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 directory and title
15	amendments)
16	Between lines 13 and 14, insert:
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18	Section 1. Paragraph (e) of subsection (2), subsection
19	(3), paragraph (c) of subsection (5), and subsection (10) of
20	section 408.909, Florida Statutes, are amended to read:
21	408.909 Health flex plans.--
22	(2) DEFINITIONS.--As used in this section, the term:
23	(e) "Health flex plan" means a health plan approved under
24	subsection (3) which guarantees payment for specified health
25	care coverage provided to the enrollee who purchases coverage
26	directly from the plan or through a small business purchasing
27	arrangement sponsored by a local government.
28	(3) PILOT PROGRAM.--The agency and the department shall
29	each approve or disapprove health flex plans that provide health
30	care coverage for eligible participants who reside in the three
31	areas of the state that have the highest number of uninsured
32	persons, as identified in the Florida Health Insurance Study
33	conducted by the agency and in Indian River County. A health
34	flex plan may limit or exclude benefits otherwise required by
35	law for insurers offering coverage in this state, may cap the
36	total amount of claims paid per year per enrollee, may limit the
37	number of enrollees or the term of coverage, or may take any
38	combination of those actions.
39	(a) The agency shall develop guidelines for the review of
40	applications for health flex plans and shall disapprove or
41	withdraw approval of plans that do not meet or no longer meet
42	minimum standards for quality of care and access to care.
43	(b) The department shall develop guidelines for the review
44	of health flex plan applications and shall disapprove or shall
45	withdraw approval of plans that:
46	1. Contain any ambiguous, inconsistent, or misleading
47	provisions or any exceptions or conditions that deceptively
48	affect or limit the benefits purported to be assumed in the
49	general coverage provided by the health flex plan;
50	2. Provide benefits that are unreasonable in relation to
51	the premium charged or contain provisions that are unfair or
52	inequitable or contrary to the public policy of this state, that
53	encourage misrepresentation, or that result in unfair
54	discrimination in sales practices; or
55	3. Cannot demonstrate that the health flex plan is
56	financially sound and that the applicant is able to underwrite
57	or finance the health care coverage provided.
58	(c) The agency and the department may adopt rules as
59	needed to administer this section.
60	(5) ELIGIBILITY.--Eligibility to enroll in an approved
61	health flex plan is limited to residents of this state who:
62	(c) Are not covered by a private insurance policy and are
63	not eligible for coverage through a public health insurance
64	program, such as Medicare or Medicaid, or another public health
65	care program, such as KidCare, and have not been covered at any
66	time during the past 6 months, except that a small business
67	purchasing arrangement sponsored by a local government may limit
68	enrollment to residents of this state who have not been covered
69	at any time during the past 12 months; and
70	(10) EXPIRATION.--This section expires July 1, 20082004.
71	Section 2. Section 627.6042, Florida Statutes, is created
72	to read:
73	627.6042 Dependent coverage.--
74	(1) If an insurer offers coverage that insures dependent
75	children of the policyholder or certificateholder, the policy
76	must insure a dependent child of the policyholder or
77	certificateholder at least until the end of the calendar year in
78	which the child reaches the age of 25, if the child meets all of
79	the following:
80	(a) The child is dependent upon the policyholder or
81	certificateholder for support.
82	(b) The child is living in the household of the
83	policyholder or certificateholder or the child is a full-time or
84	part-time student.
85	(2) Nothing in this section affects or preempts an
86	insurer's right to medically underwrite or charge the
87	appropriate premium.
88	Section 3. Section 627.60425, Florida Statutes, is created
89	to read:
90	627.60425 Binding arbitration requirement
91	limitations.--Notwithstanding any other provision of law, except
92	s. 624.155, an individual, blanket, group life, or group health
93	insurance policy; individual or group health maintenance
94	organization subscriber contract; prepaid limited health
95	organization subscriber contract; or any life or health
96	insurance policy or certificate delivered or issued for
97	delivery, including out-of-state group plans pursuant to s.
98	627.5515 or s. 627.6515 covering residents of this state, to any
99	resident of this state shall not require the submission of
100	disputes between the parties to the policy, contract, or plan to
101	binding arbitration unless the applicant has indicated that the
102	same policy, contract, or plan was offered and rejected without
103	arbitration and that the binding arbitration provision was fully
104	explained to the applicant and willingly accepted.
105	Section 4. Section 627.6044, Florida Statutes, is amended
106	to read:
107	627.6044 Use of a specific methodology for payment of
108	claims.--
109	(1) Each insurance policy that provides for payment of
110	claims to nonnetwork providers that is less than the payment of
111	the provider's billed charges to the insured, excluding
112	deductible, coinsurance, and copay amounts, shall:
113	(a) Provide benefits prior to deductible, coinsurance, and
114	copay amounts for using a nonnetwork provider that are at least
115	equal to the amount that would have been allowed had the insured
116	used a network provider but are not in excess of the actual
117	billed charges.
118	(b) Where there are multiple network providers in the
119	geographical area in which the services were provided or, if
120	none, the closest geographic area, the carrier may use an
121	averaging method of the contracted amounts but not less than the
122	80th percentile of all network contracted amounts in the
123	geographic area.
124
125	For purposes of this subsection, the term "network providers"
126	means those providers for which an insured will not be
127	responsible for any balance payment for services provided by
128	such provider, excluding deductible, coinsurance, and copay
129	amountsbased on a specific methodology, including, but not
130	limited to, usual and customary charges, reasonable and
131	customary charges, or charges based upon the prevailing rate in
132	the community, shall specify the formula or criteria used by the
133	insurer in determining the amount to be paid.
134	(2) Each insurer issuing a policy that provides for
135	payment of claims based on a specific methodology shall provide
136	to an insured, upon her or his written request, an estimate of
137	the amount the insurer will pay for a particular medical
138	procedure or service. The estimate may be in the form of a range
139	of payments or an average payment and may specify that the
140	estimate is based on the assumption of a particular service
141	code. The insurer may require the insured to provide detailed
142	information regarding the procedure or service to be performed,
143	including the procedure or service code number provided by the
144	health care provider and the health care provider's estimated
145	charge.An insurer that provides an insured with a good faith
146	estimate is not bound by the estimate. However, a pattern of
147	providing estimates that vary significantly from the ultimate
148	insurance payment constitutes a violation of this code.
149	(3) The method used for determining the payment of claims
150	shall be included in filings made pursuant to s. 627.410(6) and
151	may not be changed unless such change is filed under s.
152	627.410(6).
153	(4) Any policy that provides that the insured is
154	responsible for the balance of a claim amount, excluding
155	deductible, coinsurance, and copay amounts, must disclose such
156	feature on the face of the policy or certificate and such
157	feature must be included in any outline of coverage provided to
158	the insured.
159	Section 5. Subsections (1) and (4) of section 627.6415,
160	Florida Statutes, are amended to read:
161	627.6415 Coverage for natural-born, adopted, and foster
162	children; children in insured's custodial care.--
163	(1) A health insurance policy that provides coverage for a
164	member of the family of the insured shall, as to the family
165	member's coverage, provide that the health insurance benefits
166	applicable to children of the insured also apply to an adopted
167	child or a foster child of the insured placed in compliance with
168	chapter 63, prior to the child's 18th birthday,from the moment
169	of placement in the residence of the insured. Except in the case
170	of a foster child, the policy may not exclude coverage for any
171	preexisting condition of the child. In the case of a newborn
172	child, coverage begins at the moment of birth if a written
173	agreement to adopt the child has been entered into by the
174	insured prior to the birth of the child, whether or not the
175	agreement is enforceable. This section does not require coverage
176	for an adopted child who is not ultimately placed in the
177	residence of the insured in compliance with chapter 63.
178	(4) In order to increase access to postnatal, infant, and
179	pediatric health care for all children placed in court-ordered
180	custody, including foster children, all health insurance
181	policies that provide coverage for a member of the family of the
182	insured shall, as to such family member's coverage, also provide
183	that the health insurance benefits applicable for children shall
184	be payable with respect to a foster child or other child in
185	court-ordered temporary or other custody of the insured, prior
186	to the child's 18th birthday.
