HB 0723 2003
1	CHAMBER ACTION
2
3
4
5
6	The Committee on Health Care recommends the following:
7
8	Committee Substitute
9	Remove the entire bill and insert:
10	A bill to be entitled
11	An act relating to health insurance; amending s. 408.909,
12	F.S.; revising a definition; authorizing health flex plans
13	to limit coverage under certain circumstances; authorizing
14	a small business purchasing arrangement to limit
15	enrollment to certain residents; creating s. 627.6042,
16	F.S.; requiring policies of insurers offering coverage of
17	dependent children to maintain such coverage until a child
18	reaches age 25, under certain circumstances; providing
19	application; creating s. 627.60425, F.S.; providing
20	limitations on certain binding arbitration requirements;
21	amending s. 627.6044, F.S.; providing for payment of
22	claims to nonnetwork providers under specified conditions;
23	providing a definition; requiring the method used for
24	determining payment of claims to be included in filings;
25	providing for disclosure; amending s. 627.6415, F.S.;
26	deleting an 18th birthday age limitation on application of
27	certain dependent coverage requirements; amending s.
28	627.6475, F.S.; revising risk-assuming carrier election
29	requirements and procedures; revising certain criteria and
30	limitations under the individual health reinsurance
31	program; amending s. 627.651, F.S.; correcting a cross
32	reference; amending s. 627.662, F.S.; revising a list of
33	provisions applicable to group, blanket, or franchise
34	health insurance to include use of specific methodology
35	for payment of claims provisions; amending s. 627.667,
36	F.S.; deleting a limitation on application of certain
37	extension of benefits provisions; amending s. 627.6692,
38	F.S.; increasing a time period for payment of premium to
39	continue coverage under a group health plan; amending s.
40	627.6699, F.S.; revising definitions; revising coverage
41	enrollment eligibility criteria for small employers;
42	revising small employer carrier election requirements and
43	procedures; revising certain criteria and limitations
44	under the small employer health reinsurance program;
45	amending ss. 627.911 and 627.9175, F.S.; applying certain
46	information reporting requirements to health maintenance
47	organizations; revising health insurance information
48	requirements and criteria; authorizing the department to
49	adopt rules; deleting an annual report requirement;
50	amending s. 627.9403, F.S.; deleting an exemption for
51	limited benefit policies from a long-term care insurance
52	restriction relating to nursing home care; amending s.
53	641.185, F.S.; correcting a cross reference; amending s.
54	641.31, F.S.; requiring health maintenance organizations
55	offering coverage of dependent children to maintain such
56	coverage until a child reaches age 25, under certain
57	circumstances; providing application; providing
58	requirements for contract termination and denial of a
59	claim related to limiting age attainment; amending s.
60	641.3101, F.S.; providing a compliance requirement for
61	health maintenance contracts using a specific payment of
62	claims methodology; creating s. 641.31025, F.S.; requiring
63	specific reasons for denial of coverage under a health
64	maintenance organization contract; creating s. 641.31075,
65	F.S.; imposing compliance requirements upon health
66	maintenance organization replacements of other group
67	health coverage with organization coverage; amending s.
68	641.3111, F.S.; deleting a limitation on certain extension
69	of benefits provisions upon group health maintenance
70	contract termination; imposing additional extension of
71	benefits requirements upon such termination; amending ss.
72	627.651, 641.2018, 641.3107, and 641.513, F.S.; correcting
73	cross references; providing an effective date.
74
75	Be It Enacted by the Legislature of the State of Florida:
76
77	Section 1. Paragraph (e) of subsection (2), subsection
78	(3), and paragraph (c) of subsection (5) of section 408.909,
79	Florida Statutes, are amended to read:
80	408.909 Health flex plans.--
81	(2) DEFINITIONS.--As used in this section, the term:
82	(e) "Health flex plan" means a health plan approved under
83	subsection (3) which guarantees payment for specified health
84	care coverage provided to the enrollee who purchases coverage
85	directly from the plan or through a small business purchasing
86	arrangement sponsored by a local government.
