 groups in the program if it fails to pay assessments.
10 Section 18. Section 627.911, Florida Statutes, is
11 amended to read:
12 627.911 Scope of this part.--Any insurer or health
13 maintenance organization transacting insurance in this state
14 shall report information as required by this part.
15 Section 19. Section 627.9175, Florida Statutes, is
16 amended to read:
17 627.9175 Reports of information on health insurance.--
18 (1) Each authorized health insurer or health
19 maintenance organization shall submit annually to the office,
20 on or before March 1 of each year, information concerning
21 department as to policies of individual health insurance
22 coverage being issued or currently in force in this state. The
23 information shall include information related to premium,
24 number of policies, and covered lives for such policies and
25 other information necessary to analyze trends in enrollment,
26 premiums, and claim costs.:
27 (2) The required information shall be broken down by
28 market segment, to include:
29 (a) Health insurance issuer, company, or contact
30 person or agent.
31
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1 (b) All health insurance products issued or in force,
2 including, but not limited to:
3 1. Direct premiums earned.
4 2. Direct losses incurred.
5 3. Direct premiums earned for new business issued
6 during the year.
7 4. Number of policies.
8 5. Number of certificates.
9 6. Number of total covered lives.
10 (3) The commission may adopt rules to administer this
11 section, including rules governing compliance and provisions
12 implementing electronic methodologies for use in furnishing
13 such records or documents. The commission may by rule specify
14 a uniform format for the submission of this information in
15 order to allow for meaningful comparisons.
16 (a) A summary of typical benefits, exclusions, and
17 limitations for each type of individual policy form currently
18 being issued in the state. The summary shall include, as
19 appropriate:
20 1. The deductible amount;
21 2. The coinsurance percentage;
22 3. The out-of-pocket maximum;
23 4. Outpatient benefits;
24 5. Inpatient benefits; and
25 6. Any exclusions for preexisting conditions.
26
27 The department shall determine other appropriate benefits,
28 exclusions, and limitations to be reported for inclusion in
29 the consumer's guide published pursuant to this section.
30 (b) A schedule of rates for each type of individual
31 policy form reflecting typical variations by age, sex, region
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1 of the state, or any other applicable factor which is in use
2 and is determined to be appropriate for inclusion by the
3 department.
4
5 The department shall provide by rule a uniform format for the
6 submission of this information in order to allow for
7 meaningful comparisons of premiums charged for comparable
8 benefits. The department shall publish annually a consumer's
9 guide which summarizes and compares the information required
10 to be reported under this subsection.
11 (2)(a) Every insurer transacting health insurance in
12 this state shall report annually to the department, not later
13 than April 1, information relating to any measure the insurer
14 has implemented or proposes to implement during the next
15 calendar year for the purpose of containing health insurance
16 costs or cost increases. The reports shall identify each
17 measure and the forms to which the measure is applied, shall
18 provide an explanation as to how the measure is used, and
19 shall provide an estimate of the cost effect of the measure.
20 (b) The department shall promulgate forms to be used
21 by insurers in reporting information pursuant to this
22 subsection and shall utilize such forms to analyze the effects
23 of health care cost containment programs used by health
24 insurers in this state.
25 (c) The department shall analyze the data reported
26 under this subsection and shall annually make available to the
27 public a summary of its findings as to the types of cost
28 containment measures reported and the estimated effect of
29 these measures.
30 Section 20. Section 627.9403, Florida Statutes, is
31 amended to read:
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1 627.9403 Scope.--The provisions of this part shall
2 apply to long-term care insurance policies delivered or issued
3 for delivery in this state, and to policies delivered or
4 issued for delivery outside this state to the extent provided
5 in s. 627.9406, by an insurer, a fraternal benefit society as
6 defined in s. 632.601, a health maintenance organization as
7 defined in s. 641.19, a prepaid health clinic as defined in s.