187	Section 6. Paragraph (a) of subsection (5), paragraph (c)
188	of subsection (6), and paragraphs (b), (c), and (e) of
189	subsection (7) of section 627.6475, Florida Statutes, are
190	amended to read:
191	627.6475 Individual reinsurance pool.--
192	(5) ISSUER'S ELECTION TO BECOME A RISK-ASSUMING CARRIER.--
193	(a) Each health insurance issuer that offers individual
194	health insurance must elect to become a risk-assuming carrier or
195	a reinsuring carrier for purposes of this section. Each such
196	issuer must make an initial election, binding through December
197	31, 1999. The issuer's initial election must be made no later
198	than October 31, 1997. By October 31, 1997, all issuers must
199	file a final election, which is binding for 2 years, from
200	January 1, 1998, through December 31, 1999, after whichan
201	election that shall be binding indefinitely or until modified or
202	withdrawnfor a period of 5 years. The department may permit an
203	issuer to modify its election at any time for good cause shown,
204	after a hearing.
205	(6) ELECTION PROCESS TO BECOME A RISK-ASSUMING CARRIER.--
206	(c) The department shall provide public notice of an
207	issuer's filing adesignation of election under this subsection
208	to become a risk-assuming carrier and shall provide at least a
209	21-day period for public comment upon receipt of such filing
210	prior to making a decision on the election. The department shall
211	hold a hearing on the election at the request of the issuer.
212	(7) INDIVIDUAL HEALTH REINSURANCE PROGRAM.--
213	(b) A reinsuring carrier may reinsure with the program
214	coverage of an eligible individual, subject to each of the
215	following provisions:
216	1. A reinsuring carrier may reinsure an eligible
217	individual within 9060days after commencement of the coverage
218	of the eligible individual.
219	2. The program may not reimburse a participating carrier
220	with respect to the claims of a reinsured eligible individual
221	until the carrier has paid incurred claims of an amount equal to
222	the participating carrier’s selected deductible levelat least
223	$5,000 in a calendar year for benefits covered by the program.
224	In addition, the reinsuring carrier is responsible for 10
225	percent of the next $50,000 and 5 percent of the next $100,000
226	of incurred claims during a calendar year, and the program shall
227	reinsure the remainder.
228	3. The board shall annually adjust the initial level of
229	claims and the maximum limit to be retained by the carrier to
230	reflect increases in costs and utilization within the standard
231	market for health benefit plans within the state. The adjustment
232	may not be less than the annual change in the medical component
233	of the "Commerce Price Index for All Urban Consumers" of the
234	Bureau of Labor Statistics of the United States Department of
235	Labor, unless the board proposes and the department approves a
236	lower adjustment factor.
237	4. A reinsuring carrier may terminate reinsurance for all
238	reinsured eligible individuals on any plan anniversary.
239	5. The premium rate charged for reinsurance by the program
240	to a health maintenance organization that is approved by the
241	Secretary of Health and Human Services as a federally qualified
242	health maintenance organization pursuant to 42 U.S.C. s.
243	300e(c)(2)(A) and that, as such, is subject to requirements that
244	limit the amount of risk that may be ceded to the program, which
245	requirements are more restrictive than subparagraph 2., shall be
246	reduced by an amount equal to that portion of the risk, if any,
247	which exceeds the amount set forth in subparagraph 2., which may
248	not be ceded to the program.
249	6. The board may consider adjustments to the premium rates
250	charged for reinsurance by the program or carriers that use
251	effective cost-containment measures, including high-cost case
252	management, as defined by the board.
253	7. A reinsuring carrier shall apply its case-management
254	and claims-handling techniques, including, but not limited to,
255	utilization review, individual case management, preferred
256	provider provisions, other managed-care provisions, or methods
257	of operation consistently with both reinsured business and
258	nonreinsured business.
259	(c)1. The board, as part of the plan of operation, shall
260	establish a methodology for determining premium rates to be
261	charged by the program for reinsuring eligible individuals
262	pursuant to this section. The methodology must include a system
263	for classifying individuals which reflects the types of case
264	characteristics commonly used by carriers in this state. The
265	methodology must provide for the development of basic
266	reinsurance premium rates, which shall be multiplied by the
267	factors set for them in this paragraph to determine the premium
268	rates for the program. The basic reinsurance premium rates shall
269	be established by the board, subject to the approval of the
270	department, and shall be set at levels that reasonably
271	approximate gross premiums charged to eligible individuals for
272	individual health insurance by health insurance issuers. The
273	premium rates set by the board may vary by geographical area, as
274	determined under this section, to reflect differences in cost.
275	An eligible individual may be reinsured for a rate that is five
276	times the rate established by the board.
277	2. The board shall periodically review the methodology
278	established, including the system of classification and any
279	rating factors, to ensure that it reasonably reflects the claims
280	experience of the program. The board may propose changes to the
281	rates that are subject to the approval of the department.
282	(e)1. Before SeptemberMarch1 of each calendar year, the
283	board shall determine and report to the department the program
284	net loss in the individual account for the previous year,
285	including administrative expenses for that year and the incurred
286	losses for that year, taking into account investment income and
287	other appropriate gains and losses.
288	2. Any net loss in the individual account for the year
289	shall be recouped by assessing the carriers as follows:
290	a. The operating losses of the program shall be assessed
291	in the following order subject to the specified limitations. The
292	first tier of assessments shall be made against reinsuring
293	carriers in an amount that may not exceed 5 percent of each
294	reinsuring carrier's premiums for individual health insurance.
295	If such assessments have been collected and additional moneys
296	are needed, the board shall make a second tier of assessments in
297	an amount that may not exceed 0.5 percent of each carrier's
298	health benefit plan premiums.
299	b. Except as provided in paragraph (f), risk-assuming
300	carriers are exempt from all assessments authorized pursuant to
301	this section. The amount paid by a reinsuring carrier for the
302	first tier of assessments shall be credited against any
303	additional assessments made.
304	c. The board shall equitably assess reinsuring carriers
305	for operating losses of the individual account based on market
306	share. The board shall annually assess each carrier a portion of
307	the operating losses of the individual account. The first tier
308	of assessments shall be determined by multiplying the operating
309	losses by a fraction, the numerator of which equals the
310	reinsuring carrier's earned premium pertaining to direct
311	writings of individual health insurance in the state during the
312	calendar year for which the assessment is levied, and the
313	denominator of which equals the total of all such premiums
314	earned by reinsuring carriers in the state during that calendar
315	year. The second tier of assessments shall be based on the
316	premiums that all carriers, except risk-assuming carriers,
317	earned on all health benefit plans written in this state. The
318	board may levy interim assessments against reinsuring carriers
319	to ensure the financial ability of the plan to cover claims
320	expenses and administrative expenses paid or estimated to be
321	paid in the operation of the plan for the calendar year prior to
322	the association's anticipated receipt of annual assessments for
323	that calendar year. Any interim assessment is due and payable
324	within 30 days after receipt by a carrier of the interim
325	assessment notice. Interim assessment payments shall be credited
326	against the carrier's annual assessment. Health benefit plan
327	premiums and benefits paid by a carrier that are less than an
328	amount determined by the board to justify the cost of collection
329	may not be considered for purposes of determining assessments.
330	d. Subject to the approval of the department, the board
331	shall adjust the assessment formula for reinsuring carriers that
332	are approved as federally qualified health maintenance
333	organizations by the Secretary of Health and Human Services
334	pursuant to 42 U.S.C. s. 300e(c)(2)(A) to the extent, if any,
335	that restrictions are placed on them which are not imposed on
336	other carriers.
337	3. Before SeptemberMarch1 of each year, the board shall
338	determine and file with the department an estimate of the
339	assessments needed to fund the losses incurred by the program in
340	the individual account for the previous calendar year.
341	4. If the board determines that the assessments needed to
342	fund the losses incurred by the program in the individual
343	account for the previous calendar year will exceed the amount
344	specified in subparagraph 2., the board shall evaluate the
345	operation of the program and report its findings and
346	recommendations to the department in the format established in
347	s. 627.6699(11) for the comparable report for the small employer
348	reinsurance program.
