HOUSE AMENDMENT Bill No. SB 2020
1	CHAMBER ACTION
2	Senate House
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12	Representative Llorente offered the following:
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14	Amendment to Amendment (637059) (with title amendment)
15	Remove everything after the enacting clause, and insert:
16	Section 1. Paragraph (e) of subsection (2), subsection
17	(3), paragraph (c) of subsection (5), and subsection (10) of
18	section 408.909, Florida Statutes, are amended to read:
19	408.909 Health flex plans.--
20	(2) DEFINITIONS.--As used in this section, the term:
21	(e) "Health flex plan" means a health plan approved under
22	subsection (3) which guarantees payment for specified health
23	care coverage provided to the enrollee who purchases coverage
24	directly from the plan or through a small business purchasing
25	arrangement sponsored by a local government.
26	(3) PILOT PROGRAM.--The agency and the department shall
27	each approve or disapprove health flex plans that provide health
28	care coverage for eligible participants who reside in the three
29	areas of the state that have the highest number of uninsured
30	persons, as identified in the Florida Health Insurance Study
31	conducted by the agency and in Indian River County. A health
32	flex plan may limit or exclude benefits otherwise required by
33	law for insurers offering coverage in this state, may cap the
34	total amount of claims paid per year per enrollee, may limit the
35	number of enrollees or the term of coverage, or may take any
36	combination of those actions.
37	(a) The agency shall develop guidelines for the review of
38	applications for health flex plans and shall disapprove or
39	withdraw approval of plans that do not meet or no longer meet
40	minimum standards for quality of care and access to care.
41	(b) The department shall develop guidelines for the review
42	of health flex plan applications and shall disapprove or shall
43	withdraw approval of plans that:
44	1. Contain any ambiguous, inconsistent, or misleading
45	provisions or any exceptions or conditions that deceptively
46	affect or limit the benefits purported to be assumed in the
47	general coverage provided by the health flex plan;
48	2. Provide benefits that are unreasonable in relation to
49	the premium charged or contain provisions that are unfair or
50	inequitable or contrary to the public policy of this state, that
51	encourage misrepresentation, or that result in unfair
52	discrimination in sales practices; or
53	3. Cannot demonstrate that the health flex plan is
54	financially sound and that the applicant is able to underwrite
55	or finance the health care coverage provided.
56	(c) The agency and the department may adopt rules as
57	needed to administer this section.
58	(5) ELIGIBILITY.--Eligibility to enroll in an approved
59	health flex plan is limited to residents of this state who:
60	(c) Are not covered by a private insurance policy and are
61	not eligible for coverage through a public health insurance
62	program, such as Medicare or Medicaid, or another public health
63	care program, such as KidCare, and have not been covered at any
64	time during the past 6 months, except that a small business
65	purchasing arrangement sponsored by a local government may limit
66	enrollment to residents of this state who have not been covered
67	at any time during the past 12 months; and
68	(10) EXPIRATION.--This section expires July 1, 20082004.
69	Section 2. Section 627.6042, Florida Statutes, is created
70	to read:
71	627.6042 Dependent coverage.--
72	(1) If an insurer offers coverage that insures dependent
73	children of the policyholder or certificateholder, the policy
74	must insure a dependent child of the policyholder or
75	certificateholder at least until the end of the calendar year in
76	which the child reaches the age of 25, if the child meets all of
77	the following:
78	(a) The child is dependent upon the policyholder or
79	certificateholder for support.
80	(b) The child is living in the household of the
81	policyholder or certificateholder or the child is a full-time or
82	part-time student.
83	(2) Nothing in this section affects or preempts an
84	insurer's right to medically underwrite or charge the
85	appropriate premium.
86	Section 3. Section 627.60425, Florida Statutes, is created
87	to read:
88	627.60425 Binding arbitration requirement
89	limitations.--Notwithstanding any other provision of law, except
90	s. 624.155, an individual, blanket, group life, or group health
91	insurance policy; individual or group health maintenance
92	organization subscriber contract; prepaid limited health
93	organization subscriber contract; or any life or health
94	insurance policy or certificate delivered or issued for
95	delivery, including out-of-state group plans pursuant to s.
96	627.5515 or s. 627.6515 covering residents of this state, to any
97	resident of this state shall not require the submission of
98	disputes between the parties to the policy, contract, or plan to
99	binding arbitration unless the applicant has indicated that the
100	same policy, contract, or plan was offered and rejected without
101	arbitration and that the binding arbitration provision was fully
102	explained to the applicant and willingly accepted.
103	Section 4. Section 627.6044, Florida Statutes, is amended
104	to read:
105	627.6044 Use of a specific methodology for payment of
106	claims.--
107	(1) Each insurance policy that provides for payment of
108	claims to nonnetwork providers that is less than the payment of
109	the provider's billed charges to the insured, excluding
110	deductible, coinsurance, and copay amounts, shall:
111	(a) Provide benefits prior to deductible, coinsurance, and
112	copay amounts for using a nonnetwork provider that are at least
113	equal to the amount that would have been allowed had the insured
114	used a network provider but are not in excess of the actual
115	billed charges.
116	(b) Where there are multiple network providers in the
117	geographical area in which the services were provided or, if
118	none, the closest geographic area, the carrier may use an
119	averaging method of the contracted amounts but not less than the
120	80th percentile of all network contracted amounts in the
121	geographic area.
122
123	For purposes of this subsection, the term "network providers"
124	means those providers for which an insured will not be
125	responsible for any balance payment for services provided by
126	such provider, excluding deductible, coinsurance, and copay
127	amountsbased on a specific methodology, including, but not
128	limited to, usual and customary charges, reasonable and
129	customary charges, or charges based upon the prevailing rate in
130	the community, shall specify the formula or criteria used by the
131	insurer in determining the amount to be paid.
132	(2) Each insurer issuing a policy that provides for
133	payment of claims based on a specific methodology shall provide
134	to an insured, upon her or his written request, an estimate of
135	the amount the insurer will pay for a particular medical
136	procedure or service. The estimate may be in the form of a range
137	of payments or an average payment and may specify that the
138	estimate is based on the assumption of a particular service
139	code. The insurer may require the insured to provide detailed
140	information regarding the procedure or service to be performed,
141	including the procedure or service code number provided by the
142	health care provider and the health care provider's estimated
143	charge.An insurer that provides an insured with a good faith
144	estimate is not bound by the estimate. However, a pattern of
145	providing estimates that vary significantly from the ultimate
146	insurance payment constitutes a violation of this code.
147	(3) The method used for determining the payment of claims
148	shall be included in filings made pursuant to s. 627.410(6) and
149	may not be changed unless such change is filed under s.
150	627.410(6).
151	(4) Any policy that provides that the insured is
152	responsible for the balance of a claim amount, excluding
153	deductible, coinsurance, and copay amounts, must disclose such
154	feature on the face of the policy or certificate and such
155	feature must be included in any outline of coverage provided to
156	the insured.
157	Section 5. Subsections (1) and (4) of section 627.6415,
158	Florida Statutes, are amended to read:
159	627.6415 Coverage for natural-born, adopted, and foster
160	children; children in insured's custodial care.--
161	(1) A health insurance policy that provides coverage for a
162	member of the family of the insured shall, as to the family
163	member's coverage, provide that the health insurance benefits
164	applicable to children of the insured also apply to an adopted
165	child or a foster child of the insured placed in compliance with
166	chapter 63, prior to the child's 18th birthday,from the moment
167	of placement in the residence of the insured. Except in the case
168	of a foster child, the policy may not exclude coverage for any
169	preexisting condition of the child. In the case of a newborn
170	child, coverage begins at the moment of birth if a written
171	agreement to adopt the child has been entered into by the
172	insured prior to the birth of the child, whether or not the
173	agreement is enforceable. This section does not require coverage
174	for an adopted child who is not ultimately placed in the
175	residence of the insured in compliance with chapter 63.
176	(4) In order to increase access to postnatal, infant, and
177	pediatric health care for all children placed in court-ordered
178	custody, including foster children, all health insurance
179	policies that provide coverage for a member of the family of the
180	insured shall, as to such family member's coverage, also provide
181	that the health insurance benefits applicable for children shall
182	be payable with respect to a foster child or other child in
183	court-ordered temporary or other custody of the insured, prior
184	to the child's 18th birthday.