87	(3) PILOT PROGRAM.--The agency and the department shall
88	each approve or disapprove health flex plans that provide health
89	care coverage for eligible participants who reside in the three
90	areas of the state that have the highest number of uninsured
91	persons, as identified in the Florida Health Insurance Study
92	conducted by the agency and in Indian River County. A health
93	flex plan may limit or exclude benefits otherwise required by
94	law for insurers offering coverage in this state, may cap the
95	total amount of claims paid per year per enrollee, may limit the
96	number of enrollees or the term of coverage, or may take any
97	combination of those actions.
98	(a) The agency shall develop guidelines for the review of
99	applications for health flex plans and shall disapprove or
100	withdraw approval of plans that do not meet or no longer meet
101	minimum standards for quality of care and access to care.
102	(b) The department shall develop guidelines for the review
103	of health flex plan applications and shall disapprove or shall
104	withdraw approval of plans that:
105	1. Contain any ambiguous, inconsistent, or misleading
106	provisions or any exceptions or conditions that deceptively
107	affect or limit the benefits purported to be assumed in the
108	general coverage provided by the health flex plan;
109	2. Provide benefits that are unreasonable in relation to
110	the premium charged or contain provisions that are unfair or
111	inequitable or contrary to the public policy of this state, that
112	encourage misrepresentation, or that result in unfair
113	discrimination in sales practices; or
114	3. Cannot demonstrate that the health flex plan is
115	financially sound and that the applicant is able to underwrite
116	or finance the health care coverage provided.
117	(c) The agency and the department may adopt rules as
118	needed to administer this section.
119	(5) ELIGIBILITY.--Eligibility to enroll in an approved
120	health flex plan is limited to residents of this state who:
121	(c) Are not covered by a private insurance policy and are
122	not eligible for coverage through a public health insurance
123	program, such as Medicare or Medicaid, or another public health
124	care program, such as KidCare, and have not been covered at any
125	time during the past 6 months, except that a small business
126	purchasing arrangement sponsored by a local government may limit
127	enrollment to residents of this state who have not been covered
128	at any time during the past 12 months; and
129	Section 2. Section 627.6042, Florida Statutes, is created
130	to read:
131	627.6042 Dependent coverage.--
132	(1) If an insurer offers coverage that insures dependent
133	children of the policyholder or certificateholder, the policy
134	must insure a dependent child of the policyholder or
135	certificateholder at least until the end of the calendar year in
136	which the child reaches the age of 25, if the child meets all of
137	the following:
138	(a) The child is dependent upon the policyholder or
139	certificateholder for support.
140	(b) The child is living in the household of the
141	policyholder or certificateholder or the child is a full-time or
142	part-time student.
143	(2) Nothing in this section affects or preempts an
144	insurer's right to medically underwrite or charge the
145	appropriate premium.
146	Section 3. Section 627.60425, Florida Statutes, is created
147	to read:
148	627.60425 Binding arbitration requirement
149	limitations.--Notwithstanding any other provision of law, except
150	s. 624.155, an individual, blanket, group life, or group health
151	insurance policy; health maintenance organization subscriber
152	contract; prepaid limited health organization subscriber
153	contract; or any life or health insurance policy or certificate
154	delivered or issued for delivery, including out-of-state group
155	plans pursuant to s. 627.5515 or s. 627.6515 covering residents
156	of this state, to any resident of this state shall not require
157	the submission of disputes between the parties to the policy,
158	contract, or plan to binding arbitration unless the applicant
159	has indicated that the same policy, contract, or plan was
160	offered and rejected and that the binding arbitration provision
161	was fully explained to the applicant and willingly accepted.
162	Section 4. Section 627.6044, Florida Statutes, is amended
163	to read:
164	627.6044 Use of a specific methodology for payment of
165	claims.--
166	(1) Each insurance policy that provides for payment of
167	claims to nonnetwork providers that is less than the payment of
168	the provider's billed charges to the insured, excluding
169	deductible, coinsurance, and copay amounts, shall:
170	(a) Provide benefits prior to deductible, coinsurance, and
171	copay amounts for using a nonnetwork provider that are at least
172	equal to the amount that would have been allowed had the insured
173	used a network provider but are not in excess of the actual
174	billed charges.