349	Section 7. Subsection (4) of section 627.651, Florida
350	Statutes, is amended to read:
351	627.651 Group contracts and plans of self-insurance must
352	meet group requirements.--
353	(4) This section does not apply to any plan which is
354	established or maintained by an individual employer in
355	accordance with the Employee Retirement Income Security Act of
356	1974, Pub. L. No. 93-406, or to a multiple-employer welfare
357	arrangement as defined in s. 624.437(1), except that a multiple-
358	employer welfare arrangement shall comply with ss. 627.419,
359	627.657, 627.6575, 627.6578, 627.6579, 627.6612, 627.66121,
360	627.66122, 627.6615, 627.6616, and 627.662(8)(7). This
361	subsection does not allow an authorized insurer to issue a group
362	health insurance policy or certificate which does not comply
363	with this part.
364	Section 8. Section 627.662, Florida Statutes, is amended
365	to read:
366	627.662 Other provisions applicable.--The following
367	provisions apply to group health insurance, blanket health
368	insurance, and franchise health insurance:
369	(1) Section 627.569, relating to use of dividends,
370	refunds, rate reductions, commissions, and service fees.
371	(2) Section 627.602(1)(f) and (2), relating to
372	identification numbers and statement of deductible provisions.
373	(3) Section 627.6044, relating to the use of specific
374	methodology for payment of claims.
375	(4)(3)Section 627.635, relating to excess insurance.
376	(5)(4)Section 627.638, relating to direct payment for
377	hospital or medical services.
378	(6)(5)Section 627.640, relating to filing and
379	classification of rates.
380	(7)(6)Section 627.613, relating to timely payment of
381	claims, or s. 627.6131, relating to payment of claims, whichever
382	is applicable.
383	(8)(7)Section 627.645(1), relating to denial of claims.
384	(9)(8)Section 627.6471, relating to preferred provider
385	organizations.
386	(10)(9)Section 627.6472, relating to exclusive provider
387	organizations.
388	(11)(10)Section 627.6473, relating to combined preferred
389	provider and exclusive provider policies.
390	(12)(11)Section 627.6474, relating to provider contracts.
391	Section 9. Subsection (6) of section 627.667, Florida
392	Statutes, is amended to read:
393	627.667 Extension of benefits.--
394	(6) This section also applies to holders of group
395	certificates which are renewed, delivered, or issued for
396	delivery to residents of this state under group policies
397	effectuated or delivered outside this state, unless a succeeding
398	carrier under a group policy has agreed to assume liability for
399	the benefits.
400	Section 10. Paragraph (e) of subsection (5) of section
401	627.6692, Florida Statutes, is amended to read:
402	627.6692 Florida Health Insurance Coverage Continuation
403	Act.--
404	(5) CONTINUATION OF COVERAGE UNDER GROUP HEALTH PLANS.--
405	(e)1. A covered employee or other qualified beneficiary
406	who wishes continuation of coverage must pay the initial premium
407	and elect such continuation in writing to the insurance carrier
408	issuing the employer's group health plan within 6330days after
409	receiving notice from the insurance carrier under paragraph (d).
410	Subsequent premiums are due by the grace period expiration date.
411	The insurance carrier or the insurance carrier's designee shall
412	process all elections promptly and provide coverage
413	retroactively to the date coverage would otherwise have
414	terminated. The premium due shall be for the period beginning on
415	the date coverage would have otherwise terminated due to the
416	qualifying event. The first premium payment must include the
417	coverage paid to the end of the month in which the first payment
418	is made. After the election, the insurance carrier must bill the
419	qualified beneficiary for premiums once each month, with a due
420	date on the first of the month of coverage and allowing a 30-day
421	grace period for payment.
422	2. Except as otherwise specified in an election, any
423	election by a qualified beneficiary shall be deemed to include
424	an election of continuation of coverage on behalf of any other
425	qualified beneficiary residing in the same household who would
426	lose coverage under the group health plan by reason of a
427	qualifying event. This subparagraph does not preclude a
428	qualified beneficiary from electing continuation of coverage on
429	behalf of any other qualified beneficiary.
430	Section 11. Paragraphs (g), (h), (i), and (u) of
431	subsection (3), paragraph (c) of subsection (5), paragraph (a)
432	of subsection (9), paragraph (d) of subsection (10), and
433	paragraphs (f), (g), (h), and (j) of subsection (11) of section
434	627.6699, Florida Statutes, are amended to read:
435	627.6699 Employee Health Care Access Act.--
436	(3) DEFINITIONS.--As used in this section, the term:
437	(g) "Dependent" means the spouse or child as described in
438	s. 627.6562 of an eligible employee, subject to the applicable
439	terms of the health benefit plan covering that employee.
440	(h) "Eligible employee" means an employee who works full
441	time, having a normal workweek of 25 or more hours, who is paid
442	wages or a salary at least equal to the federal minimum hourly
443	wage applicable to such employee,and who has met any applicable
444	waiting-period requirements or other requirements of this act.
445	The term includes a self-employed individual, a sole proprietor,
446	a partner of a partnership, or an independent contractor, if the
447	sole proprietor, partner, or independent contractor is included
448	as an employee under a health benefit plan of a small employer,
449	but does not include a part-time, temporary, or substitute
450	employee.
451	(i) "Established geographic area" means the county or
452	counties, or any portion of a county or counties,within which
453	the carrier provides or arranges for health care services to be
454	available to its insureds, members, or subscribers.
455	(u) "Self-employed individual" means an individual or sole
456	proprietor who derives his or her income from a trade or
457	business carried on by the individual or sole proprietor which
458	necessitates that the individual file federal income tax forms
459	with supporting schedules and accompanying income reporting
460	forms or federal income tax extensions of time to file forms
461	with the Internal Revenue Service for the most recent tax year
462	results in taxable income as indicated on IRS Form 1040,
463	schedule C or F, and which generated taxable income in one of
464	the 2 previous years.
465	(5) AVAILABILITY OF COVERAGE.--
466	(c) Every small employer carrier must, as a condition of
467	transacting business in this state:
468	1. Beginning July 1, 2000, offer and issue all small
469	employer health benefit plans on a guaranteed-issue basis to
470	every eligible small employer, with 2 to 50 eligible employees,
471	that elects to be covered under such plan, agrees to make the
472	required premium payments, and satisfies the other provisions of
473	the plan. A rider for additional or increased benefits may be
474	medically underwritten and may only be added to the standard
475	health benefit plan. The increased rate charged for the
476	additional or increased benefit must be rated in accordance with
477	this section.
478	2. Beginning July 1, 2000, and until July 31, 2001, offer
479	and issue basic and standard small employer health benefit plans
480	on a guaranteed-issue basis to every eligible small employer
481	which is eligible for guaranteed renewal, has less than two
482	eligible employees, is not formed primarily for the purpose of
483	buying health insurance, elects to be covered under such plan,
484	agrees to make the required premium payments, and satisfies the
485	other provisions of the plan. A rider for additional or
486	increased benefits may be medically underwritten and may be
487	added only to the standard benefit plan. The increased rate
488	charged for the additional or increased benefit must be rated in
489	accordance with this section. For purposes of this subparagraph,
490	a person, his or her spouse, and his or her dependent children
491	shall constitute a single eligible employee if that person and
492	spouse are employed by the same small employer and either one
493	has a normal work week of less than 25 hours.
494	3.a.Beginning August 1, 2001, offer and issue basic and
495	standard small employer health benefit plans on a guaranteed-
496	issue basis, during a 31-day open enrollment period of August 1
497	through August 31 of each year, to every eligible small
498	employer, with fewer than two eligible employees, which small
499	employer is not formed primarily for the purpose of buying
500	health insurance and which elects to be covered under such plan,
501	agrees to make the required premium payments, and satisfies the
502	other provisions of the plan. Coverage provided under this sub-
503	subparagraphsubparagraphshall begin on October 1 of the same
504	year as the date of enrollment, unless the small employer
505	carrier and the small employer agree to a different date. A
506	rider for additional or increased benefits may be medically
507	underwritten and may only be added to the standard health
508	benefit plan. The increased rate charged for the additional or
509	increased benefit must be rated in accordance with this section.