8 641.402, or a multiple-employer welfare arrangement as defined
9 in s. 624.437. A policy which is advertised, marketed, or
10 offered as a long-term care policy and as a Medicare
11 supplement policy shall meet the requirements of this part and
12 the requirements of ss. 627.671-627.675 and, to the extent of
13 a conflict, be subject to the requirement that is more
14 favorable to the policyholder or certificateholder. The
15 provisions of this part shall not apply to a continuing care
16 contract issued pursuant to chapter 651 and shall not apply to
17 guaranteed renewable policies issued prior to October 1, 1988.
18 Any limited benefit policy that limits coverage to care in a
19 nursing home or to one or more lower levels of care required
20 or authorized to be provided by this part or by department
21 rule must meet all requirements of this part that apply to
22 long-term care insurance policies, except ss. 627.9407(3)(c)
23 and (d), (9), (10)(f), and (12) and 627.94073(2). If the
24 limited benefit policy does not provide coverage for care in a
25 nursing home, but does provide coverage for one or more lower
26 levels of care, the policy shall also be exempt from the
27 requirements of s. 627.9407(3)(d).
28 Section 21. Subsection (2), paragraph (d) of
29 subsection (3), and subsections (9) through (17) of section
30 641.31, Florida Statutes, are amended to read:
31 641.31 Health maintenance contracts.--
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1 (2) The rates charged by any health maintenance
2 organization to its subscribers shall not be excessive,
3 inadequate, or unfairly discriminatory or follow a rating
4 methodology that is inconsistent, indeterminate, or ambiguous
5 or encourages misrepresentation or misunderstanding. A law
6 restricting or limiting deductibles, coinsurance, copayments,
7 or annual or lifetime maximum payments shall not apply to any
8 health maintenance organization contract offered or delivered
9 to an individual or a group of 51 or more persons which
10 provides coverage as described in s. 641.31071(5)(a)2. The
11 department, in accordance with generally accepted actuarial
12 practice as applied to health maintenance organizations, may
13 define by rule what constitutes excessive, inadequate, or
14 unfairly discriminatory rates and may require whatever
15 information it deems necessary to determine that a rate or
16 proposed rate meets the requirements of this subsection.
17 (3)
18 (d) Any change in rates charged for the contract must
19 be filed with the department not less than 30 days in advance
20 of the effective date. At the expiration of such 30 days, the
21 rate filing shall be deemed approved unless prior to such time
22 the filing has been affirmatively approved or disapproved by
23 order of the department. The approval of the filing by the
24 department constitutes a waiver of any unexpired portion of
25 such waiting period. The department may extend by not more
26 than an additional 15 days the period within which it may so
27 affirmatively approve or disapprove any such filing, by giving
28 notice of such extension before expiration of the initial
29 30-day period. At the expiration of any such period as so
30 extended, and in the absence of such prior affirmative
31 approval or disapproval, any such filing shall be deemed
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1 approved. This paragraph does not apply to group contracts
2 effectuated and delivered in this state insuring groups of 51
3 or more persons, except for Medicare supplement insurance,
4 long-term care insurance, and any coverage under which the
5 increase in claims costs over the lifetime of the contract due
6 to advancing age or duration is refunded in the premium.
7 (9)(a)1. If a health maintenance organization offers
8 coverage for dependent children of the subscriber, the
9 contract must cover a dependent child of the subscriber at
10 least until the end of the calendar year in which the child
11 reaches the age of 25, if the child meets all of the
12 following:
13 a. The child is dependent upon the subscriber for
14 support.
15 b. The child is living in the household of the
16 subscriber, or the child is a full-time or part-time student.
17 2. Nothing in this paragraph affects or preempts a
18 health maintenance organization's right to medically
19 underwrite or charge the appropriate premium.
20 (b)1. A contract that provides coverage for a family
21 member of the subscriber shall, as to such family member's
22 coverage, provide that benefits applicable to children of the
23 subscriber also apply to an adopted child or a foster child of
24 the subscriber placed in compliance with chapter 63 from the
25 moment of placement in the residence of the subscriber. Except
26 in the case of a foster child, the contract may not exclude
27 coverage for any preexisting condition of the child. In the
28 case of a newborn child, coverage begins at the moment of
29 birth if a written agreement to adopt such child has been
30 entered into by the subscriber prior to the birth of the
31 child, whether or not the agreement is enforceable. This
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1 section does not require coverage for an adopted child who is
2 not ultimately placed in the residence of the subscriber in
3 compliance with chapter 63.