185	Section 6. Paragraph (a) of subsection (5), paragraph (c)
186	of subsection (6), and paragraphs (b), (c), and (e) of
187	subsection (7) of section 627.6475, Florida Statutes, are
188	amended to read:
189	627.6475 Individual reinsurance pool.--
190	(5) ISSUER'S ELECTION TO BECOME A RISK-ASSUMING CARRIER.--
191	(a) Each health insurance issuer that offers individual
192	health insurance must elect to become a risk-assuming carrier or
193	a reinsuring carrier for purposes of this section. Each such
194	issuer must make an initial election, binding through December
195	31, 1999. The issuer's initial election must be made no later
196	than October 31, 1997. By October 31, 1997, all issuers must
197	file a final election, which is binding for 2 years, from
198	January 1, 1998, through December 31, 1999, after whichan
199	election that shall be binding indefinitely or until modified or
200	withdrawnfor a period of 5 years. The department may permit an
201	issuer to modify its election at any time for good cause shown,
202	after a hearing.
203	(6) ELECTION PROCESS TO BECOME A RISK-ASSUMING CARRIER.--
204	(c) The department shall provide public notice of an
205	issuer's filing adesignation of election under this subsection
206	to become a risk-assuming carrier and shall provide at least a
207	21-day period for public comment upon receipt of such filing
208	prior to making a decision on the election. The department shall
209	hold a hearing on the election at the request of the issuer.
210	(7) INDIVIDUAL HEALTH REINSURANCE PROGRAM.--
211	(b) A reinsuring carrier may reinsure with the program
212	coverage of an eligible individual, subject to each of the
213	following provisions:
214	1. A reinsuring carrier may reinsure an eligible
215	individual within 9060days after commencement of the coverage
216	of the eligible individual.
217	2. The program may not reimburse a participating carrier
218	with respect to the claims of a reinsured eligible individual
219	until the carrier has paid incurred claims of an amount equal to
220	the participating carrier’s selected deductible levelat least
221	$5,000 in a calendar year for benefits covered by the program.
222	In addition, the reinsuring carrier is responsible for 10
223	percent of the next $50,000 and 5 percent of the next $100,000
224	of incurred claims during a calendar year, and the program shall
225	reinsure the remainder.
226	3. The board shall annually adjust the initial level of
227	claims and the maximum limit to be retained by the carrier to
228	reflect increases in costs and utilization within the standard
229	market for health benefit plans within the state. The adjustment
230	may not be less than the annual change in the medical component
231	of the "Commerce Price Index for All Urban Consumers" of the
232	Bureau of Labor Statistics of the United States Department of
233	Labor, unless the board proposes and the department approves a
234	lower adjustment factor.
235	4. A reinsuring carrier may terminate reinsurance for all
236	reinsured eligible individuals on any plan anniversary.
237	5. The premium rate charged for reinsurance by the program
238	to a health maintenance organization that is approved by the
239	Secretary of Health and Human Services as a federally qualified
240	health maintenance organization pursuant to 42 U.S.C. s.
241	300e(c)(2)(A) and that, as such, is subject to requirements that
242	limit the amount of risk that may be ceded to the program, which
243	requirements are more restrictive than subparagraph 2., shall be
244	reduced by an amount equal to that portion of the risk, if any,
245	which exceeds the amount set forth in subparagraph 2., which may
246	not be ceded to the program.
247	6. The board may consider adjustments to the premium rates
248	charged for reinsurance by the program or carriers that use
249	effective cost-containment measures, including high-cost case
250	management, as defined by the board.
251	7. A reinsuring carrier shall apply its case-management
252	and claims-handling techniques, including, but not limited to,
253	utilization review, individual case management, preferred
254	provider provisions, other managed-care provisions, or methods
255	of operation consistently with both reinsured business and
256	nonreinsured business.
257	(c)1. The board, as part of the plan of operation, shall
258	establish a methodology for determining premium rates to be
259	charged by the program for reinsuring eligible individuals
260	pursuant to this section. The methodology must include a system
261	for classifying individuals which reflects the types of case
262	characteristics commonly used by carriers in this state. The
263	methodology must provide for the development of basic
264	reinsurance premium rates, which shall be multiplied by the
265	factors set for them in this paragraph to determine the premium
266	rates for the program. The basic reinsurance premium rates shall
267	be established by the board, subject to the approval of the
268	department, and shall be set at levels that reasonably
269	approximate gross premiums charged to eligible individuals for
270	individual health insurance by health insurance issuers. The
271	premium rates set by the board may vary by geographical area, as
272	determined under this section, to reflect differences in cost.
273	An eligible individual may be reinsured for a rate that is five
274	times the rate established by the board.
275	2. The board shall periodically review the methodology
276	established, including the system of classification and any
277	rating factors, to ensure that it reasonably reflects the claims
278	experience of the program. The board may propose changes to the
279	rates that are subject to the approval of the department.
280	(e)1. Before SeptemberMarch1 of each calendar year, the
281	board shall determine and report to the department the program
282	net loss in the individual account for the previous year,
283	including administrative expenses for that year and the incurred
284	losses for that year, taking into account investment income and
285	other appropriate gains and losses.
286	2. Any net loss in the individual account for the year
287	shall be recouped by assessing the carriers as follows:
288	a. The operating losses of the program shall be assessed
289	in the following order subject to the specified limitations. The
290	first tier of assessments shall be made against reinsuring
291	carriers in an amount that may not exceed 5 percent of each
292	reinsuring carrier's premiums for individual health insurance.
293	If such assessments have been collected and additional moneys
294	are needed, the board shall make a second tier of assessments in
295	an amount that may not exceed 0.5 percent of each carrier's
296	health benefit plan premiums.
297	b. Except as provided in paragraph (f), risk-assuming
298	carriers are exempt from all assessments authorized pursuant to
299	this section. The amount paid by a reinsuring carrier for the
300	first tier of assessments shall be credited against any
301	additional assessments made.
302	c. The board shall equitably assess reinsuring carriers
303	for operating losses of the individual account based on market
304	share. The board shall annually assess each carrier a portion of
305	the operating losses of the individual account. The first tier
306	of assessments shall be determined by multiplying the operating
307	losses by a fraction, the numerator of which equals the
308	reinsuring carrier's earned premium pertaining to direct
309	writings of individual health insurance in the state during the
310	calendar year for which the assessment is levied, and the
311	denominator of which equals the total of all such premiums
312	earned by reinsuring carriers in the state during that calendar
313	year. The second tier of assessments shall be based on the
314	premiums that all carriers, except risk-assuming carriers,
315	earned on all health benefit plans written in this state. The
316	board may levy interim assessments against reinsuring carriers
317	to ensure the financial ability of the plan to cover claims
318	expenses and administrative expenses paid or estimated to be
319	paid in the operation of the plan for the calendar year prior to
320	the association's anticipated receipt of annual assessments for
321	that calendar year. Any interim assessment is due and payable
322	within 30 days after receipt by a carrier of the interim
323	assessment notice. Interim assessment payments shall be credited
324	against the carrier's annual assessment. Health benefit plan
325	premiums and benefits paid by a carrier that are less than an
326	amount determined by the board to justify the cost of collection
327	may not be considered for purposes of determining assessments.
328	d. Subject to the approval of the department, the board
329	shall adjust the assessment formula for reinsuring carriers that
330	are approved as federally qualified health maintenance
331	organizations by the Secretary of Health and Human Services
332	pursuant to 42 U.S.C. s. 300e(c)(2)(A) to the extent, if any,
333	that restrictions are placed on them which are not imposed on
334	other carriers.
335	3. Before SeptemberMarch1 of each year, the board shall
336	determine and file with the department an estimate of the
337	assessments needed to fund the losses incurred by the program in
338	the individual account for the previous calendar year.
339	4. If the board determines that the assessments needed to
340	fund the losses incurred by the program in the individual
341	account for the previous calendar year will exceed the amount
342	specified in subparagraph 2., the board shall evaluate the
343	operation of the program and report its findings and
344	recommendations to the department in the format established in
345	s. 627.6699(11) for the comparable report for the small employer
346	reinsurance program.