175	(b) Where there are multiple network providers in the
176	geographical area in which the services were provided or, if
177	none, the closest geographic area, the carrier may use an
178	averaging method of the contracted amounts but not less than the
179	80th percentile of all network contracted amounts in the
180	geographic area.
181
182	For purposes of this subsection, the term "network providers"
183	means those providers for which an insured will not be
184	responsible for any balance payment for services provided by
185	such provider, excluding deductible, coinsurance, and copay
186	amountsbased on a specific methodology, including, but not
187	limited to, usual and customary charges, reasonable and
188	customary charges, or charges based upon the prevailing rate in
189	the community, shall specify the formula or criteria used by the
190	insurer in determining the amount to be paid.
191	(2) Each insurer issuing a policy that provides for
192	payment of claims based on a specific methodology shall provide
193	to an insured, upon her or his written request, an estimate of
194	the amount the insurer will pay for a particular medical
195	procedure or service. The estimate may be in the form of a range
196	of payments or an average payment and may specify that the
197	estimate is based on the assumption of a particular service
198	code. The insurer may require the insured to provide detailed
199	information regarding the procedure or service to be performed,
200	including the procedure or service code number provided by the
201	health care provider and the health care provider's estimated
202	charge.An insurer that provides an insured with a good faith
203	estimate is not bound by the estimate. However, a pattern of
204	providing estimates that vary significantly from the ultimate
205	insurance payment constitutes a violation of this code.
206	(3) The method used for determining the payment of claims
207	shall be included in filings made pursuant to s. 627.410(6) and
208	may not be changed unless such change is filed under s.
209	627.410(6).
210	(4) Any policy that provides that the insured is
211	responsible for the balance of a claim amount, excluding
212	deductible, coinsurance, and copay amounts, must disclose such
213	feature on the face of the policy or certificate and such
214	feature must be included in any outline of coverage provided to
215	the insured.
216	Section 5. Subsections (1) and (4) of section 627.6415,
217	Florida Statutes, are amended to read:
218	627.6415 Coverage for natural-born, adopted, and foster
219	children; children in insured's custodial care.--
220	(1) A health insurance policy that provides coverage for a
221	member of the family of the insured shall, as to the family
222	member's coverage, provide that the health insurance benefits
223	applicable to children of the insured also apply to an adopted
224	child or a foster child of the insured placed in compliance with
225	chapter 63, prior to the child's 18th birthday,from the moment
226	of placement in the residence of the insured. Except in the case
227	of a foster child, the policy may not exclude coverage for any
228	preexisting condition of the child. In the case of a newborn
229	child, coverage begins at the moment of birth if a written
230	agreement to adopt the child has been entered into by the
231	insured prior to the birth of the child, whether or not the
232	agreement is enforceable. This section does not require coverage
233	for an adopted child who is not ultimately placed in the
234	residence of the insured in compliance with chapter 63.
235	(4) In order to increase access to postnatal, infant, and
236	pediatric health care for all children placed in court-ordered
237	custody, including foster children, all health insurance
238	policies that provide coverage for a member of the family of the
239	insured shall, as to such family member's coverage, also provide
240	that the health insurance benefits applicable for children shall
241	be payable with respect to a foster child or other child in
242	court-ordered temporary or other custody of the insured, prior
243	to the child's 18th birthday.
244	Section 6. Paragraph (a) of subsection (5), paragraph (c)
245	of subsection (6), and paragraphs (b), (c), and (e) of
246	subsection (7) of section 627.6475, Florida Statutes, are
247	amended to read:
248	627.6475 Individual reinsurance pool.--
249	(5) ISSUER'S ELECTION TO BECOME A RISK-ASSUMING CARRIER.--
250	(a) Each health insurance issuer that offers individual
251	health insurance must elect to become a risk-assuming carrier or
252	a reinsuring carrier for purposes of this section. Each such
253	issuer must make an initial election, binding through December
254	31, 1999. The issuer's initial election must be made no later
255	than October 31, 1997. By October 31, 1997, all issuers must
256	file a final election, which is binding for 2 years, from
257	January 1, 1998, through December 31, 1999, after whichan
258	election that shall be binding indefinitely or until modified or
259	withdrawnfor a period of 5 years. The department may permit an
260	issuer to modify its election at any time for good cause shown,
261	after a hearing.