4 2. A contract may require the subscriber to notify the
5 health maintenance organization of the birth or placement of
6 an adopted child within a specified time period of not less
7 than 30 days after the birth or placement in the residence of
8 a child adopted by the subscriber. If timely notice is given,
9 the health maintenance organization may not charge an
10 additional premium for coverage of the child for the duration
11 of the notice period. If timely notice is not given, the
12 health maintenance organization may charge an additional
13 premium from the date of birth or placement. If notice is
14 given within 60 days after the birth or placement of the
15 child, the health maintenance organization may not deny
16 coverage for the child due to the failure of the subscriber to
17 timely notify the health maintenance organization of the birth
18 or placement of the child.
19 3. If the contract does not require the subscriber to
20 notify the health maintenance organization of the birth or
21 placement of an adopted child within a specified time period,
22 the health maintenance organization may not deny coverage for
23 such child or retroactively charge the subscriber an
24 additional premium for such child. However, the health
25 maintenance organization may prospectively charge the
26 subscriber an additional premium for the child if the health
27 maintenance organization provides at least 45 days' notice of
28 the additional premium required.
29 4. In order to increase access to postnatal, infant,
30 and pediatric health care for all children placed in
31 court-ordered custody, including foster children, all health
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1 maintenance organization contracts that provide coverage for a
2 family member of the subscriber shall, as to such family
3 member's coverage, provide that benefits applicable for
4 children shall be payable with respect to a foster child or
5 other child in court-ordered temporary or other custody of the
6 subscriber.
7 (10) A contract that provides that coverage of a
8 dependent child shall terminate upon attainment of the
9 limiting age for dependent children specified in the contract
10 shall also provide in substance that attainment of the
11 limiting age does not terminate the coverage of the child
12 while the child continues to be:
13 (a) Incapable of self-sustaining employment by reason
14 of mental retardation or physical handicap.
15 (b) Chiefly dependent upon the subscriber for support
16 and maintenance.
17
18 If a claim is denied under a contract for the stated reason
19 that the child has attained the limiting age for dependent
20 children specified in the contract, the notice of denial must
21 state that the subscriber has the burden of establishing that
22 the child continues to meet the criteria specified in
23 paragraphs (a) and (b). All health maintenance contracts that
24 provide coverage, benefits, or services for a member of the
25 family of the subscriber must, as to such family member's
26 coverage, benefits, or services, provide also that the
27 coverage, benefits, or services applicable for children must
28 be provided with respect to a newborn child of the subscriber,
29 or covered family member of the subscriber, from the moment of
30 birth. However, with respect to a newborn child of a covered
31 family member other than the spouse of the insured or
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1 subscriber, the coverage for the newborn child terminates 18
2 months after the birth of the newborn child. The coverage,
3 benefits, or services for newborn children must consist of
4 coverage for injury or sickness, including the necessary care
5 or treatment of medically diagnosed congenital defects, birth
6 abnormalities, or prematurity, and transportation costs of the
7 newborn to and from the nearest appropriate facility
8 appropriately staffed and equipped to treat the newborn's
9 condition, when such transportation is certified by the
10 attending physician as medically necessary to protect the
11 health and safety of the newborn child.
12 (a) A contract may require the subscriber to notify
13 the plan of the birth of a child within a time period, as
14 specified in the contract, of not less than 30 days after the
15 birth, or a contract may require the preenrollment of a
16 newborn prior to birth. However, if timely notice is given, a
17 plan may not charge an additional premium for additional
18 coverage of the newborn child for not less than 30 days after
19 the birth of the child. If timely notice is not given, the
20 plan may charge an additional premium from the date of birth.
21 If notice is given within 60 days of the birth of the child,
22 the contract may not deny coverage of the child due to failure
23 of the subscriber to timely notify the plan of the birth of
24 the child or to preenroll the child.