347	Section 7. Subsection (4) of section 627.651, Florida
348	Statutes, is amended to read:
349	627.651 Group contracts and plans of self-insurance must
350	meet group requirements.--
351	(4) This section does not apply to any plan which is
352	established or maintained by an individual employer in
353	accordance with the Employee Retirement Income Security Act of
354	1974, Pub. L. No. 93-406, or to a multiple-employer welfare
355	arrangement as defined in s. 624.437(1), except that a multiple-
356	employer welfare arrangement shall comply with ss. 627.419,
357	627.657, 627.6575, 627.6578, 627.6579, 627.6612, 627.66121,
358	627.66122, 627.6615, 627.6616, and 627.662(8)(7). This
359	subsection does not allow an authorized insurer to issue a group
360	health insurance policy or certificate which does not comply
361	with this part.
362	Section 8. Section 627.662, Florida Statutes, is amended
363	to read:
364	627.662 Other provisions applicable.--The following
365	provisions apply to group health insurance, blanket health
366	insurance, and franchise health insurance:
367	(1) Section 627.569, relating to use of dividends,
368	refunds, rate reductions, commissions, and service fees.
369	(2) Section 627.602(1)(f) and (2), relating to
370	identification numbers and statement of deductible provisions.
371	(3) Section 627.6044, relating to the use of specific
372	methodology for payment of claims.
373	(4)(3)Section 627.635, relating to excess insurance.
374	(5)(4)Section 627.638, relating to direct payment for
375	hospital or medical services.
376	(6)(5)Section 627.640, relating to filing and
377	classification of rates.
378	(7)(6)Section 627.613, relating to timely payment of
379	claims, or s. 627.6131, relating to payment of claims, whichever
380	is applicable.
381	(8)(7)Section 627.645(1), relating to denial of claims.
382	(9)(8)Section 627.6471, relating to preferred provider
383	organizations.
384	(10)(9)Section 627.6472, relating to exclusive provider
385	organizations.
386	(11)(10)Section 627.6473, relating to combined preferred
387	provider and exclusive provider policies.
388	(12)(11)Section 627.6474, relating to provider contracts.
389	Section 9. Subsection (6) of section 627.667, Florida
390	Statutes, is amended to read:
391	627.667 Extension of benefits.--
392	(6) This section also applies to holders of group
393	certificates which are renewed, delivered, or issued for
394	delivery to residents of this state under group policies
395	effectuated or delivered outside this state, unless a succeeding
396	carrier under a group policy has agreed to assume liability for
397	the benefits.
398	Section 10. Paragraph (e) of subsection (5) of section
399	627.6692, Florida Statutes, is amended to read:
400	627.6692 Florida Health Insurance Coverage Continuation
401	Act.--
402	(5) CONTINUATION OF COVERAGE UNDER GROUP HEALTH PLANS.--
403	(e)1. A covered employee or other qualified beneficiary
404	who wishes continuation of coverage must pay the initial premium
405	and elect such continuation in writing to the insurance carrier
406	issuing the employer's group health plan within 6330days after
407	receiving notice from the insurance carrier under paragraph (d).
408	Subsequent premiums are due by the grace period expiration date.
409	The insurance carrier or the insurance carrier's designee shall
410	process all elections promptly and provide coverage
411	retroactively to the date coverage would otherwise have
412	terminated. The premium due shall be for the period beginning on
413	the date coverage would have otherwise terminated due to the
414	qualifying event. The first premium payment must include the
415	coverage paid to the end of the month in which the first payment
416	is made. After the election, the insurance carrier must bill the
417	qualified beneficiary for premiums once each month, with a due
418	date on the first of the month of coverage and allowing a 30-day
419	grace period for payment.
420	2. Except as otherwise specified in an election, any
421	election by a qualified beneficiary shall be deemed to include
422	an election of continuation of coverage on behalf of any other
423	qualified beneficiary residing in the same household who would
424	lose coverage under the group health plan by reason of a
425	qualifying event. This subparagraph does not preclude a
426	qualified beneficiary from electing continuation of coverage on
427	behalf of any other qualified beneficiary.
428	Section 11. Paragraphs (g), (h), (i), and (u) of
429	subsection (3), paragraph (c) of subsection (5), paragraph (a)
430	of subsection (9), paragraph (d) of subsection (10), and
431	paragraphs (f), (g), (h), and (j) of subsection (11) of section
432	627.6699, Florida Statutes, are amended to read:
433	627.6699 Employee Health Care Access Act.--
434	(3) DEFINITIONS.--As used in this section, the term:
435	(g) "Dependent" means the spouse or child as described in
436	s. 627.6562 of an eligible employee, subject to the applicable
437	terms of the health benefit plan covering that employee.
438	(h) "Eligible employee" means an employee who works full
439	time, having a normal workweek of 25 or more hours, who is paid
440	wages or a salary at least equal to the federal minimum hourly
441	wage applicable to such employee,and who has met any applicable
442	waiting-period requirements or other requirements of this act.
443	The term includes a self-employed individual, a sole proprietor,
444	a partner of a partnership, or an independent contractor, if the
445	sole proprietor, partner, or independent contractor is included
446	as an employee under a health benefit plan of a small employer,
447	but does not include a part-time, temporary, or substitute
448	employee.
449	(i) "Established geographic area" means the county or
450	counties, or any portion of a county or counties,within which
451	the carrier provides or arranges for health care services to be
452	available to its insureds, members, or subscribers.
453	(u) "Self-employed individual" means an individual or sole
454	proprietor who derives his or her income from a trade or
455	business carried on by the individual or sole proprietor which
456	necessitates that the individual file federal income tax forms
457	with supporting schedules and accompanying income reporting
458	forms or federal income tax extensions of time to file forms
459	with the Internal Revenue Service for the most recent tax year
460	results in taxable income as indicated on IRS Form 1040,
461	schedule C or F, and which generated taxable income in one of
462	the 2 previous years.
463	(5) AVAILABILITY OF COVERAGE.--
464	(c) Every small employer carrier must, as a condition of
465	transacting business in this state:
466	1. Beginning July 1, 2000, offer and issue all small
467	employer health benefit plans on a guaranteed-issue basis to
468	every eligible small employer, with 2 to 50 eligible employees,
469	that elects to be covered under such plan, agrees to make the
470	required premium payments, and satisfies the other provisions of
471	the plan. A rider for additional or increased benefits may be
472	medically underwritten and may only be added to the standard
473	health benefit plan. The increased rate charged for the
474	additional or increased benefit must be rated in accordance with
475	this section.
476	2. Beginning July 1, 2000, and until July 31, 2001, offer
477	and issue basic and standard small employer health benefit plans
478	on a guaranteed-issue basis to every eligible small employer
479	which is eligible for guaranteed renewal, has less than two
480	eligible employees, is not formed primarily for the purpose of
481	buying health insurance, elects to be covered under such plan,
482	agrees to make the required premium payments, and satisfies the
483	other provisions of the plan. A rider for additional or
484	increased benefits may be medically underwritten and may be
485	added only to the standard benefit plan. The increased rate
486	charged for the additional or increased benefit must be rated in
487	accordance with this section. For purposes of this subparagraph,
488	a person, his or her spouse, and his or her dependent children
489	shall constitute a single eligible employee if that person and
490	spouse are employed by the same small employer and either one
491	has a normal work week of less than 25 hours.
492	3.a.Beginning August 1, 2001, offer and issue basic and
493	standard small employer health benefit plans on a guaranteed-
494	issue basis, during a 31-day open enrollment period of August 1
495	through August 31 of each year, to every eligible small
496	employer, with fewer than two eligible employees, which small
497	employer is not formed primarily for the purpose of buying
498	health insurance and which elects to be covered under such plan,
499	agrees to make the required premium payments, and satisfies the
500	other provisions of the plan. Coverage provided under this sub-
501	subparagraphsubparagraphshall begin on October 1 of the same
502	year as the date of enrollment, unless the small employer
503	carrier and the small employer agree to a different date. A
504	rider for additional or increased benefits may be medically
505	underwritten and may only be added to the standard health
506	benefit plan. The increased rate charged for the additional or
507	increased benefit must be rated in accordance with this section.