510	For purposes of this sub-subparagraphsubparagraph, a person,
511	his or her spouse, and his or her dependent children constitute
512	a single eligible employee if that person and spouse are
513	employed by the same small employer and either that person or
514	his or her spouse has a normal work week of less than 25 hours.
515	b. Notwithstanding the restrictions set forth in sub-
516	subparagraph a., when a small employer group is losing coverage
517	because a carrier is exercising the provisions of s.
518	627.6571(3)(b) or s. 641.31074(3)(b), the eligible small
519	employer, as defined in sub-subparagraph a., shall be entitled
520	to enroll with another carrier offering small employer coverage
521	within 63 days after the notice of termination or the
522	termination date of the prior coverage, whichever is later.
523	Coverage provided under this sub-subparagraph shall begin
524	immediately upon enrollment unless the small employer carrier
525	and the small employer agree to a different date.
526	4. This paragraph does not limit a carrier's ability to
527	offer other health benefit plans to small employers if the
528	standard and basic health benefit plans are offered and
529	rejected.
530	(9) SMALL EMPLOYER CARRIER'S ELECTION TO BECOME A RISK-
531	ASSUMING CARRIER OR A REINSURING CARRIER.--
532	(a) A small employer carrier must elect to become either a
533	risk-assuming carrier or a reinsuring carrier. Each small
534	employer carrier must make an initial election, binding through
535	January 1, 1994. The carrier's initial election must be made no
536	later than October 31, 1992. By October 31, 1993, all small
537	employer carriers must file a final election, which is binding
538	for 2 years, from January 1, 1994, through December 31, 1995,
539	after which an election shall be binding for a period of 5
540	years.Any carrier that is not a small employer carrier on
541	October 31, 1992, and intends to become a small employer carrier
542	after October 31, 1992, must file its designation when it files
543	the forms and rates it intends to use for small employer group
544	health insurance; such designation shall be binding indefinitely
545	or until modified or withdrawnfor 2 years after the date of
546	approval of the forms and rates, and any subsequent designation
547	is binding for 5 years. The department may permit a carrier to
548	modify its election at any time for good cause shown, after a
549	hearing.
550	(10) ELECTION PROCESS TO BECOME A RISK-ASSUMING CARRIER.--
551	(d) The department shall provide public notice of a small
552	employer carrier's filing adesignation of election under
553	subsection (9) to become a risk-assuming carrier and shall
554	provide at least a 21-day period for public comment upon receipt
555	of such filingprior to making a decision on the election. The
556	department shall hold a hearing on the election at the request
557	of the carrier.
558	(11) SMALL EMPLOYER HEALTH REINSURANCE PROGRAM.--
559	(f) The program has the general powers and authority
560	granted under the laws of this state to insurance companies and
561	health maintenance organizations licensed to transact business,
562	except the power to issue health benefit plans directly to
563	groups or individuals. In addition thereto, the program has
564	specific authority to:
565	1. Enter into contracts as necessary or proper to carry
566	out the provisions and purposes of this act, including the
567	authority to enter into contracts with similar programs of other
568	states for the joint performance of common functions or with
569	persons or other organizations for the performance of
570	administrative functions.
571	2. Sue or be sued, including taking any legal action
572	necessary or proper for recovering any assessments and penalties
573	for, on behalf of, or against the program or any carrier.
574	3. Take any legal action necessary to avoid the payment of
575	improper claims against the program.
576	4. Issue reinsurance policies, in accordance with the
577	requirements of this act.
578	5. Establish rules, conditions, and procedures for
579	reinsurance risks under the program participation.
580	6. Establish actuarial functions as appropriate for the
581	operation of the program.
582	7. Assess participating carriers in accordance with
583	paragraph (j), and make advance interim assessments as may be
584	reasonable and necessary for organizational and interim
585	operating expenses. Interim assessments shall be credited as
586	offsets against any regular assessments due following the close
587	of the calendar year.
588	8. Appoint appropriate legal, actuarial, and other
589	committees as necessary to provide technical assistance in the
590	operation of the program, and in any other function within the
591	authority of the program.
592	9. Borrow money to effect the purposes of the program. Any
593	notes or other evidences of indebtedness of the program which
594	are not in default constitute legal investments for carriers and
595	may be carried as admitted assets.
596	10. To the extent necessary, increase the $5,000
597	deductible reinsurance requirement to adjust for the effects of
598	inflation. The program may evaluate the desirability of
599	establishing different levels of deductibles. If different
600	levels of deductibles are established, such levels and the
601	resulting premiums shall be approved by the department.
602	(g) A reinsuring carrier may reinsure with the program
603	coverage of an eligible employee of a small employer, or any
604	dependent of such an employee, subject to each of the following
605	provisions:
606	1. With respect to a standard and basic health care plan,
607	the program maymustreinsure the level of coverage provided;
608	and, with respect to any other plan, the program maymust
609	reinsure the coverage up to, but not exceeding, the level of
610	coverage provided under the standard and basic health care plan.
611	As an alternative to reinsuring the level of coverage provided
612	under the standard and basic health care plan, the program may
613	develop alternate levels of reinsurance designed to coordinate
614	with a reinsuring carrier’s existing reinsurance. The levels of
615	reinsurance and resulting premiums must be approved by the
616	department.
617	2. Except in the case of a late enrollee, a reinsuring
618	carrier may reinsure an eligible employee or dependent within 60
619	days after the commencement of the coverage of the small
620	employer. A newly employed eligible employee or dependent of a
621	small employer may be reinsured within 60 days after the
622	commencement of his or her coverage.
623	3. A small employer carrier may reinsure an entire
624	employer group within 60 days after the commencement of the
625	group's coverage under the plan. The carrier may choose to
626	reinsure newly eligible employees and dependents of the
627	reinsured group pursuant to subparagraph 1.
628	4. The program may evaluate the option of allowing a small
629	employer carrier to reinsure an entire employer group or an
630	eligible employee at the first or subsequent renewal date. Any
631	such option and the resulting premium must be approved by the
632	department.
633	5.4.The program may not reimburse a participating carrier
634	with respect to the claims of a reinsured employee or dependent
635	until the carrier has paid incurred claims of an amount equal to
636	the participating carrier’s selected deductible levelat least
637	$5,000 in a calendar year for benefits covered by the program.
638	In addition, the reinsuring carrier shall be responsible for 10
639	percent of the next $50,000 and 5 percent of the next $100,000
640	of incurred claims during a calendar year and the program shall
641	reinsure the remainder.
642	6.5.The board annually shall adjust the initial level of
643	claims and the maximum limit to be retained by the carrier to
644	reflect increases in costs and utilization within the standard
645	market for health benefit plans within the state. The adjustment
646	shall not be less than the annual change in the medical
647	component of the "Consumer Price Index for All Urban Consumers"
648	of the Bureau of Labor Statistics of the Department of Labor,
649	unless the board proposes and the department approves a lower
650	adjustment factor.
651	7.6.A small employer carrier may terminate reinsurance
652	for all reinsured employees or dependents on any plan
653	anniversary.
654	8.7.The premium rate charged for reinsurance by the
655	program to a health maintenance organization that is approved by
656	the Secretary of Health and Human Services as a federally
657	qualified health maintenance organization pursuant to 42 U.S.C.
658	s. 300e(c)(2)(A) and that, as such, is subject to requirements
659	that limit the amount of risk that may be ceded to the program,
660	which requirements are more restrictive than subparagraph 5.4.,
661	shall be reduced by an amount equal to that portion of the risk,
662	if any, which exceeds the amount set forth in subparagraph 5.4.
663	which may not be ceded to the program.
664	9.8.The board may consider adjustments to the premium
665	rates charged for reinsurance by the program for carriers that
666	use effective cost containment measures, including high-cost
667	case management, as defined by the board.
668	10.9.A reinsuring carrier shall apply its case-management
669	and claims-handling techniques, including, but not limited to,
670	utilization review, individual case management, preferred
671	provider provisions, other managed care provisions or methods of
672	operation, consistently with both reinsured business and
673	nonreinsured business.