25 (b) If the contract does not require the subscriber to
26 notify the plan of the birth of a child within a specified
27 time period, the plan may not deny coverage of the child nor
28 may it retroactively charge the subscriber an additional
29 premium for the child; however, the contract may prospectively
30 charge the member an additional premium for the child if the
31
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1 plan provides at least 45 days' notice of the additional
2 charge.
3 (11)(10) No alteration of any written application for
4 any health maintenance contract shall be made by any person
5 other than the applicant without his or her written consent,
6 except that insertions may be made by the health maintenance
7 organization, for administrative purposes only, in such manner
8 as to indicate clearly that such insertions are not to be
9 ascribed to the applicant.
10 (12)(11) No contract shall contain any waiver of
11 rights or benefits provided to or available to subscribers
12 under the provisions of any law or rule applicable to health
13 maintenance organizations.
14 (13)(12) Each health maintenance contract,
15 certificate, or member handbook shall state that emergency
16 services and care shall be provided to subscribers in
17 emergency situations not permitting treatment through the
18 health maintenance organization's providers, without prior
19 notification to and approval of the organization. Not less
20 than 75 percent of the reasonable charges for covered services
21 and supplies shall be paid by the organization, up to the
22 subscriber contract benefit limits. Payment also may be
23 subject to additional applicable copayment provisions, not to
24 exceed $100 per claim. The health maintenance contract,
25 certificate, or member handbook shall contain the definitions
26 of "emergency services and care" and "emergency medical
27 condition" as specified in s. 641.19(7) and (8), shall
28 describe procedures for determination by the health
29 maintenance organization of whether the services qualify for
30 reimbursement as emergency services and care, and shall
31 contain specific examples of what does constitute an
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1 emergency. In providing for emergency services and care as a
2 covered service, a health maintenance organization shall be
3 governed by s. 641.513.
4 (14)(13) In addition to the requirements of this
5 section, with respect to a person who is entitled to have
6 payments for health care costs made under Medicare, Title
7 XVIII of the Social Security Act ("Medicare"), parts A and/or
8 B:
9 (a) The health maintenance organization shall mail or
10 deliver notification to the Medicare beneficiary of the date
11 of enrollment in the health maintenance organization within 10
12 days after receiving notification of enrollment approval from
13 the United States Department of Health and Human Services,
14 Health Care Financing Administration. When a Medicare
15 beneficiary who is a subscriber of the health maintenance
16 organization requests disenrollment from the organization, the
17 organization shall mail or deliver to the beneficiary notice
18 of the effective date of the disenrollment within 10 days
19 after receipt of the written disenrollment request. The health
20 maintenance organization shall forward the disenrollment
21 request to the United States Department of Health and Human
22 Services, Health Care Financing Administration, in a timely
23 manner so as to effectuate the next available disenrollment
24 date, as prescribed by such federal agency.
25 (b) The health maintenance contract, certificate, or
26 member handbook shall be delivered to the subscriber no later
27 than the earlier of 10 working days after the health
28 maintenance organization and the Health Care Financing
29 Administration of the United States Department of Health and
30 Human Services approve the subscriber's enrollment application
31 or the effective date of coverage of the subscriber under the
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1 health maintenance contract. However, if notice from the
2 Health Care Financing Administration of its approval of the
3 subscriber's enrollment application is received by the health
4 maintenance organization after the effective coverage date
5 prescribed by the Health Care Financing Administration, the
6 health maintenance organization shall deliver the contract,
7 certificate, or member handbook to the subscriber within 10
8 days after receiving such notice. When a Medicare recipient is
9 enrolled in a health maintenance organization program, the
10 contract, certificate, or member handbook shall be accompanied
11 by a health maintenance organization identification sticker
12 with instruction to the Medicare beneficiary to place the
13 sticker on the Medicare identification card.
14 (15)(14) Whenever a subscriber of a health maintenance
15 organization is also a Medicaid recipient, the health
16 maintenance organization's coverage shall be primary to the
17 recipient's Medicaid benefits and the organization shall be a
18 third party subject to the provisions of s. 409.910(4).