508	For purposes of this sub-subparagraphsubparagraph, a person,
509	his or her spouse, and his or her dependent children constitute
510	a single eligible employee if that person and spouse are
511	employed by the same small employer and either that person or
512	his or her spouse has a normal work week of less than 25 hours.
513	b. Notwithstanding the restrictions set forth in sub-
514	subparagraph a., when a small employer group is losing coverage
515	because a carrier is exercising the provisions of s.
516	627.6571(3)(b) or s. 641.31074(3)(b), the eligible small
517	employer, as defined in sub-subparagraph a., shall be entitled
518	to enroll with another carrier offering small employer coverage
519	within 63 days after the notice of termination or the
520	termination date of the prior coverage, whichever is later.
521	Coverage provided under this sub-subparagraph shall begin
522	immediately upon enrollment unless the small employer carrier
523	and the small employer agree to a different date.
524	4. This paragraph does not limit a carrier's ability to
525	offer other health benefit plans to small employers if the
526	standard and basic health benefit plans are offered and
527	rejected.
528	(9) SMALL EMPLOYER CARRIER'S ELECTION TO BECOME A RISK-
529	ASSUMING CARRIER OR A REINSURING CARRIER.--
530	(a) A small employer carrier must elect to become either a
531	risk-assuming carrier or a reinsuring carrier. Each small
532	employer carrier must make an initial election, binding through
533	January 1, 1994. The carrier's initial election must be made no
534	later than October 31, 1992. By October 31, 1993, all small
535	employer carriers must file a final election, which is binding
536	for 2 years, from January 1, 1994, through December 31, 1995,
537	after which an election shall be binding for a period of 5
538	years.Any carrier that is not a small employer carrier on
539	October 31, 1992, and intends to become a small employer carrier
540	after October 31, 1992, must file its designation when it files
541	the forms and rates it intends to use for small employer group
542	health insurance; such designation shall be binding indefinitely
543	or until modified or withdrawnfor 2 years after the date of
544	approval of the forms and rates, and any subsequent designation
545	is binding for 5 years. The department may permit a carrier to
546	modify its election at any time for good cause shown, after a
547	hearing.
548	(10) ELECTION PROCESS TO BECOME A RISK-ASSUMING CARRIER.--
549	(d) The department shall provide public notice of a small
550	employer carrier's filing adesignation of election under
551	subsection (9) to become a risk-assuming carrier and shall
552	provide at least a 21-day period for public comment upon receipt
553	of such filingprior to making a decision on the election. The
554	department shall hold a hearing on the election at the request
555	of the carrier.
556	(11) SMALL EMPLOYER HEALTH REINSURANCE PROGRAM.--
557	(f) The program has the general powers and authority
558	granted under the laws of this state to insurance companies and
559	health maintenance organizations licensed to transact business,
560	except the power to issue health benefit plans directly to
561	groups or individuals. In addition thereto, the program has
562	specific authority to:
563	1. Enter into contracts as necessary or proper to carry
564	out the provisions and purposes of this act, including the
565	authority to enter into contracts with similar programs of other
566	states for the joint performance of common functions or with
567	persons or other organizations for the performance of
568	administrative functions.
569	2. Sue or be sued, including taking any legal action
570	necessary or proper for recovering any assessments and penalties
571	for, on behalf of, or against the program or any carrier.
572	3. Take any legal action necessary to avoid the payment of
573	improper claims against the program.
574	4. Issue reinsurance policies, in accordance with the
575	requirements of this act.
576	5. Establish rules, conditions, and procedures for
577	reinsurance risks under the program participation.
578	6. Establish actuarial functions as appropriate for the
579	operation of the program.
580	7. Assess participating carriers in accordance with
581	paragraph (j), and make advance interim assessments as may be
582	reasonable and necessary for organizational and interim
583	operating expenses. Interim assessments shall be credited as
584	offsets against any regular assessments due following the close
585	of the calendar year.
586	8. Appoint appropriate legal, actuarial, and other
587	committees as necessary to provide technical assistance in the
588	operation of the program, and in any other function within the
589	authority of the program.
590	9. Borrow money to effect the purposes of the program. Any
591	notes or other evidences of indebtedness of the program which
592	are not in default constitute legal investments for carriers and
593	may be carried as admitted assets.
594	10. To the extent necessary, increase the $5,000
595	deductible reinsurance requirement to adjust for the effects of
596	inflation. The program may evaluate the desirability of
597	establishing different levels of deductibles. If different
598	levels of deductibles are established, such levels and the
599	resulting premiums shall be approved by the department.
600	(g) A reinsuring carrier may reinsure with the program
601	coverage of an eligible employee of a small employer, or any
602	dependent of such an employee, subject to each of the following
603	provisions:
604	1. With respect to a standard and basic health care plan,
605	the program maymustreinsure the level of coverage provided;
606	and, with respect to any other plan, the program maymust
607	reinsure the coverage up to, but not exceeding, the level of
608	coverage provided under the standard and basic health care plan.
609	As an alternative to reinsuring the level of coverage provided
610	under the standard and basic health care plan, the program may
611	develop alternate levels of reinsurance designed to coordinate
612	with a reinsuring carrier’s existing reinsurance. The levels of
613	reinsurance and resulting premiums must be approved by the
614	department.
615	2. Except in the case of a late enrollee, a reinsuring
616	carrier may reinsure an eligible employee or dependent within 60
617	days after the commencement of the coverage of the small
618	employer. A newly employed eligible employee or dependent of a
619	small employer may be reinsured within 60 days after the
620	commencement of his or her coverage.
621	3. A small employer carrier may reinsure an entire
622	employer group within 60 days after the commencement of the
623	group's coverage under the plan. The carrier may choose to
624	reinsure newly eligible employees and dependents of the
625	reinsured group pursuant to subparagraph 1.
626	4. The program may evaluate the option of allowing a small
627	employer carrier to reinsure an entire employer group or an
628	eligible employee at the first or subsequent renewal date. Any
629	such option and the resulting premium must be approved by the
630	department.
631	5.4.The program may not reimburse a participating carrier
632	with respect to the claims of a reinsured employee or dependent
633	until the carrier has paid incurred claims of an amount equal to
634	the participating carrier’s selected deductible levelat least
635	$5,000 in a calendar year for benefits covered by the program.
636	In addition, the reinsuring carrier shall be responsible for 10
637	percent of the next $50,000 and 5 percent of the next $100,000
638	of incurred claims during a calendar year and the program shall
639	reinsure the remainder.
640	6.5.The board annually shall adjust the initial level of
641	claims and the maximum limit to be retained by the carrier to
642	reflect increases in costs and utilization within the standard
643	market for health benefit plans within the state. The adjustment
644	shall not be less than the annual change in the medical
645	component of the "Consumer Price Index for All Urban Consumers"
646	of the Bureau of Labor Statistics of the Department of Labor,
647	unless the board proposes and the department approves a lower
648	adjustment factor.
649	7.6.A small employer carrier may terminate reinsurance
650	for all reinsured employees or dependents on any plan
651	anniversary.
652	8.7.The premium rate charged for reinsurance by the
653	program to a health maintenance organization that is approved by
654	the Secretary of Health and Human Services as a federally
655	qualified health maintenance organization pursuant to 42 U.S.C.
656	s. 300e(c)(2)(A) and that, as such, is subject to requirements
657	that limit the amount of risk that may be ceded to the program,
658	which requirements are more restrictive than subparagraph 5.4.,
659	shall be reduced by an amount equal to that portion of the risk,
660	if any, which exceeds the amount set forth in subparagraph 5.4.
661	which may not be ceded to the program.
662	9.8.The board may consider adjustments to the premium
663	rates charged for reinsurance by the program for carriers that
664	use effective cost containment measures, including high-cost
665	case management, as defined by the board.
666	10.9.A reinsuring carrier shall apply its case-management
667	and claims-handling techniques, including, but not limited to,
668	utilization review, individual case management, preferred
669	provider provisions, other managed care provisions or methods of
670	operation, consistently with both reinsured business and
671	nonreinsured business.