674	(h)1. The board, as part of the plan of operation, shall
675	establish a methodology for determining premium rates to be
676	charged by the program for reinsuring small employers and
677	individuals pursuant to this section. The methodology shall
678	include a system for classification of small employers that
679	reflects the types of case characteristics commonly used by
680	small employer carriers in the state. The methodology shall
681	provide for the development of basic reinsurance premium rates,
682	which shall be multiplied by the factors set for them in this
683	paragraph to determine the premium rates for the program. The
684	basic reinsurance premium rates shall be established by the
685	board, subject to the approval of the department, and shall be
686	set at levels which reasonably approximate gross premiums
687	charged to small employers by small employer carriers for health
688	benefit plans with benefits similar to the standard and basic
689	health benefit plan. The premium rates set by the board may vary
690	by geographical area, as determined under this section, to
691	reflect differences in cost. The multiplying factors must be
692	established as follows:
693	a. The entire group may be reinsured for a rate that is
694	1.5 times the rate established by the board.
695	b. An eligible employee or dependent may be reinsured for
696	a rate that is 5 times the rate established by the board.
697	2. The board periodically shall review the methodology
698	established, including the system of classification and any
699	rating factors, to assure that it reasonably reflects the claims
700	experience of the program. The board may propose changes to the
701	rates which shall be subject to the approval of the department.
702	(j)1. Before SeptemberMarch1 of each calendar year, the
703	board shall determine and report to the department the program
704	net loss for the previous year, including administrative
705	expenses for that year, and the incurred losses for the year,
706	taking into account investment income and other appropriate
707	gains and losses.
708	2. Any net loss for the year shall be recouped by
709	assessment of the carriers, as follows:
710	a. The operating losses of the program shall be assessed
711	in the following order subject to the specified limitations. The
712	first tier of assessments shall be made against reinsuring
713	carriers in an amount which shall not exceed 5 percent of each
714	reinsuring carrier's premiums from health benefit plans covering
715	small employers. If such assessments have been collected and
716	additional moneys are needed, the board shall make a second tier
717	of assessments in an amount which shall not exceed 0.5 percent
718	of each carrier's health benefit plan premiums. Except as
719	provided in paragraph (n), risk-assuming carriers are exempt
720	from all assessments authorized pursuant to this section. The
721	amount paid by a reinsuring carrier for the first tier of
722	assessments shall be credited against any additional assessments
723	made.
724	b. The board shall equitably assess carriers for operating
725	losses of the plan based on market share. The board shall
726	annually assess each carrier a portion of the operating losses
727	of the plan. The first tier of assessments shall be determined
728	by multiplying the operating losses by a fraction, the numerator
729	of which equals the reinsuring carrier's earned premium
730	pertaining to direct writings of small employer health benefit
731	plans in the state during the calendar year for which the
732	assessment is levied, and the denominator of which equals the
733	total of all such premiums earned by reinsuring carriers in the
734	state during that calendar year. The second tier of assessments
735	shall be based on the premiums that all carriers, except risk-
736	assuming carriers, earned on all health benefit plans written in
737	this state. The board may levy interim assessments against
738	carriers to ensure the financial ability of the plan to cover
739	claims expenses and administrative expenses paid or estimated to
740	be paid in the operation of the plan for the calendar year prior
741	to the association's anticipated receipt of annual assessments
742	for that calendar year. Any interim assessment is due and
743	payable within 30 days after receipt by a carrier of the interim
744	assessment notice. Interim assessment payments shall be credited
745	against the carrier's annual assessment. Health benefit plan
746	premiums and benefits paid by a carrier that are less than an
747	amount determined by the board to justify the cost of collection
748	may not be considered for purposes of determining assessments.
749	c. Subject to the approval of the department, the board
750	shall make an adjustment to the assessment formula for
751	reinsuring carriers that are approved as federally qualified
752	health maintenance organizations by the Secretary of Health and
753	Human Services pursuant to 42 U.S.C. s. 300e(c)(2)(A) to the
754	extent, if any, that restrictions are placed on them that are
755	not imposed on other small employer carriers.
756	3. Before SeptemberMarch1 of each year, the board shall
757	determine and file with the department an estimate of the
758	assessments needed to fund the losses incurred by the program in
759	the previous calendar year.
760	4. If the board determines that the assessments needed to
761	fund the losses incurred by the program in the previous calendar
762	year will exceed the amount specified in subparagraph 2., the
763	board shall evaluate the operation of the program and report its
764	findings, including any recommendations for changes to the plan
765	of operation, to the department within 24090days following the
766	end of the calendar year in which the losses were incurred. The
767	evaluation shall include an estimate of future assessments, the
768	administrative costs of the program, the appropriateness of the
769	premiums charged and the level of carrier retention under the
770	program, and the costs of coverage for small employers. If the
771	board fails to file a report with the department within 24090
772	days following the end of the applicable calendar year, the
773	department may evaluate the operations of the program and
774	implement such amendments to the plan of operation the
775	department deems necessary to reduce future losses and
776	assessments.
777	5. If assessments exceed the amount of the actual losses
778	and administrative expenses of the program, the excess shall be
779	held as interest and used by the board to offset future losses
780	or to reduce program premiums. As used in this paragraph, the
781	term "future losses" includes reserves for incurred but not
782	reported claims.
783	6. Each carrier's proportion of the assessment shall be
784	determined annually by the board, based on annual statements and
785	other reports considered necessary by the board and filed by the
786	carriers with the board.
787	7. Provision shall be made in the plan of operation for
788	the imposition of an interest penalty for late payment of an
789	assessment.
790	8. A carrier may seek, from the commissioner, a deferment,
791	in whole or in part, from any assessment made by the board. The
792	department may defer, in whole or in part, the assessment of a
793	carrier if, in the opinion of the department, the payment of the
794	assessment would place the carrier in a financially impaired
795	condition. If an assessment against a carrier is deferred, in
796	whole or in part, the amount by which the assessment is deferred
797	may be assessed against the other carriers in a manner
798	consistent with the basis for assessment set forth in this
799	section. The carrier receiving such deferment remains liable to
800	the program for the amount deferred and is prohibited from
801	reinsuring any individuals or groups in the program if it fails
802	to pay assessments.
803	Section 12. Section 627.911, Florida Statutes, is amended
804	to read:
805	627.911 Scope of this part.--Any insurer or health
806	maintenance organizationtransacting insurance in this state
807	shall report information as required by this part.
808	Section 13. Section 627.9175, Florida Statutes, is amended
809	to read:
810	627.9175 Reports of information on health insurance.--
811	(1) Each authorized health insurer or health maintenance
812	organization shall submit annually to the office, on or before
813	March 1 of each year, information concerningdepartment as to
814	policies of individual health insurance coverage being issued or
815	currently in force in this state. The information shall include
816	information related to premium, number of policies, and covered
817	lives for such policies and other information necessary to
818	analyze trends in enrollment, premiums, and claim costs.
819	(2) The required information shall be broken down by
820	market segment, to include:
821	(a) Health insurance issuer, company, contact person, or
822	agent.
823	(b) All health insurance products issued or in force,
824	including, but not limited to:
825	1. Direct premiums earned.
826	2. Direct losses incurred.
827	3. Direct premiums earned for new business issued during
828	the year.
829	4. Number of policies.
830	5. Number of certificates.
831	6. Number of total covered lives.
832	(a) A summary of typical benefits, exclusions, and
833	limitations for each type of individual policy form currently
834	being issued in the state. The summary shall include, as
835	appropriate:
836	1. The deductible amount;
837	2. The coinsurance percentage;
838	3. The out-of-pocket maximum;
839	4. Outpatient benefits;
840	5. Inpatient benefits; and
841	6. Any exclusions for preexisting conditions.
842
843	The department shall determine other appropriate benefits,
844	exclusions, and limitations to be reported for inclusion in the
845	consumer's guide published pursuant to this section.
846	(b) A schedule of rates for each type of individual policy
847	form reflecting typical variations by age, sex, region of the
848	state, or any other applicable factor which is in use and is
849	determined to be appropriate for inclusion by the department.
850
851	The department shall provide by rule a uniform format for the
852	submission of this information in order to allow for meaningful
853	comparisons of premiums charged for comparable benefits.