19 (16)(15)(a) All health maintenance contracts,
20 certificates, and member handbooks shall contain the following
21 provision:
22
23 "Grace Period: This contract has a (insert a number not
24 less than 10) day grace period. This provision means that if
25 any required premium is not paid on or before the date it is
26 due, it may be paid during the following grace period. During
27 the grace period, the contract will stay in force."
28
29 (b) The required provision of paragraph (a) shall not
30 apply to certificates or member handbooks delivered to
31 individual subscribers under a group health maintenance
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1 contract when the employer or other person who will hold the
2 contract on behalf of the subscriber group pays the entire
3 premium for the individual subscribers. However, such required
4 provision shall apply to the group health maintenance
5 contract.
6 (17)(16) The contracts must clearly disclose the
7 intent of the health maintenance organization as to the
8 applicability or nonapplicability of coverage to preexisting
9 conditions. If coverage of the contract is not to be
10 applicable to preexisting conditions, the contract shall
11 specify, in substance, that coverage pertains solely to
12 accidental bodily injuries resulting from accidents occurring
13 after the effective date of coverage and that sicknesses are
14 limited to those which first manifest themselves subsequent to
15 the effective date of coverage.
16 (17) All health maintenance contracts that provide
17 coverage for a member of the family of the subscriber, shall,
18 as to such family member's coverage, provide that coverage,
19 benefits, or services applicable for children shall be
20 provided with respect to an adopted child of the subscriber,
21 which child is placed in compliance with chapter 63, from the
22 moment of placement in the residence of the subscriber. Such
23 contracts may not exclude coverage for any preexisting
24 condition of the child. In the case of a newborn child,
25 coverage shall begin from the moment of birth if a written
26 agreement to adopt such child has been entered into by the
27 subscriber prior to the birth of the child, whether or not
28 such agreement is enforceable. However, coverage for such
29 child shall not be required in the event that the child is not
30 ultimately placed in the residence of the subscriber in
31 compliance with chapter 63.
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1 Section 22. Section 641.3101, Florida Statutes, is
2 amended to read:
3 641.3101 Additional contract contents.--
4 (1) A health maintenance contract may contain
5 additional provisions not inconsistent with this part which
6 are:
7 (a)(1) Necessary, on account of the manner in which
8 the organization is constituted or operated, in order to state
9 the rights and obligations of the parties to the contract; or
10 (b)(2) Desired by the organization and neither
11 prohibited by law nor in conflict with any provisions required
12 to be included therein.
13 (2) A health maintenance contract that uses a specific
14 methodology for payment of claims shall comply with s.
15 627.6044. The method used for determining the payment of
16 claims shall be included in filings made pursuant to s.
17 641.31(3), and may not be changed unless such change is filed
18 under s. 641.31(3).
19 Section 23. Section 641.31025, Florida Statutes, is
20 created to read:
21 641.31025 Specific reasons for denial of
22 coverage.--The denial of an application for a health
23 maintenance organization contract must be accompanied by the
24 specific reasons for the denial, including, but not limited
25 to, the specific underwriting reasons, if applicable.
26 Section 24. Section 641.31075, Florida Statutes, is
27 created to read:
28 641.31075 Replacement.--Any health maintenance
29 organization that is replacing any other group health coverage
30 with its group health maintenance coverage shall comply with
31 s. 627.666.
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1 Section 25. Subsections (1) and (3) of section
2 641.3111, Florida Statutes, are amended to read:
3 641.3111 Extension of benefits.--
4 (1) Every group health maintenance contract shall
5 provide that termination of the contract shall be without
6 prejudice to any continuous loss which commenced while the
7 contract was in force, but any extension of benefits beyond
8 the period the contract was in force may be predicated upon
9 the continuous total disability of the subscriber and may be
10 limited to payment for the treatment of a specific accident or
11 illness incurred while the subscriber was a member. The
12 extension is required regardless of whether the group contract
13 holder or other entity secures replacement coverage from a new
14 insurer or health maintenance organization or foregoes the
15 provision of coverage. The required provision must provide for
16 continuation of contract benefits in connection with the
17 treatment of a specific accident or illness incurred while the
18 contract was in effect. Such extension of benefits may be
19 limited to the occurrence of the earliest of the following
20 events:
21 (a) The expiration of 12 months.