672	(h)1. The board, as part of the plan of operation, shall
673	establish a methodology for determining premium rates to be
674	charged by the program for reinsuring small employers and
675	individuals pursuant to this section. The methodology shall
676	include a system for classification of small employers that
677	reflects the types of case characteristics commonly used by
678	small employer carriers in the state. The methodology shall
679	provide for the development of basic reinsurance premium rates,
680	which shall be multiplied by the factors set for them in this
681	paragraph to determine the premium rates for the program. The
682	basic reinsurance premium rates shall be established by the
683	board, subject to the approval of the department, and shall be
684	set at levels which reasonably approximate gross premiums
685	charged to small employers by small employer carriers for health
686	benefit plans with benefits similar to the standard and basic
687	health benefit plan. The premium rates set by the board may vary
688	by geographical area, as determined under this section, to
689	reflect differences in cost. The multiplying factors must be
690	established as follows:
691	a. The entire group may be reinsured for a rate that is
692	1.5 times the rate established by the board.
693	b. An eligible employee or dependent may be reinsured for
694	a rate that is 5 times the rate established by the board.
695	2. The board periodically shall review the methodology
696	established, including the system of classification and any
697	rating factors, to assure that it reasonably reflects the claims
698	experience of the program. The board may propose changes to the
699	rates which shall be subject to the approval of the department.
700	(j)1. Before SeptemberMarch1 of each calendar year, the
701	board shall determine and report to the department the program
702	net loss for the previous year, including administrative
703	expenses for that year, and the incurred losses for the year,
704	taking into account investment income and other appropriate
705	gains and losses.
706	2. Any net loss for the year shall be recouped by
707	assessment of the carriers, as follows:
708	a. The operating losses of the program shall be assessed
709	in the following order subject to the specified limitations. The
710	first tier of assessments shall be made against reinsuring
711	carriers in an amount which shall not exceed 5 percent of each
712	reinsuring carrier's premiums from health benefit plans covering
713	small employers. If such assessments have been collected and
714	additional moneys are needed, the board shall make a second tier
715	of assessments in an amount which shall not exceed 0.5 percent
716	of each carrier's health benefit plan premiums. Except as
717	provided in paragraph (n), risk-assuming carriers are exempt
718	from all assessments authorized pursuant to this section. The
719	amount paid by a reinsuring carrier for the first tier of
720	assessments shall be credited against any additional assessments
721	made.
722	b. The board shall equitably assess carriers for operating
723	losses of the plan based on market share. The board shall
724	annually assess each carrier a portion of the operating losses
725	of the plan. The first tier of assessments shall be determined
726	by multiplying the operating losses by a fraction, the numerator
727	of which equals the reinsuring carrier's earned premium
728	pertaining to direct writings of small employer health benefit
729	plans in the state during the calendar year for which the
730	assessment is levied, and the denominator of which equals the
731	total of all such premiums earned by reinsuring carriers in the
732	state during that calendar year. The second tier of assessments
733	shall be based on the premiums that all carriers, except risk-
734	assuming carriers, earned on all health benefit plans written in
735	this state. The board may levy interim assessments against
736	carriers to ensure the financial ability of the plan to cover
737	claims expenses and administrative expenses paid or estimated to
738	be paid in the operation of the plan for the calendar year prior
739	to the association's anticipated receipt of annual assessments
740	for that calendar year. Any interim assessment is due and
741	payable within 30 days after receipt by a carrier of the interim
742	assessment notice. Interim assessment payments shall be credited
743	against the carrier's annual assessment. Health benefit plan
744	premiums and benefits paid by a carrier that are less than an
745	amount determined by the board to justify the cost of collection
746	may not be considered for purposes of determining assessments.
747	c. Subject to the approval of the department, the board
748	shall make an adjustment to the assessment formula for
749	reinsuring carriers that are approved as federally qualified
750	health maintenance organizations by the Secretary of Health and
751	Human Services pursuant to 42 U.S.C. s. 300e(c)(2)(A) to the
752	extent, if any, that restrictions are placed on them that are
753	not imposed on other small employer carriers.
754	3. Before SeptemberMarch1 of each year, the board shall
755	determine and file with the department an estimate of the
756	assessments needed to fund the losses incurred by the program in
757	the previous calendar year.
758	4. If the board determines that the assessments needed to
759	fund the losses incurred by the program in the previous calendar
760	year will exceed the amount specified in subparagraph 2., the
761	board shall evaluate the operation of the program and report its
762	findings, including any recommendations for changes to the plan
763	of operation, to the department within 24090days following the
764	end of the calendar year in which the losses were incurred. The
765	evaluation shall include an estimate of future assessments, the
766	administrative costs of the program, the appropriateness of the
767	premiums charged and the level of carrier retention under the
768	program, and the costs of coverage for small employers. If the
769	board fails to file a report with the department within 24090
770	days following the end of the applicable calendar year, the
771	department may evaluate the operations of the program and
772	implement such amendments to the plan of operation the
773	department deems necessary to reduce future losses and
774	assessments.
775	5. If assessments exceed the amount of the actual losses
776	and administrative expenses of the program, the excess shall be
777	held as interest and used by the board to offset future losses
778	or to reduce program premiums. As used in this paragraph, the
779	term "future losses" includes reserves for incurred but not
780	reported claims.
781	6. Each carrier's proportion of the assessment shall be
782	determined annually by the board, based on annual statements and
783	other reports considered necessary by the board and filed by the
784	carriers with the board.
785	7. Provision shall be made in the plan of operation for
786	the imposition of an interest penalty for late payment of an
787	assessment.
788	8. A carrier may seek, from the commissioner, a deferment,
789	in whole or in part, from any assessment made by the board. The
790	department may defer, in whole or in part, the assessment of a
791	carrier if, in the opinion of the department, the payment of the
792	assessment would place the carrier in a financially impaired
793	condition. If an assessment against a carrier is deferred, in
794	whole or in part, the amount by which the assessment is deferred
795	may be assessed against the other carriers in a manner
796	consistent with the basis for assessment set forth in this
797	section. The carrier receiving such deferment remains liable to
798	the program for the amount deferred and is prohibited from
799	reinsuring any individuals or groups in the program if it fails
800	to pay assessments.
801	Section 12. Section 627.911, Florida Statutes, is amended
802	to read:
803	627.911 Scope of this part.--Any insurer or health
804	maintenance organizationtransacting insurance in this state
805	shall report information as required by this part.
806	Section 13. Section 627.9175, Florida Statutes, is amended
807	to read:
808	627.9175 Reports of information on health insurance.--
809	(1) Each authorized health insurer or health maintenance
810	organization shall submit annually to the office, on or before
811	March 1 of each year, information concerningdepartment as to
812	policies of individual health insurance coverage being issued or
813	currently in force in this state. The information shall include
814	information related to premium, number of policies, and covered
815	lives for such policies and other information necessary to
816	analyze trends in enrollment, premiums, and claim costs.
817	(2) The required information shall be broken down by
818	market segment, to include:
819	(a) Health insurance issuer, company, contact person, or
820	agent.
821	(b) All health insurance products issued or in force,
822	including, but not limited to:
823	1. Direct premiums earned.
824	2. Direct losses incurred.
825	3. Direct premiums earned for new business issued during
826	the year.
827	4. Number of policies.
828	5. Number of certificates.
829	6. Number of total covered lives.
830	(a) A summary of typical benefits, exclusions, and
831	limitations for each type of individual policy form currently
832	being issued in the state. The summary shall include, as
833	appropriate:
834	1. The deductible amount;
835	2. The coinsurance percentage;
836	3. The out-of-pocket maximum;
837	4. Outpatient benefits;
838	5. Inpatient benefits; and
839	6. Any exclusions for preexisting conditions.
840
841	The department shall determine other appropriate benefits,
842	exclusions, and limitations to be reported for inclusion in the
843	consumer's guide published pursuant to this section.
844	(b) A schedule of rates for each type of individual policy
845	form reflecting typical variations by age, sex, region of the
846	state, or any other applicable factor which is in use and is
847	determined to be appropriate for inclusion by the department.
848
849	The department shall provide by rule a uniform format for the
850	submission of this information in order to allow for meaningful
851	comparisons of premiums charged for comparable benefits.