262	(6) ELECTION PROCESS TO BECOME A RISK-ASSUMING CARRIER.--
263	(c) The department shall provide public notice of an
264	issuer's filing adesignation of election under this subsection
265	to become a risk-assuming carrier and shall provide at least a
266	21-day period for public comment upon receipt of such filing
267	prior to making a decision on the election. The department shall
268	hold a hearing on the election at the request of the issuer.
269	(7) INDIVIDUAL HEALTH REINSURANCE PROGRAM.--
270	(b) A reinsuring carrier may reinsure with the program
271	coverage of an eligible individual, subject to each of the
272	following provisions:
273	1. A reinsuring carrier may reinsure an eligible
274	individual within 9060days after commencement of the coverage
275	of the eligible individual.
276	2. The program may not reimburse a participating carrier
277	with respect to the claims of a reinsured eligible individual
278	until the carrier has paid incurred claims of an amount equal to
279	the participating carrier’s selected deductible levelat least
280	$5,000 in a calendar year for benefits covered by the program.
281	In addition, the reinsuring carrier is responsible for 10
282	percent of the next $50,000 and 5 percent of the next $100,000
283	of incurred claims during a calendar year, and the program shall
284	reinsure the remainder.
285	3. The board shall annually adjust the initial level of
286	claims and the maximum limit to be retained by the carrier to
287	reflect increases in costs and utilization within the standard
288	market for health benefit plans within the state. The adjustment
289	may not be less than the annual change in the medical component
290	of the "Commerce Price Index for All Urban Consumers" of the
291	Bureau of Labor Statistics of the United States Department of
292	Labor, unless the board proposes and the department approves a
293	lower adjustment factor.
294	4. A reinsuring carrier may terminate reinsurance for all
295	reinsured eligible individuals on any plan anniversary.
296	5. The premium rate charged for reinsurance by the program
297	to a health maintenance organization that is approved by the
298	Secretary of Health and Human Services as a federally qualified
299	health maintenance organization pursuant to 42 U.S.C. s.
300	300e(c)(2)(A) and that, as such, is subject to requirements that
301	limit the amount of risk that may be ceded to the program, which
302	requirements are more restrictive than subparagraph 2., shall be
303	reduced by an amount equal to that portion of the risk, if any,
304	which exceeds the amount set forth in subparagraph 2., which may
305	not be ceded to the program.
306	6. The board may consider adjustments to the premium rates
307	charged for reinsurance by the program or carriers that use
308	effective cost-containment measures, including high-cost case
309	management, as defined by the board.
310	7. A reinsuring carrier shall apply its case-management
311	and claims-handling techniques, including, but not limited to,
312	utilization review, individual case management, preferred
313	provider provisions, other managed-care provisions, or methods
314	of operation consistently with both reinsured business and
315	nonreinsured business.
316	(c)1. The board, as part of the plan of operation, shall
317	establish a methodology for determining premium rates to be
318	charged by the program for reinsuring eligible individuals
319	pursuant to this section. The methodology must include a system
320	for classifying individuals which reflects the types of case
321	characteristics commonly used by carriers in this state. The
322	methodology must provide for the development of basic
323	reinsurance premium rates, which shall be multiplied by the
324	factors set for them in this paragraph to determine the premium
325	rates for the program. The basic reinsurance premium rates shall
326	be established by the board, subject to the approval of the
327	department, and shall be set at levels that reasonably
328	approximate gross premiums charged to eligible individuals for
329	individual health insurance by health insurance issuers. The
330	premium rates set by the board may vary by geographical area, as
331	determined under this section, to reflect differences in cost.
332	An eligible individual may be reinsured for a rate that is five
333	times the rate established by the board.
334	2. The board shall periodically review the methodology
335	established, including the system of classification and any
336	rating factors, to ensure that it reasonably reflects the claims
337	experience of the program. The board may propose changes to the
338	rates that are subject to the approval of the department.
339	(e)1. Before SeptemberMarch1 of each calendar year, the
340	board shall determine and report to the department the program
341	net loss in the individual account for the previous year,
342	including administrative expenses for that year and the incurred
343	losses for that year, taking into account investment income and
344	other appropriate gains and losses.