22 (b) Such time as the member is no longer totally
23 disabled.
24 (c) A succeeding carrier elects to provide replacement
25 coverage without limitation as to the disability condition.
26 (c)(d) The maximum benefits payable under the contract
27 have been paid.
28 (3) In the case of maternity coverage, when not
29 covered by the succeeding carrier, a reasonable extension of
30 benefits or accrued liability provision is required, which
31 provision provides for continuation of the contract benefits
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1 in connection with maternity expenses for a pregnancy that
2 commenced while the policy was in effect. The extension shall
3 be for the period of that pregnancy and shall not be based
4 upon total disability.
5 Section 26. Subsection (1) of section 641.2018,
6 Florida Statutes, is amended to read:
7 641.2018 Limited coverage for home health care
8 authorized.--
9 (1) Notwithstanding other provisions of this chapter,
10 a health maintenance organization may issue a contract that
11 limits coverage to home health care services only. The
12 organization and the contract shall be subject to all of the
13 requirements of this part that do not require or otherwise
14 apply to specific benefits other than home care services. To
15 this extent, all of the requirements of this part apply to any
16 organization or contract that limits coverage to home care
17 services, except the requirements for providing comprehensive
18 health care services as provided in ss. 641.19(4), (12), and
19 (13), and 641.31(1), except ss. 641.31(9), (13)(12), (17),
20 (18), (19), (20), (21), and (24) and 641.31095.
21 Section 27. Section 641.3107, Florida Statutes, is
22 amended to read:
23 641.3107 Delivery of contract.--Unless delivered upon
24 execution or issuance, a health maintenance contract,
25 certificate of coverage, or member handbook shall be mailed or
26 delivered to the subscriber or, in the case of a group health
27 maintenance contract, to the employer or other person who will
28 hold the contract on behalf of the subscriber group within 10
29 working days from approval of the enrollment form by the
30 health maintenance organization or by the effective date of
31 coverage, whichever occurs first. However, if the employer or
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1 other person who will hold the contract on behalf of the
2 subscriber group requires retroactive enrollment of a
3 subscriber, the organization shall deliver the contract,
4 certificate, or member handbook to the subscriber within 10
5 days after receiving notice from the employer of the
6 retroactive enrollment. This section does not apply to the
7 delivery of those contracts specified in s. 641.31(14)(13).
8 Section 28. Subsection (4) of section 641.513, Florida
9 Statutes, is amended to read:
10 641.513 Requirements for providing emergency services
11 and care.--
12 (4) A subscriber may be charged a reasonable
13 copayment, as provided in s. 641.31(13)(12), for the use of an
14 emergency room.
15 Section 29. Section 627.6410, Florida Statutes, is
16 created to read:
17 627.6410 Optional coverage for speech, language,
18 swallowing, and hearing disorders.--
19 (1) Insurers issuing individual health insurance
20 policies in this state shall make available to the
21 policyholder as part of the application for any such policy of
22 insurance, for an appropriate additional premium, the benefits
23 or levels of benefits specified in the December 1999 Florida
24 Medicaid Therapy Services Handbook for genetic or congenital
25 disorders or conditions involving speech, language,
26 swallowing, and hearing and a hearing aid and earmolds benefit
27 at the level of benefits specified in the January 2001 Florida
28 Medicaid Hearing Services Handbook.
29 (2) This section does not apply to specified-accident,
30 specified-disease, hospital indemnity, limited benefit,
31 disability income, or long-term care insurance policies.
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1 (3) Such optional coverage is not required to be
2 offered when substantially similar benefits are included in
3 the policy of insurance issued to the policyholder.
4 (4) This section does not require or prohibit the use
5 of a provider network.