854	(3) The department may adopt rules to administer this
855	section, including, but not limited to, rules governing
856	compliance and provisions implementing electronic methodologies
857	for use in furnishing such records or documents. The commission
858	may by rule specify a uniform format for the submission of this
859	information in order to allow for meaningful comparisonsshall
860	publish annually a consumer's guide which summarizes and
861	compares the information required to be reported under this
862	subsection.
863	(2)(a) Every insurer transacting health insurance in this
864	state shall report annually to the department, not later than
865	April 1, information relating to any measure the insurer has
866	implemented or proposes to implement during the next calendar
867	year for the purpose of containing health insurance costs or
868	cost increases. The reports shall identify each measure and the
869	forms to which the measure is applied, shall provide an
870	explanation as to how the measure is used, and shall provide an
871	estimate of the cost effect of the measure.
872	(b) The department shall promulgate forms to be used by
873	insurers in reporting information pursuant to this subsection
874	and shall utilize such forms to analyze the effects of health
875	care cost containment programs used by health insurers in this
876	state.
877	(c) The department shall analyze the data reported under
878	this subsection and shall annually make available to the public
879	a summary of its findings as to the types of cost containment
880	measures reported and the estimated effect of these measures.
881	Section 14. Section 627.9403, Florida Statutes, is amended
882	to read:
883	627.9403 Scope.--The provisions of this part shall apply
884	to long-term care insurance policies delivered or issued for
885	delivery in this state, and to policies delivered or issued for
886	delivery outside this state to the extent provided in s.
887	627.9406, by an insurer, a fraternal benefit society as defined
888	in s. 632.601, a health maintenance organization as defined in
889	s. 641.19, a prepaid health clinic as defined in s. 641.402, or
890	a multiple-employer welfare arrangement as defined in s.
891	624.437. A policy which is advertised, marketed, or offered as a
892	long-term care policy and as a Medicare supplement policy shall
893	meet the requirements of this part and the requirements of ss.
894	627.671-627.675 and, to the extent of a conflict, be subject to
895	the requirement that is more favorable to the policyholder or
896	certificateholder. The provisions of this part shall not apply
897	to a continuing care contract issued pursuant to chapter 651 and
898	shall not apply to guaranteed renewable policies issued prior to
899	October 1, 1988. Any limited benefit policy that limits coverage
900	to care in a nursing home or to one or more lower levels of care
901	required or authorized to be provided by this part or by
902	department rule must meet all requirements of this part that
903	apply to long-term care insurance policies, except ss.
904	627.9407(3)(c) and (d), (9), (10)(f), and (12) and 627.94073(2).
905	If the limited benefit policy does not provide coverage for care
906	in a nursing home, but does provide coverage for one or more
907	lower levels of care, the policy shall also be exempt from the
908	requirements of s. 627.9407(3)(d).
909	Section 15. Paragraph (b) of subsection (1) of section
910	641.185, Florida Statutes, is amended to read:
911	641.185 Health maintenance organization subscriber
912	protections.--
913	(1) With respect to the provisions of this part and part
914	III, the principles expressed in the following statements shall
915	serve as standards to be followed by the Department of Insurance
916	and the Agency for Health Care Administration in exercising
917	their powers and duties, in exercising administrative
918	discretion, in administrative interpretations of the law, in
919	enforcing its provisions, and in adopting rules:
920	(b) A health maintenance organization subscriber should
921	receive quality health care from a broad panel of providers,
922	including referrals, preventive care pursuant to s. 641.402(1),
923	emergency screening and services pursuant to ss. 641.31(13)(12)
924	and 641.513, and second opinions pursuant to s. 641.51.
925	Section 16. Paragraph (d) of subsection (3) and
926	subsections (9) through (17) of section 641.31, Florida
927	Statutes, are amended to read:
928	641.31 Health maintenance contracts.--
929	(3)
930	(d) Any change in rates charged for the contract must be
931	filed with the department not less than 30 days in advance of
932	the effective date. At the expiration of such 30 days, the rate
933	filing shall be deemed approved unless prior to such time the
934	filing has been affirmatively approved or disapproved by order
935	of the department. The approval of the filing by the department
936	constitutes a waiver of any unexpired portion of such waiting
937	period. The department may extend by not more than an additional
938	15 days the period within which it may so affirmatively approve
939	or disapprove any such filing, by giving notice of such
940	extension before expiration of the initial 30-day period. At the
941	expiration of any such period as so extended, and in the absence
942	of such prior affirmative approval or disapproval, any such
943	filing shall be deemed approved. This paragraph does not apply
944	to group health maintenance organization contracts effectuated
945	and delivered in this state insuring groups of 51 or more
946	persons.
947	(9)(a)1. If a health maintenance organization offers
948	coverage for dependent children of the subscriber, the contract
949	must cover a dependent child of the subscriber at least until
950	the end of the calendar year in which the child reaches the age
951	of 23, if the child meets all of the following:
952	a. The child is dependent upon the subscriber for support.
953	b. The child is living in the household of the subscriber,
954	or the child is a full-time or part-time student.
955	2. Nothing in this paragraph affects or preempts a health
956	maintenance organization's right to medically underwrite or
957	charge the appropriate premium.
958	(b)1. A contract that provides coverage for a family
959	member of the subscriber shall, as to such family member's
960	coverage, provide that benefits applicable to children of the
961	subscriber also apply to an adopted child or a foster child of
962	the subscriber placed in compliance with chapter 63 from the
963	moment of placement in the residence of the subscriber. Except
964	in the case of a foster child, the contract may not exclude
965	coverage for any preexisting condition of the child. In the case
966	of a newborn child, coverage begins at the moment of birth if a
967	written agreement to adopt such child has been entered into by
968	the subscriber prior to the birth of the child, whether or not
969	the agreement is enforceable. This section does not require
970	coverage for an adopted child who is not ultimately placed in
971	the residence of the subscriber in compliance with chapter 63.
972	2. A contract may require the subscriber to notify the
973	health maintenance organization of the birth or placement of an
974	adopted child within a specified time period of not less than 30
975	days after the birth or placement in the residence of a child
976	adopted by the subscriber. If timely notice is given, the health
977	maintenance organization may not charge an additional premium
978	for coverage of the child for the duration of the notice period.
979	If timely notice is not given, the health maintenance
980	organization may charge an additional premium from the date of
981	birth or placement. If notice is given within 60 days after the
982	birth or placement of the child, the health maintenance
983	organization may not deny coverage for the child due to the
984	failure of the subscriber to timely notify the health
985	maintenance organization of the birth or placement of the child.
986	3. If the contract does not require the subscriber to
987	notify the health maintenance organization of the birth or
988	placement of an adopted child within a specified time period,
989	the health maintenance organization may not deny coverage for
990	such child or retroactively charge the subscriber an additional
991	premium for such child. However, the health maintenance
992	organization may prospectively charge the subscriber an
993	additional premium for the child if the health maintenance
994	organization provides at least 45 days' notice of the additional
995	premium required.
996	4. In order to increase access to postnatal, infant, and
997	pediatric health care for all children placed in court-ordered
998	custody, including foster children, all health maintenance
999	organization contracts that provide coverage for a family member
1000	of the subscriber shall, as to such family member's coverage,
1001	provide that benefits applicable for children shall be payable
1002	with respect to a foster child or other child in court-ordered,
1003	temporary, or other custody of the subscriber.
1004	(10) A contract that provides that coverage of a dependent
1005	child shall terminate upon attainment of the limiting age for
1006	dependent children specified in the contract shall also provide
1007	in substance that attainment of the limiting age does not
1008	terminate the coverage of the child while the child continues to
1009	be:
1010	(a) Incapable of self-sustaining employment by reason of
1011	mental retardation or physical handicap.
1012	(b) Chiefly dependent upon the subscriber for support and
1013	maintenance.