852	(3) The department may adopt rules to administer this
853	section, including, but not limited to, rules governing
854	compliance and provisions implementing electronic methodologies
855	for use in furnishing such records or documents. The commission
856	may by rule specify a uniform format for the submission of this
857	information in order to allow for meaningful comparisonsshall
858	publish annually a consumer's guide which summarizes and
859	compares the information required to be reported under this
860	subsection.
861	(2)(a) Every insurer transacting health insurance in this
862	state shall report annually to the department, not later than
863	April 1, information relating to any measure the insurer has
864	implemented or proposes to implement during the next calendar
865	year for the purpose of containing health insurance costs or
866	cost increases. The reports shall identify each measure and the
867	forms to which the measure is applied, shall provide an
868	explanation as to how the measure is used, and shall provide an
869	estimate of the cost effect of the measure.
870	(b) The department shall promulgate forms to be used by
871	insurers in reporting information pursuant to this subsection
872	and shall utilize such forms to analyze the effects of health
873	care cost containment programs used by health insurers in this
874	state.
875	(c) The department shall analyze the data reported under
876	this subsection and shall annually make available to the public
877	a summary of its findings as to the types of cost containment
878	measures reported and the estimated effect of these measures.
879	Section 14. Section 627.9403, Florida Statutes, is amended
880	to read:
881	627.9403 Scope.--The provisions of this part shall apply
882	to long-term care insurance policies delivered or issued for
883	delivery in this state, and to policies delivered or issued for
884	delivery outside this state to the extent provided in s.
885	627.9406, by an insurer, a fraternal benefit society as defined
886	in s. 632.601, a health maintenance organization as defined in
887	s. 641.19, a prepaid health clinic as defined in s. 641.402, or
888	a multiple-employer welfare arrangement as defined in s.
889	624.437. A policy which is advertised, marketed, or offered as a
890	long-term care policy and as a Medicare supplement policy shall
891	meet the requirements of this part and the requirements of ss.
892	627.671-627.675 and, to the extent of a conflict, be subject to
893	the requirement that is more favorable to the policyholder or
894	certificateholder. The provisions of this part shall not apply
895	to a continuing care contract issued pursuant to chapter 651 and
896	shall not apply to guaranteed renewable policies issued prior to
897	October 1, 1988. Any limited benefit policy that limits coverage
898	to care in a nursing home or to one or more lower levels of care
899	required or authorized to be provided by this part or by
900	department rule must meet all requirements of this part that
901	apply to long-term care insurance policies, except ss.
902	627.9407(3)(c) and (d), (9), (10)(f), and (12) and 627.94073(2).
903	If the limited benefit policy does not provide coverage for care
904	in a nursing home, but does provide coverage for one or more
905	lower levels of care, the policy shall also be exempt from the
906	requirements of s. 627.9407(3)(d).
907	Section 15. Paragraph (b) of subsection (1) of section
908	641.185, Florida Statutes, is amended to read:
909	641.185 Health maintenance organization subscriber
910	protections.--
911	(1) With respect to the provisions of this part and part
912	III, the principles expressed in the following statements shall
913	serve as standards to be followed by the Department of Insurance
914	and the Agency for Health Care Administration in exercising
915	their powers and duties, in exercising administrative
916	discretion, in administrative interpretations of the law, in
917	enforcing its provisions, and in adopting rules:
918	(b) A health maintenance organization subscriber should
919	receive quality health care from a broad panel of providers,
920	including referrals, preventive care pursuant to s. 641.402(1),
921	emergency screening and services pursuant to ss. 641.31(13)(12)
922	and 641.513, and second opinions pursuant to s. 641.51.
923	Section 16. Paragraph (d) of subsection (3) and
924	subsections (9) through (17) of section 641.31, Florida
925	Statutes, are amended to read:
926	641.31 Health maintenance contracts.--
927	(3)
928	(d) Any change in rates charged for the contract must be
929	filed with the department not less than 30 days in advance of
930	the effective date. At the expiration of such 30 days, the rate
931	filing shall be deemed approved unless prior to such time the
932	filing has been affirmatively approved or disapproved by order
933	of the department. The approval of the filing by the department
934	constitutes a waiver of any unexpired portion of such waiting
935	period. The department may extend by not more than an additional
936	15 days the period within which it may so affirmatively approve
937	or disapprove any such filing, by giving notice of such
938	extension before expiration of the initial 30-day period. At the
939	expiration of any such period as so extended, and in the absence
940	of such prior affirmative approval or disapproval, any such
941	filing shall be deemed approved. This paragraph does not apply
942	to group health maintenance organization contracts effectuated
943	and delivered in this state insuring groups of 51 or more
944	persons.
945	(9)(a)1. If a health maintenance organization offers
946	coverage for dependent children of the subscriber, the contract
947	must cover a dependent child of the subscriber at least until
948	the end of the calendar year in which the child reaches the age
949	of 23, if the child meets all of the following:
950	a. The child is dependent upon the subscriber for support.
951	b. The child is living in the household of the subscriber,
952	or the child is a full-time or part-time student.
953	2. Nothing in this paragraph affects or preempts a health
954	maintenance organization's right to medically underwrite or
955	charge the appropriate premium.
956	(b)1. A contract that provides coverage for a family
957	member of the subscriber shall, as to such family member's
958	coverage, provide that benefits applicable to children of the
959	subscriber also apply to an adopted child or a foster child of
960	the subscriber placed in compliance with chapter 63 from the
961	moment of placement in the residence of the subscriber. Except
962	in the case of a foster child, the contract may not exclude
963	coverage for any preexisting condition of the child. In the case
964	of a newborn child, coverage begins at the moment of birth if a
965	written agreement to adopt such child has been entered into by
966	the subscriber prior to the birth of the child, whether or not
967	the agreement is enforceable. This section does not require
968	coverage for an adopted child who is not ultimately placed in
969	the residence of the subscriber in compliance with chapter 63.
970	2. A contract may require the subscriber to notify the
971	health maintenance organization of the birth or placement of an
972	adopted child within a specified time period of not less than 30
973	days after the birth or placement in the residence of a child
974	adopted by the subscriber. If timely notice is given, the health
975	maintenance organization may not charge an additional premium
976	for coverage of the child for the duration of the notice period.
977	If timely notice is not given, the health maintenance
978	organization may charge an additional premium from the date of
979	birth or placement. If notice is given within 60 days after the
980	birth or placement of the child, the health maintenance
981	organization may not deny coverage for the child due to the
982	failure of the subscriber to timely notify the health
983	maintenance organization of the birth or placement of the child.
984	3. If the contract does not require the subscriber to
985	notify the health maintenance organization of the birth or
986	placement of an adopted child within a specified time period,
987	the health maintenance organization may not deny coverage for
988	such child or retroactively charge the subscriber an additional
989	premium for such child. However, the health maintenance
990	organization may prospectively charge the subscriber an
991	additional premium for the child if the health maintenance
992	organization provides at least 45 days' notice of the additional
993	premium required.
994	4. In order to increase access to postnatal, infant, and
995	pediatric health care for all children placed in court-ordered
996	custody, including foster children, all health maintenance
997	organization contracts that provide coverage for a family member
998	of the subscriber shall, as to such family member's coverage,
999	provide that benefits applicable for children shall be payable
1000	with respect to a foster child or other child in court-ordered,
1001	temporary, or other custody of the subscriber.
1002	(10) A contract that provides that coverage of a dependent
1003	child shall terminate upon attainment of the limiting age for
1004	dependent children specified in the contract shall also provide
1005	in substance that attainment of the limiting age does not
1006	terminate the coverage of the child while the child continues to
1007	be:
1008	(a) Incapable of self-sustaining employment by reason of
1009	mental retardation or physical handicap.
1010	(b) Chiefly dependent upon the subscriber for support and
1011	maintenance.