345	2. Any net loss in the individual account for the year
346	shall be recouped by assessing the carriers as follows:
347	a. The operating losses of the program shall be assessed
348	in the following order subject to the specified limitations. The
349	first tier of assessments shall be made against reinsuring
350	carriers in an amount that may not exceed 5 percent of each
351	reinsuring carrier's premiums for individual health insurance.
352	If such assessments have been collected and additional moneys
353	are needed, the board shall make a second tier of assessments in
354	an amount that may not exceed 0.5 percent of each carrier's
355	health benefit plan premiums.
356	b. Except as provided in paragraph (f), risk-assuming
357	carriers are exempt from all assessments authorized pursuant to
358	this section. The amount paid by a reinsuring carrier for the
359	first tier of assessments shall be credited against any
360	additional assessments made.
361	c. The board shall equitably assess reinsuring carriers
362	for operating losses of the individual account based on market
363	share. The board shall annually assess each carrier a portion of
364	the operating losses of the individual account. The first tier
365	of assessments shall be determined by multiplying the operating
366	losses by a fraction, the numerator of which equals the
367	reinsuring carrier's earned premium pertaining to direct
368	writings of individual health insurance in the state during the
369	calendar year for which the assessment is levied, and the
370	denominator of which equals the total of all such premiums
371	earned by reinsuring carriers in the state during that calendar
372	year. The second tier of assessments shall be based on the
373	premiums that all carriers, except risk-assuming carriers,
374	earned on all health benefit plans written in this state. The
375	board may levy interim assessments against reinsuring carriers
376	to ensure the financial ability of the plan to cover claims
377	expenses and administrative expenses paid or estimated to be
378	paid in the operation of the plan for the calendar year prior to
379	the association's anticipated receipt of annual assessments for
380	that calendar year. Any interim assessment is due and payable
381	within 30 days after receipt by a carrier of the interim
382	assessment notice. Interim assessment payments shall be credited
383	against the carrier's annual assessment. Health benefit plan
384	premiums and benefits paid by a carrier that are less than an
385	amount determined by the board to justify the cost of collection
386	may not be considered for purposes of determining assessments.
387	d. Subject to the approval of the department, the board
388	shall adjust the assessment formula for reinsuring carriers that
389	are approved as federally qualified health maintenance
390	organizations by the Secretary of Health and Human Services
391	pursuant to 42 U.S.C. s. 300e(c)(2)(A) to the extent, if any,
392	that restrictions are placed on them which are not imposed on
393	other carriers.
394	3. Before SeptemberMarch1 of each year, the board shall
395	determine and file with the department an estimate of the
396	assessments needed to fund the losses incurred by the program in
397	the individual account for the previous calendar year.
398	4. If the board determines that the assessments needed to
399	fund the losses incurred by the program in the individual
400	account for the previous calendar year will exceed the amount
401	specified in subparagraph 2., the board shall evaluate the
402	operation of the program and report its findings and
403	recommendations to the department in the format established in
404	s. 627.6699(11) for the comparable report for the small employer
405	reinsurance program.
406	Section 7. Subsection (4) of section 627.651, Florida
407	Statutes, is amended to read:
408	627.651 Group contracts and plans of self-insurance must
409	meet group requirements.--
410	(4) This section does not apply to any plan which is
411	established or maintained by an individual employer in
412	accordance with the Employee Retirement Income Security Act of
413	1974, Pub. L. No. 93-406, or to a multiple-employer welfare
414	arrangement as defined in s. 624.437(1), except that a multiple-
415	employer welfare arrangement shall comply with ss. 627.419,
416	627.657, 627.6575, 627.6578, 627.6579, 627.6612, 627.66121,
417	627.66122, 627.6615, 627.6616, and 627.662(8)(7). This
418	subsection does not allow an authorized insurer to issue a group
419	health insurance policy or certificate which does not comply
420	with this part.
421	Section 8. Section 627.662, Florida Statutes, is amended
422	to read:
423	627.662 Other provisions applicable.--The following
424	provisions apply to group health insurance, blanket health
425	insurance, and franchise health insurance:
426	(1) Section 627.569, relating to use of dividends,
427	refunds, rate reductions, commissions, and service fees.