1014
1015	If a claim is denied under a contract for the stated reason that
1016	the child has attained the limiting age for dependent children
1017	specified in the contract, the notice of denial must state that
1018	the subscriber has the burden of establishing that the child
1019	continues to meet the criteria specified in paragraphs (a) and
1020	(b).All health maintenance contracts that provide coverage,
1021	benefits, or services for a member of the family of the
1022	subscriber must, as to such family member's coverage, benefits,
1023	or services, provide also that the coverage, benefits, or
1024	services applicable for children must be provided with respect
1025	to a newborn child of the subscriber, or covered family member
1026	of the subscriber, from the moment of birth. However, with
1027	respect to a newborn child of a covered family member other than
1028	the spouse of the insured or subscriber, the coverage for the
1029	newborn child terminates 18 months after the birth of the
1030	newborn child. The coverage, benefits, or services for newborn
1031	children must consist of coverage for injury or sickness,
1032	including the necessary care or treatment of medically diagnosed
1033	congenital defects, birth abnormalities, or prematurity, and
1034	transportation costs of the newborn to and from the nearest
1035	appropriate facility appropriately staffed and equipped to treat
1036	the newborn's condition, when such transportation is certified
1037	by the attending physician as medically necessary to protect the
1038	health and safety of the newborn child.
1039	(a) A contract may require the subscriber to notify the
1040	plan of the birth of a child within a time period, as specified
1041	in the contract, of not less than 30 days after the birth, or a
1042	contract may require the preenrollment of a newborn prior to
1043	birth. However, if timely notice is given, a plan may not charge
1044	an additional premium for additional coverage of the newborn
1045	child for not less than 30 days after the birth of the child. If
1046	timely notice is not given, the plan may charge an additional
1047	premium from the date of birth. If notice is given within 60
1048	days of the birth of the child, the contract may not deny
1049	coverage of the child due to failure of the subscriber to timely
1050	notify the plan of the birth of the child or to preenroll the
1051	child.
1052	(b) If the contract does not require the subscriber to
1053	notify the plan of the birth of a child within a specified time
1054	period, the plan may not deny coverage of the child nor may it
1055	retroactively charge the subscriber an additional premium for
1056	the child; however, the contract may prospectively charge the
1057	member an additional premium for the child if the plan provides
1058	at least 45 days' notice of the additional charge.
1059	(11)(10)No alteration of any written application for any
1060	health maintenance contract shall be made by any person other
1061	than the applicant without his or her written consent, except
1062	that insertions may be made by the health maintenance
1063	organization, for administrative purposes only, in such manner
1064	as to indicate clearly that such insertions are not to be
1065	ascribed to the applicant.
1066	(12)(11)No contract shall contain any waiver of rights or
1067	benefits provided to or available to subscribers under the
1068	provisions of any law or rule applicable to health maintenance
1069	organizations.
1070	(13)(12)Each health maintenance contract, certificate, or
1071	member handbook shall state that emergency services and care
1072	shall be provided to subscribers in emergency situations not
1073	permitting treatment through the health maintenance
1074	organization's providers, without prior notification to and
1075	approval of the organization. Not less than 75 percent of the
1076	reasonable charges for covered services and supplies shall be
1077	paid by the organization, up to the subscriber contract benefit
1078	limits. Payment also may be subject to additional applicable
1079	copayment provisions, not to exceed $100 per claim. The health
1080	maintenance contract, certificate, or member handbook shall
1081	contain the definitions of "emergency services and care" and
1082	"emergency medical condition" as specified in s. 641.19(7) and
1083	(8), shall describe procedures for determination by the health
1084	maintenance organization of whether the services qualify for
1085	reimbursement as emergency services and care, and shall contain
1086	specific examples of what does constitute an emergency. In
1087	providing for emergency services and care as a covered service,
1088	a health maintenance organization shall be governed by s.
1089	641.513.
1090	(14)(13)In addition to the requirements of this section,
1091	with respect to a person who is entitled to have payments for
1092	health care costs made under Medicare, Title XVIII of the Social
1093	Security Act ("Medicare"), parts A and/or B:
1094	(a) The health maintenance organization shall mail or
1095	deliver notification to the Medicare beneficiary of the date of
1096	enrollment in the health maintenance organization within 10 days
1097	after receiving notification of enrollment approval from the
1098	United States Department of Health and Human Services, Health
1099	Care Financing Administration. When a Medicare beneficiary who
1100	is a subscriber of the health maintenance organization requests
1101	disenrollment from the organization, the organization shall mail
1102	or deliver to the beneficiary notice of the effective date of
1103	the disenrollment within 10 days after receipt of the written
1104	disenrollment request. The health maintenance organization shall
1105	forward the disenrollment request to the United States
1106	Department of Health and Human Services, Health Care Financing
1107	Administration, in a timely manner so as to effectuate the next
1108	available disenrollment date, as prescribed by such federal
1109	agency.
1110	(b) The health maintenance contract, certificate, or
1111	member handbook shall be delivered to the subscriber no later
1112	than the earlier of 10 working days after the health maintenance
1113	organization and the Health Care Financing Administration of the
1114	United States Department of Health and Human Services approve
1115	the subscriber's enrollment application or the effective date of
1116	coverage of the subscriber under the health maintenance
1117	contract. However, if notice from the Health Care Financing
1118	Administration of its approval of the subscriber's enrollment
1119	application is received by the health maintenance organization
1120	after the effective coverage date prescribed by the Health Care
1121	Financing Administration, the health maintenance organization
1122	shall deliver the contract, certificate, or member handbook to
1123	the subscriber within 10 days after receiving such notice. When
1124	a Medicare recipient is enrolled in a health maintenance
1125	organization program, the contract, certificate, or member
1126	handbook shall be accompanied by a health maintenance
1127	organization identification sticker with instruction to the
1128	Medicare beneficiary to place the sticker on the Medicare
1129	identification card.
1130	(15)(14)Whenever a subscriber of a health maintenance
1131	organization is also a Medicaid recipient, the health
1132	maintenance organization's coverage shall be primary to the
1133	recipient's Medicaid benefits and the organization shall be a
1134	third party subject to the provisions of s. 409.910(4).
1135	(16)(15)(a) All health maintenance contracts,
1136	certificates, and member handbooks shall contain the following
1137	provision:
1138
1139	"Grace Period: This contract has a (insert a number not less
1140	than 10) day grace period. This provision means that if any
1141	required premium is not paid on or before the date it is due, it
1142	may be paid during the following grace period. During the grace
1143	period, the contract will stay in force."
1144
1145	(b) The required provision of paragraph (a) shall not
1146	apply to certificates or member handbooks delivered to
1147	individual subscribers under a group health maintenance contract
1148	when the employer or other person who will hold the contract on
1149	behalf of the subscriber group pays the entire premium for the
1150	individual subscribers. However, such required provision shall
1151	apply to the group health maintenance contract.
1152	(17)(16)The contracts must clearly disclose the intent of
1153	the health maintenance organization as to the applicability or
1154	nonapplicability of coverage to preexisting conditions. If
1155	coverage of the contract is not to be applicable to preexisting
1156	conditions, the contract shall specify, in substance, that
1157	coverage pertains solely to accidental bodily injuries resulting
1158	from accidents occurring after the effective date of coverage
1159	and that sicknesses are limited to those which first manifest
1160	themselves subsequent to the effective date of coverage.
1161	(17) All health maintenance contracts that provide
1162	coverage for a member of the family of the subscriber, shall, as
1163	to such family member's coverage, provide that coverage,
1164	benefits, or services applicable for children shall be provided
1165	with respect to an adopted child of the subscriber, which child
1166	is placed in compliance with chapter 63, from the moment of
1167	placement in the residence of the subscriber. Such contracts may
1168	not exclude coverage for any preexisting condition of the child.
1169	In the case of a newborn child, coverage shall begin from the
1170	moment of birth if a written agreement to adopt such child has
1171	been entered into by the subscriber prior to the birth of the
1172	child, whether or not such agreement is enforceable. However,
1173	coverage for such child shall not be required in the event that
1174	the child is not ultimately placed in the residence of the
1175	subscriber in compliance with chapter 63.
1176	Section 17. Section 641.31025, Florida Statutes, is
1177	created to read:
1178	641.31025 Specific reasons for denial of coverage.--The
1179	denial of an application for a health maintenance organization
1180	contract must be accompanied by the specific reasons for the
1181	denial, including, but not limited to, the specific underwriting
1182	reasons, if applicable.