6 (5) This section does not prohibit an insurer from
7 requiring prior authorization for the benefits under this
8 section.
9 Section 30. Section 627.66912, Florida Statutes, is
10 created to read:
11 627.66912 Optional coverage for speech, language,
12 swallowing, and hearing disorders.--
13 (1) Insurers issuing group health insurance policies
14 in this state shall make available to the policyholder as part
15 of the application for any such policy of insurance, for an
16 appropriate additional premium, the benefits or levels of
17 benefits specified in the December 1999 Florida Medicaid
18 Therapy Services Handbook for genetic or congenital disorders
19 or conditions involving speech, language, swallowing, and
20 hearing and a hearing aid and earmolds benefit at the level of
21 benefits specified in the January 2001 Florida Medicaid
22 Hearing Services Handbook.
23 (2) This section does not apply to specified-accident,
24 specified-disease, hospital indemnity, limited benefit,
25 disability income, or long-term care insurance policies.
26 (3) Such optional coverage is not required to be
27 offered when substantially similar benefits are included in
28 the policy of insurance issued to the policyholder.
29 (4) This section does not require or prohibit the use
30 of a provider network.
31
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1 (5) This section does not prohibit an insurer from
2 requiring prior authorization for the benefits under this
3 section.
4 Section 31. Subsection (40) is added to section
5 641.31, Florida Statutes, to read:
6 641.31 Health maintenance contracts.--
7 (40) Health maintenance organizations shall make
8 available to the contract holder as part of the application
9 for any such contract, for an appropriate additional premium,
10 the benefits or levels of benefits specified in the December
11 1999 Florida Medicaid Therapy Services Handbook for genetic or
12 congenital disorders or conditions involving speech, language,
13 swallowing, and hearing and a hearing aid and earmolds benefit
14 at the level of benefits specified in the January 2001 Florida
15 Medicaid Hearing Services Handbook.
16 (a) Such optional coverage is not required to be
17 offered when substantially similar benefits are included in
18 the contract issued to the subscriber.
19 (b) This section does not require or prohibit the use
20 of a provider network.
21 (c) This section does not prohibit an organization
22 from requiring prior authorization for the benefits under this
23 subsection.
24 (d) This subsection does not apply to health
25 maintenance organizations issuing individual coverage to fewer
26 than 50,000 members.
27 Section 32. This act shall take effect July 1, 2003.
28
29
30
31
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1 STATEMENT OF SUBSTANTIAL CHANGES CONTAINED IN
COMMITTEE SUBSTITUTE FOR
2 Senate Bill 1796
3
4 The committee substitute does the following:
5 - Requires hospitals to have an Internet web site that
lists charges and codes for certain procedures, to
6 furnish a patient a reasonable estimate of charges, and
to make available records that are necessary to verify
7 the accuracy of the patient's bill.
8 - Extends the term of the pilot project for health flex
plans for an additional 4 years.
9
- Allows health insurers to transact reinsurance for the
10 medical and lost wages benefits under a workers'
compensation insurance policy.
11
- Revises the prohibition on mandatory arbitration clauses
12 in life, health, and disability insurance.
13 - Allows large group health insurance policies and HMO
contracts covering a group of 51 or more persons to be
14 exempt from any law that restricts deductibles,
coinsurance, copayments, or annual or lifetime maximum
15 benefits.
16 - Requires health insurance policies and HMO contracts that
provide coverage to non-network providers to provide
17 certain payments.
18 - Allows insurers issuing individual coverage on a
guarantee-issue basis to HIPAA-eligible individuals whose
19 most recent coverage was in another state, to impose a
surcharge as would be permitted in that state.
20
- Requires small employers to annually provide information
21 on at least three different health benefit plans for
their employees.
22
- Requires insurers and HMOs to offer coverage for speech,
23 language, swallowing, and hearing disorders.
24 - Deletes provisions of the bill relating to prescription
drug benefits and home health services.
25
- Reinserts the current law allowing small group carriers
26 to adjust rates by plus or minus 15 percent based on
health status or claims experience.
27
28
29
30
31
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