428	(2) Section 627.602(1)(f) and (2), relating to
429	identification numbers and statement of deductible provisions.
430	(3) Section 627.6044, relating to the use of specific
431	methodology for payment of claims.
432	(4)(3)Section 627.635, relating to excess insurance.
433	(5)(4)Section 627.638, relating to direct payment for
434	hospital or medical services.
435	(6)(5)Section 627.640, relating to filing and
436	classification of rates.
437	(7)(6)Section 627.613, relating to timely payment of
438	claims, or s. 627.6131, relating to payment of claims, whichever
439	is applicable.
440	(8)(7)Section 627.645(1), relating to denial of claims.
441	(9)(8)Section 627.6471, relating to preferred provider
442	organizations.
443	(10)(9)Section 627.6472, relating to exclusive provider
444	organizations.
445	(11)(10)Section 627.6473, relating to combined preferred
446	provider and exclusive provider policies.
447	(12)(11)Section 627.6474, relating to provider contracts.
448	Section 9. Subsection (6) of section 627.667, Florida
449	Statutes, is amended to read:
450	627.667 Extension of benefits.--
451	(6) This section also applies to holders of group
452	certificates which are renewed, delivered, or issued for
453	delivery to residents of this state under group policies
454	effectuated or delivered outside this state, unless a succeeding
455	carrier under a group policy has agreed to assume liability for
456	the benefits.
457	Section 10. Paragraph (e) of subsection (5) of section
458	627.6692, Florida Statutes, is amended to read:
459	627.6692 Florida Health Insurance Coverage Continuation
460	Act.--
461	(5) CONTINUATION OF COVERAGE UNDER GROUP HEALTH PLANS.--
462	(e)1. A covered employee or other qualified beneficiary
463	who wishes continuation of coverage must pay the initial premium
464	and elect such continuation in writing to the insurance carrier
465	issuing the employer's group health plan within 6330days after
466	receiving notice from the insurance carrier under paragraph (d).
467	Subsequent premiums are due by the grace period expiration date.
468	The insurance carrier or the insurance carrier's designee shall
469	process all elections promptly and provide coverage
470	retroactively to the date coverage would otherwise have
471	terminated. The premium due shall be for the period beginning on
472	the date coverage would have otherwise terminated due to the
473	qualifying event. The first premium payment must include the
474	coverage paid to the end of the month in which the first payment
475	is made. After the election, the insurance carrier must bill the
476	qualified beneficiary for premiums once each month, with a due
477	date on the first of the month of coverage and allowing a 30-day
478	grace period for payment.
479	2. Except as otherwise specified in an election, any
480	election by a qualified beneficiary shall be deemed to include
481	an election of continuation of coverage on behalf of any other
482	qualified beneficiary residing in the same household who would
483	lose coverage under the group health plan by reason of a
484	qualifying event. This subparagraph does not preclude a
485	qualified beneficiary from electing continuation of coverage on
486	behalf of any other qualified beneficiary.
487	Section 11. Paragraphs (g), (h), (i), and (u) of
488	subsection (3), paragraph (c) of subsection (5), paragraph (a)
489	of subsection (9), paragraph (d) of subsection (10), and
490	paragraphs (f), (g), (h), and (j) of subsection (11) of section
491	627.6699, Florida Statutes, are amended to read:
492	627.6699 Employee Health Care Access Act.--
493	(3) DEFINITIONS.--As used in this section, the term:
494	(g) "Dependent" has the same meaning as that provided in
495	s. 627.6562means the spouse or child of an eligible employee,
496	subject to the applicable terms of the health benefit plan
497	covering that employee.
498	(h) "Eligible employee" means an employee who works full
499	time, having a normal workweek of 25 or more hours, who is paid
500	wages or a salary at least equal to the federal minimum hourly
501	wage applicable to such employee,and who has met any applicable
502	waiting-period requirements or other requirements of this act.
503	The term includes a self-employed individual, a sole proprietor,
504	a partner of a partnership, or an independent contractor, if the
505	sole proprietor, partner, or independent contractor is included
506	as an employee under a health benefit plan of a small employer,
507	but does not include a part-time, temporary, or substitute
508	employee.