1183	Section 18. Section 641.31075, Florida Statutes, is
1184	created to read:
1185	641.31075 Replacement.--Any health maintenance
1186	organization that is replacing any other group health coverage
1187	with its group health maintenance coverage shall comply with s.
1188	627.666.
1189	Section 19. Subsections (1) and (3) of section 641.3111,
1190	Florida Statutes, are amended to read:
1191	641.3111 Extension of benefits.--
1192	(1) Every group health maintenance contract shall provide
1193	that termination of the contract shall be without prejudice to
1194	any continuous loss which commenced while the contract was in
1195	force, but any extension of benefits beyond the period the
1196	contract was in force may be predicated upon the continuous
1197	total disability of the subscriber and may be limited to payment
1198	for the treatment of a specific accident or illness incurred
1199	while the subscriber was a member. The extension is required
1200	regardless of whether the group contract holder or other entity
1201	secures replacement coverage from a new insurer or health
1202	maintenance organization or foregoes the provision of coverage.
1203	The required provision must provide for continuation of contract
1204	benefits in connection with the treatment of a specific accident
1205	or illness incurred while the contract was in effect.Such
1206	extension of benefits may be limited to the occurrence of the
1207	earliest of the following events:
1208	(a) The expiration of 12 months.
1209	(b) Such time as the member is no longer totally disabled.
1210	(c) A succeeding carrier elects to provide replacement
1211	coverage without limitation as to the disability condition.
1212	(c)(d)The maximum benefits payable under the contract
1213	have been paid.
1214	(3) In the case of maternity coverage, when not covered by
1215	the succeeding carrier,a reasonable extension of benefits or
1216	accrued liability provision is required, which provision
1217	provides for continuation of the contract benefits in connection
1218	with maternity expenses for a pregnancy that commenced while the
1219	policy was in effect. The extension shall be for the period of
1220	that pregnancy and shall not be based upon total disability.
1221	Section 20. Subsection (4) of section 627.651, Florida
1222	Statutes, is amended to read:
1223	627.651 Group contracts and plans of self-insurance must
1224	meet group requirements.--
1225	(4) This section does not apply to any plan which is
1226	established or maintained by an individual employer in
1227	accordance with the Employee Retirement Income Security Act of
1228	1974, Pub. L. No. 93-406, or to a multiple-employer welfare
1229	arrangement as defined in s. 624.437(1), except that a multiple-
1230	employer welfare arrangement shall comply with ss. 627.419,
1231	627.657, 627.6575, 627.6578, 627.6579, 627.6612, 627.66121,
1232	627.66122, 627.6615, 627.6616, and 627.662(8)(7). This
1233	subsection does not allow an authorized insurer to issue a group
1234	health insurance policy or certificate which does not comply
1235	with this part.
1236	Section 21. Subsection (1) of section 641.2018, Florida
1237	Statutes, is amended to read:
1238	641.2018 Limited coverage for home health care
1239	authorized.--
1240	(1) Notwithstanding other provisions of this chapter, a
1241	health maintenance organization may issue a contract that limits
1242	coverage to home health care services only. The organization and
1243	the contract shall be subject to all of the requirements of this
1244	part that do not require or otherwise apply to specific benefits
1245	other than home care services. To this extent, all of the
1246	requirements of this part apply to any organization or contract
1247	that limits coverage to home care services, except the
1248	requirements for providing comprehensive health care services as
1249	provided in ss. 641.19(4), (12), and (13), and 641.31(1), except
1250	ss. 641.31(9),(13)(12), (17),(18), (19), (20), (21), and (24)
1251	and 641.31095.
1252	Section 22. Section 641.3107, Florida Statutes, is amended
1253	to read:
1254	641.3107 Delivery of contract.--Unless delivered upon
1255	execution or issuance, a health maintenance contract,
1256	certificate of coverage, or member handbook shall be mailed or
1257	delivered to the subscriber or, in the case of a group health
1258	maintenance contract, to the employer or other person who will
1259	hold the contract on behalf of the subscriber group within 10
1260	working days from approval of the enrollment form by the health
1261	maintenance organization or by the effective date of coverage,
1262	whichever occurs first. However, if the employer or other person
1263	who will hold the contract on behalf of the subscriber group
1264	requires retroactive enrollment of a subscriber, the
1265	organization shall deliver the contract, certificate, or member
1266	handbook to the subscriber within 10 days after receiving notice
1267	from the employer of the retroactive enrollment. This section
1268	does not apply to the delivery of those contracts specified in
1269	s. 641.31(14)(13).
1270	Section 23. Subsection (4) of section 641.513, Florida
1271	Statutes, is amended to read:
1272	641.513 Requirements for providing emergency services and
1273	care.--
1274	(4) A subscriber may be charged a reasonable copayment, as
1275	provided in s. 641.31(13)(12), for the use of an emergency room.
1276	Section 24. This act shall take effect upon becoming a
1277	law.
1278
1279	================= T I T L E A M E N D M E N T =================
1280	Remove line 607, and insert:
1281	An act relating to health insurance; amending s. 408.909,
1282	F.S.; revising a definition; authorizing health flex plans
1283	to limit coverage under certain circumstances; authorizing
1284	a small business purchasing arrangement to limit
1285	enrollment to certain residents; extending an expiration
1286	date; creating s. 627.6042, F.S.; requiring policies of
1287	insurers offering coverage of dependent children to
1288	maintain such coverage until a child reaches age 25, under
1289	certain circumstances; providing application; creating s.
1290	627.60425, F.S.; providing limitations on certain binding
1291	arbitration requirements; amending s. 627.6044, F.S.;
1292	providing for payment of claims to nonnetwork providers
1293	under specified conditions; providing a definition;
1294	requiring the method used for determining payment of
1295	claims to be included in filings; providing for
1296	disclosure; amending s. 627.6415, F.S.; deleting an 18th
1297	birthday age limitation on application of certain
1298	dependent coverage requirements; amending s. 627.6475,
1299	F.S.; revising risk-assuming carrier election requirements
1300	and procedures; revising certain criteria and limitations
1301	under the individual health reinsurance program; amending
1302	s. 627.651, F.S.; correcting a cross reference; amending
1303	s. 627.662, F.S.; revising a list of provisions applicable
1304	to group, blanket, or franchise health insurance to
1305	include use of specific methodology for payment of claims
1306	provisions; amending s. 627.667, F.S.; deleting a
1307	limitation on application of certain extension of benefits
1308	provisions; amending s. 627.6692, F.S.; increasing a time
1309	period for payment of premium to continue coverage under a
1310	group health plan; amending s. 627.6699, F.S.; revising
1311	definitions; revising coverage enrollment eligibility
1312	criteria for small employers; revising small employer
1313	carrier election requirements and procedures; revising
1314	certain criteria and limitations under the small employer
1315	health reinsurance program; amending ss. 627.911 and
1316	627.9175, F.S.; applying certain information reporting
1317	requirements to health maintenance organizations; revising
1318	health insurance information requirements and criteria;
1319	authorizing the department to adopt rules; deleting an
1320	annual report requirement; amending s. 627.9403, F.S.;
1321	deleting an exemption for limited benefit policies from a
1322	long-term care insurance restriction relating to nursing
1323	home care; amending s. 641.185, F.S.; correcting a cross
1324	reference; amending s. 641.31, F.S.; specifying
1325	nonapplication to certain contracts; requiring health
1326	maintenance organizations offering coverage of dependent
1327	children to maintain such coverage until a child reaches
1328	age 25, under certain circumstances; providing
1329	application; providing requirements for contract
1330	termination and denial of a claim related to limiting age
1331	attainment; creating s. 641.31025, F.S.; requiring
1332	specific reasons for denial of coverage under a health
1333	maintenance organization contract; creating s. 641.31075,
1334	F.S.; imposing compliance requirements upon health
1335	maintenance organization replacements of other group
1336	health coverage with organization coverage; amending s.
1337	641.3111, F.S.; deleting a limitation on certain extension
1338	of benefits provisions upon group health maintenance
1339	contract termination; imposing additional extension of
1340	benefits requirements upon such termination; amending ss.
1341	627.651, 641.2018, 641.3107, and 641.513, F.S.; correcting
1342	cross references; amending s. 395.301,