1012
1013	If a claim is denied under a contract for the stated reason that
1014	the child has attained the limiting age for dependent children
1015	specified in the contract, the notice of denial must state that
1016	the subscriber has the burden of establishing that the child
1017	continues to meet the criteria specified in paragraphs (a) and
1018	(b).All health maintenance contracts that provide coverage,
1019	benefits, or services for a member of the family of the
1020	subscriber must, as to such family member's coverage, benefits,
1021	or services, provide also that the coverage, benefits, or
1022	services applicable for children must be provided with respect
1023	to a newborn child of the subscriber, or covered family member
1024	of the subscriber, from the moment of birth. However, with
1025	respect to a newborn child of a covered family member other than
1026	the spouse of the insured or subscriber, the coverage for the
1027	newborn child terminates 18 months after the birth of the
1028	newborn child. The coverage, benefits, or services for newborn
1029	children must consist of coverage for injury or sickness,
1030	including the necessary care or treatment of medically diagnosed
1031	congenital defects, birth abnormalities, or prematurity, and
1032	transportation costs of the newborn to and from the nearest
1033	appropriate facility appropriately staffed and equipped to treat
1034	the newborn's condition, when such transportation is certified
1035	by the attending physician as medically necessary to protect the
1036	health and safety of the newborn child.
1037	(a) A contract may require the subscriber to notify the
1038	plan of the birth of a child within a time period, as specified
1039	in the contract, of not less than 30 days after the birth, or a
1040	contract may require the preenrollment of a newborn prior to
1041	birth. However, if timely notice is given, a plan may not charge
1042	an additional premium for additional coverage of the newborn
1043	child for not less than 30 days after the birth of the child. If
1044	timely notice is not given, the plan may charge an additional
1045	premium from the date of birth. If notice is given within 60
1046	days of the birth of the child, the contract may not deny
1047	coverage of the child due to failure of the subscriber to timely
1048	notify the plan of the birth of the child or to preenroll the
1049	child.
1050	(b) If the contract does not require the subscriber to
1051	notify the plan of the birth of a child within a specified time
1052	period, the plan may not deny coverage of the child nor may it
1053	retroactively charge the subscriber an additional premium for
1054	the child; however, the contract may prospectively charge the
1055	member an additional premium for the child if the plan provides
1056	at least 45 days' notice of the additional charge.
1057	(11)(10)No alteration of any written application for any
1058	health maintenance contract shall be made by any person other
1059	than the applicant without his or her written consent, except
1060	that insertions may be made by the health maintenance
1061	organization, for administrative purposes only, in such manner
1062	as to indicate clearly that such insertions are not to be
1063	ascribed to the applicant.
1064	(12)(11)No contract shall contain any waiver of rights or
1065	benefits provided to or available to subscribers under the
1066	provisions of any law or rule applicable to health maintenance
1067	organizations.
1068	(13)(12)Each health maintenance contract, certificate, or
1069	member handbook shall state that emergency services and care
1070	shall be provided to subscribers in emergency situations not
1071	permitting treatment through the health maintenance
1072	organization's providers, without prior notification to and
1073	approval of the organization. Not less than 75 percent of the
1074	reasonable charges for covered services and supplies shall be
1075	paid by the organization, up to the subscriber contract benefit
1076	limits. Payment also may be subject to additional applicable
1077	copayment provisions, not to exceed $100 per claim. The health
1078	maintenance contract, certificate, or member handbook shall
1079	contain the definitions of "emergency services and care" and
1080	"emergency medical condition" as specified in s. 641.19(7) and
1081	(8), shall describe procedures for determination by the health
1082	maintenance organization of whether the services qualify for
1083	reimbursement as emergency services and care, and shall contain
1084	specific examples of what does constitute an emergency. In
1085	providing for emergency services and care as a covered service,
1086	a health maintenance organization shall be governed by s.
1087	641.513.
1088	(14)(13)In addition to the requirements of this section,
1089	with respect to a person who is entitled to have payments for
1090	health care costs made under Medicare, Title XVIII of the Social
1091	Security Act ("Medicare"), parts A and/or B:
1092	(a) The health maintenance organization shall mail or
1093	deliver notification to the Medicare beneficiary of the date of
1094	enrollment in the health maintenance organization within 10 days
1095	after receiving notification of enrollment approval from the
1096	United States Department of Health and Human Services, Health
1097	Care Financing Administration. When a Medicare beneficiary who
1098	is a subscriber of the health maintenance organization requests
1099	disenrollment from the organization, the organization shall mail
1100	or deliver to the beneficiary notice of the effective date of
1101	the disenrollment within 10 days after receipt of the written
1102	disenrollment request. The health maintenance organization shall
1103	forward the disenrollment request to the United States
1104	Department of Health and Human Services, Health Care Financing
1105	Administration, in a timely manner so as to effectuate the next
1106	available disenrollment date, as prescribed by such federal
1107	agency.
1108	(b) The health maintenance contract, certificate, or
1109	member handbook shall be delivered to the subscriber no later
1110	than the earlier of 10 working days after the health maintenance
1111	organization and the Health Care Financing Administration of the
1112	United States Department of Health and Human Services approve
1113	the subscriber's enrollment application or the effective date of
1114	coverage of the subscriber under the health maintenance
1115	contract. However, if notice from the Health Care Financing
1116	Administration of its approval of the subscriber's enrollment
1117	application is received by the health maintenance organization
1118	after the effective coverage date prescribed by the Health Care
1119	Financing Administration, the health maintenance organization
1120	shall deliver the contract, certificate, or member handbook to
1121	the subscriber within 10 days after receiving such notice. When
1122	a Medicare recipient is enrolled in a health maintenance
1123	organization program, the contract, certificate, or member
1124	handbook shall be accompanied by a health maintenance
1125	organization identification sticker with instruction to the
1126	Medicare beneficiary to place the sticker on the Medicare
1127	identification card.
1128	(15)(14)Whenever a subscriber of a health maintenance
1129	organization is also a Medicaid recipient, the health
1130	maintenance organization's coverage shall be primary to the
1131	recipient's Medicaid benefits and the organization shall be a
1132	third party subject to the provisions of s. 409.910(4).
1133	(16)(15)(a) All health maintenance contracts,
1134	certificates, and member handbooks shall contain the following
1135	provision:
1136
1137	"Grace Period: This contract has a (insert a number not less
1138	than 10) day grace period. This provision means that if any
1139	required premium is not paid on or before the date it is due, it
1140	may be paid during the following grace period. During the grace
1141	period, the contract will stay in force."
1142
1143	(b) The required provision of paragraph (a) shall not
1144	apply to certificates or member handbooks delivered to
1145	individual subscribers under a group health maintenance contract
1146	when the employer or other person who will hold the contract on
1147	behalf of the subscriber group pays the entire premium for the
1148	individual subscribers. However, such required provision shall
1149	apply to the group health maintenance contract.
1150	(17)(16)The contracts must clearly disclose the intent of
1151	the health maintenance organization as to the applicability or
1152	nonapplicability of coverage to preexisting conditions. If
1153	coverage of the contract is not to be applicable to preexisting
1154	conditions, the contract shall specify, in substance, that
1155	coverage pertains solely to accidental bodily injuries resulting
1156	from accidents occurring after the effective date of coverage
1157	and that sicknesses are limited to those which first manifest
1158	themselves subsequent to the effective date of coverage.
1159	(17) All health maintenance contracts that provide
1160	coverage for a member of the family of the subscriber, shall, as
1161	to such family member's coverage, provide that coverage,
1162	benefits, or services applicable for children shall be provided
1163	with respect to an adopted child of the subscriber, which child
1164	is placed in compliance with chapter 63, from the moment of
1165	placement in the residence of the subscriber. Such contracts may
1166	not exclude coverage for any preexisting condition of the child.
1167	In the case of a newborn child, coverage shall begin from the
1168	moment of birth if a written agreement to adopt such child has
1169	been entered into by the subscriber prior to the birth of the
1170	child, whether or not such agreement is enforceable. However,
1171	coverage for such child shall not be required in the event that
1172	the child is not ultimately placed in the residence of the
1173	subscriber in compliance with chapter 63.
1174	Section 17. Section 641.31025, Florida Statutes, is
1175	created to read:
1176	641.31025 Specific reasons for denial of coverage.--The
1177	denial of an application for a health maintenance organization
1178	contract must be accompanied by the specific reasons for the
1179	denial, including, but not limited to, the specific underwriting
1180	reasons, if applicable.