509	(i) "Established geographic area" means the county or
510	counties, or any portion of a county or counties,within which
511	the carrier provides or arranges for health care services to be
512	available to its insureds, members, or subscribers.
513	(u) "Self-employed individual" means an individual or sole
514	proprietor who derives his or her income from a trade or
515	business carried on by the individual or sole proprietor which
516	necessitates that the individual file federal income tax forms
517	with supporting schedules and accompanying income reporting
518	forms or federal income tax extensions of time to file forms
519	with the Internal Revenue Service for the most recent tax year
520	results in taxable income as indicated on IRS Form 1040,
521	schedule C or F, and which generated taxable income in one of
522	the 2 previous years.
523	(5) AVAILABILITY OF COVERAGE.--
524	(c) Every small employer carrier must, as a condition of
525	transacting business in this state:
526	1. Beginning July 1, 2000, offer and issue all small
527	employer health benefit plans on a guaranteed-issue basis to
528	every eligible small employer, with 2 to 50 eligible employees,
529	that elects to be covered under such plan, agrees to make the
530	required premium payments, and satisfies the other provisions of
531	the plan. A rider for additional or increased benefits may be
532	medically underwritten and may only be added to the standard
533	health benefit plan. The increased rate charged for the
534	additional or increased benefit must be rated in accordance with
535	this section.
536	2. Beginning July 1, 2000, and until July 31, 2001, offer
537	and issue basic and standard small employer health benefit plans
538	on a guaranteed-issue basis to every eligible small employer
539	which is eligible for guaranteed renewal, has less than two
540	eligible employees, is not formed primarily for the purpose of
541	buying health insurance, elects to be covered under such plan,
542	agrees to make the required premium payments, and satisfies the
543	other provisions of the plan. A rider for additional or
544	increased benefits may be medically underwritten and may be
545	added only to the standard benefit plan. The increased rate
546	charged for the additional or increased benefit must be rated in
547	accordance with this section. For purposes of this subparagraph,
548	a person, his or her spouse, and his or her dependent children
549	shall constitute a single eligible employee if that person and
550	spouse are employed by the same small employer and either one
551	has a normal work week of less than 25 hours.
552	3.a.Beginning August 1, 2001, offer and issue basic and
553	standard small employer health benefit plans on a guaranteed-
554	issue basis, during a 31-day open enrollment period of August 1
555	through August 31 of each year, to every eligible small
556	employer, with fewer than two eligible employees, which small
557	employer is not formed primarily for the purpose of buying
558	health insurance and which elects to be covered under such plan,
559	agrees to make the required premium payments, and satisfies the
560	other provisions of the plan. Coverage provided under this sub-
561	subparagraphsubparagraphshall begin on October 1 of the same
562	year as the date of enrollment, unless the small employer
563	carrier and the small employer agree to a different date. A
564	rider for additional or increased benefits may be medically
565	underwritten and may only be added to the standard health
566	benefit plan. The increased rate charged for the additional or
567	increased benefit must be rated in accordance with this section.
568	For purposes of this sub-subparagraphsubparagraph, a person,
569	his or her spouse, and his or her dependent children constitute
570	a single eligible employee if that person and spouse are
571	employed by the same small employer and either that person or
572	his or her spouse has a normal work week of less than 25 hours.
573	b. Notwithstanding the restrictions set forth in sub-
574	subparagraph a., when a small employer group is losing coverage
575	because a carrier is exercising the provisions of s.
576	627.6571(3)(b) or s. 641.31074(3)(b), the eligible small
577	employer, as defined in sub-subparagraph a., shall be entitled
578	to enroll with another carrier offering small employer coverage
579	within 63 days after the notice of termination or the
580	termination date of the prior coverage, whichever is later.
581	Coverage provided under this sub-subparagraph shall begin
582	immediately upon enrollment unless the small employer carrier
583	and the small employer agree to a different date.
584	4. This paragraph does not limit a carrier's ability to
585	offer other health benefit plans to small employers if the
586	standard and basic health benefit plans are offered and
587	rejected.