1181	Section 18. Section 641.31075, Florida Statutes, is
1182	created to read:
1183	641.31075 Replacement.--Any health maintenance
1184	organization that is replacing any other group health coverage
1185	with its group health maintenance coverage shall comply with s.
1186	627.666.
1187	Section 19. Subsections (1) and (3) of section 641.3111,
1188	Florida Statutes, are amended to read:
1189	641.3111 Extension of benefits.--
1190	(1) Every group health maintenance contract shall provide
1191	that termination of the contract shall be without prejudice to
1192	any continuous loss which commenced while the contract was in
1193	force, but any extension of benefits beyond the period the
1194	contract was in force may be predicated upon the continuous
1195	total disability of the subscriber and may be limited to payment
1196	for the treatment of a specific accident or illness incurred
1197	while the subscriber was a member. The extension is required
1198	regardless of whether the group contract holder or other entity
1199	secures replacement coverage from a new insurer or health
1200	maintenance organization or foregoes the provision of coverage.
1201	The required provision must provide for continuation of contract
1202	benefits in connection with the treatment of a specific accident
1203	or illness incurred while the contract was in effect.Such
1204	extension of benefits may be limited to the occurrence of the
1205	earliest of the following events:
1206	(a) The expiration of 12 months.
1207	(b) Such time as the member is no longer totally disabled.
1208	(c) A succeeding carrier elects to provide replacement
1209	coverage without limitation as to the disability condition.
1210	(c)(d)The maximum benefits payable under the contract
1211	have been paid.
1212	(3) In the case of maternity coverage, when not covered by
1213	the succeeding carrier,a reasonable extension of benefits or
1214	accrued liability provision is required, which provision
1215	provides for continuation of the contract benefits in connection
1216	with maternity expenses for a pregnancy that commenced while the
1217	policy was in effect. The extension shall be for the period of
1218	that pregnancy and shall not be based upon total disability.
1219	Section 20. Subsection (4) of section 627.651, Florida
1220	Statutes, is amended to read:
1221	627.651 Group contracts and plans of self-insurance must
1222	meet group requirements.--
1223	(4) This section does not apply to any plan which is
1224	established or maintained by an individual employer in
1225	accordance with the Employee Retirement Income Security Act of
1226	1974, Pub. L. No. 93-406, or to a multiple-employer welfare
1227	arrangement as defined in s. 624.437(1), except that a multiple-
1228	employer welfare arrangement shall comply with ss. 627.419,
1229	627.657, 627.6575, 627.6578, 627.6579, 627.6612, 627.66121,
1230	627.66122, 627.6615, 627.6616, and 627.662(8)(7). This
1231	subsection does not allow an authorized insurer to issue a group
1232	health insurance policy or certificate which does not comply
1233	with this part.
1234	Section 21. Subsection (1) of section 641.2018, Florida
1235	Statutes, is amended to read:
1236	641.2018 Limited coverage for home health care
1237	authorized.--
1238	(1) Notwithstanding other provisions of this chapter, a
1239	health maintenance organization may issue a contract that limits
1240	coverage to home health care services only. The organization and
1241	the contract shall be subject to all of the requirements of this
1242	part that do not require or otherwise apply to specific benefits
1243	other than home care services. To this extent, all of the
1244	requirements of this part apply to any organization or contract
1245	that limits coverage to home care services, except the
1246	requirements for providing comprehensive health care services as
1247	provided in ss. 641.19(4), (12), and (13), and 641.31(1), except
1248	ss. 641.31(9),(13)(12), (17),(18), (19), (20), (21), and (24)
1249	and 641.31095.
1250	Section 22. Section 641.3107, Florida Statutes, is amended
1251	to read:
1252	641.3107 Delivery of contract.--Unless delivered upon
1253	execution or issuance, a health maintenance contract,
1254	certificate of coverage, or member handbook shall be mailed or
1255	delivered to the subscriber or, in the case of a group health
1256	maintenance contract, to the employer or other person who will
1257	hold the contract on behalf of the subscriber group within 10
1258	working days from approval of the enrollment form by the health
1259	maintenance organization or by the effective date of coverage,
1260	whichever occurs first. However, if the employer or other person
1261	who will hold the contract on behalf of the subscriber group
1262	requires retroactive enrollment of a subscriber, the
1263	organization shall deliver the contract, certificate, or member
1264	handbook to the subscriber within 10 days after receiving notice
1265	from the employer of the retroactive enrollment. This section
1266	does not apply to the delivery of those contracts specified in
1267	s. 641.31(14)(13).
1268	Section 23. Subsection (4) of section 641.513, Florida
1269	Statutes, is amended to read:
1270	641.513 Requirements for providing emergency services and
1271	care.--
1272	(4) A subscriber may be charged a reasonable copayment, as
1273	provided in s. 641.31(13)(12), for the use of an emergency room.
1274	Section 24. This act shall take effect upon becoming a
1275	law.
1276
1277	================= T I T L E A M E N D M E N T =================
1278	Remove the entire title, and insert:
1279	A bill to be entitled
1280	An act relating to health insurance; amending s. 408.909,
1281	F.S.; revising a definition; authorizing health flex plans
1282	to limit coverage under certain circumstances; authorizing
1283	a small business purchasing arrangement to limit
1284	enrollment to certain residents; extending an expiration
1285	date; creating s. 627.6042, F.S.; requiring policies of
1286	insurers offering coverage of dependent children to
1287	maintain such coverage until a child reaches age 25, under
1288	certain circumstances; providing application; creating s.
1289	627.60425, F.S.; providing limitations on certain binding
1290	arbitration requirements; amending s. 627.6044, F.S.;
1291	providing for payment of claims to nonnetwork providers
1292	under specified conditions; providing a definition;
1293	requiring the method used for determining payment of
1294	claims to be included in filings; providing for
1295	disclosure; amending s. 627.6415, F.S.; deleting an 18th
1296	birthday age limitation on application of certain
1297	dependent coverage requirements; amending s. 627.6475,
1298	F.S.; revising risk-assuming carrier election requirements
1299	and procedures; revising certain criteria and limitations
1300	under the individual health reinsurance program; amending
1301	s. 627.651, F.S.; correcting a cross reference; amending
1302	s. 627.662, F.S.; revising a list of provisions applicable
1303	to group, blanket, or franchise health insurance to
1304	include use of specific methodology for payment of claims
1305	provisions; amending s. 627.667, F.S.; deleting a
1306	limitation on application of certain extension of benefits
1307	provisions; amending s. 627.6692, F.S.; increasing a time
1308	period for payment of premium to continue coverage under a
1309	group health plan; amending s. 627.6699, F.S.; revising
1310	definitions; revising coverage enrollment eligibility
1311	criteria for small employers; revising small employer
1312	carrier election requirements and procedures; revising
1313	certain criteria and limitations under the small employer
1314	health reinsurance program; amending ss. 627.911 and
1315	627.9175, F.S.; applying certain information reporting
1316	requirements to health maintenance organizations; revising
1317	health insurance information requirements and criteria;
1318	authorizing the department to adopt rules; deleting an
1319	annual report requirement; amending s. 627.9403, F.S.;
1320	deleting an exemption for limited benefit policies from a
1321	long-term care insurance restriction relating to nursing
1322	home care; amending s. 641.185, F.S.; correcting a cross
1323	reference; amending s. 641.31, F.S.; specifying
1324	nonapplication to certain contracts; requiring health
1325	maintenance organizations offering coverage of dependent
1326	children to maintain such coverage until a child reaches
1327	age 25, under certain circumstances; providing
1328	application; providing requirements for contract
1329	termination and denial of a claim related to limiting age
1330	attainment; creating s. 641.31025, F.S.; requiring
1331	specific reasons for denial of coverage under a health
1332	maintenance organization contract; creating s. 641.31075,
1333	F.S.; imposing compliance requirements upon health
1334	maintenance organization replacements of other group
1335	health coverage with organization coverage; amending s.
1336	641.3111, F.S.; deleting a limitation on certain extension
1337	of benefits provisions upon group health maintenance
1338	contract termination; imposing additional extension of
1339	benefits requirements upon such termination; amending ss.
1340	627.651, 641.2018, 641.3107, and 641.513, F.S.; correcting
1341	cross references; providing an effective date.
1342