588	(9) SMALL EMPLOYER CARRIER'S ELECTION TO BECOME A RISK-
589	ASSUMING CARRIER OR A REINSURING CARRIER.--
590	(a) A small employer carrier must elect to become either a
591	risk-assuming carrier or a reinsuring carrier. Each small
592	employer carrier must make an initial election, binding through
593	January 1, 1994. The carrier's initial election must be made no
594	later than October 31, 1992. By October 31, 1993, all small
595	employer carriers must file a final election, which is binding
596	for 2 years, from January 1, 1994, through December 31, 1995,
597	after which an election shall be binding for a period of 5
598	years.Any carrier that is not a small employer carrier on
599	October 31, 1992, and intends to become a small employer carrier
600	after October 31, 1992, must file its designation when it files
601	the forms and rates it intends to use for small employer group
602	health insurance; such designation shall be binding indefinitely
603	or until modified or withdrawnfor 2 years after the date of
604	approval of the forms and rates, and any subsequent designation
605	is binding for 5 years. The department may permit a carrier to
606	modify its election at any time for good cause shown, after a
607	hearing.
608	(10) ELECTION PROCESS TO BECOME A RISK-ASSUMING CARRIER.--
609	(d) The department shall provide public notice of a small
610	employer carrier's filing adesignation of election under
611	subsection (9) to become a risk-assuming carrier and shall
612	provide at least a 21-day period for public comment upon receipt
613	of such filingprior to making a decision on the election. The
614	department shall hold a hearing on the election at the request
615	of the carrier.
616	(11) SMALL EMPLOYER HEALTH REINSURANCE PROGRAM.--
617	(f) The program has the general powers and authority
618	granted under the laws of this state to insurance companies and
619	health maintenance organizations licensed to transact business,
620	except the power to issue health benefit plans directly to
621	groups or individuals. In addition thereto, the program has
622	specific authority to:
623	1. Enter into contracts as necessary or proper to carry
624	out the provisions and purposes of this act, including the
625	authority to enter into contracts with similar programs of other
626	states for the joint performance of common functions or with
627	persons or other organizations for the performance of
628	administrative functions.
629	2. Sue or be sued, including taking any legal action
630	necessary or proper for recovering any assessments and penalties
631	for, on behalf of, or against the program or any carrier.
632	3. Take any legal action necessary to avoid the payment of
633	improper claims against the program.
634	4. Issue reinsurance policies, in accordance with the
635	requirements of this act.
636	5. Establish rules, conditions, and procedures for
637	reinsurance risks under the program participation.
638	6. Establish actuarial functions as appropriate for the
639	operation of the program.
640	7. Assess participating carriers in accordance with
641	paragraph (j), and make advance interim assessments as may be
642	reasonable and necessary for organizational and interim
643	operating expenses. Interim assessments shall be credited as
644	offsets against any regular assessments due following the close
645	of the calendar year.
646	8. Appoint appropriate legal, actuarial, and other
647	committees as necessary to provide technical assistance in the
648	operation of the program, and in any other function within the
649	authority of the program.
650	9. Borrow money to effect the purposes of the program. Any
651	notes or other evidences of indebtedness of the program which
652	are not in default constitute legal investments for carriers and
653	may be carried as admitted assets.
654	10. To the extent necessary, increase the $5,000
655	deductible reinsurance requirement to adjust for the effects of
656	inflation. The program may evaluate the desirability of
657	establishing different levels of deductibles. If different
658	levels of deductibles are established, such levels and the
659	resulting premiums shall be approved by the department.
660	(g) A reinsuring carrier may reinsure with the program
661	coverage of an eligible employee of a small employer, or any
662	dependent of such an employee, subject to each of the following
663	provisions:
664	1. With respect to a standard and basic health care plan,
665	the program maymustreinsure the level of coverage provided;
666	and, with respect to any other plan, the program maymust
667	reinsure the coverage up to, but not exceeding, the level of
668	coverage provided under the standard and basic health care plan.
669	As an alternative to reinsuring the level of coverage provided
670	under the standard and basic health care plan, the program may
671	develop alternate levels of reinsurance designed to coordinate
672	with a reinsuring carrier’s existing reinsurance. The levels of
673	reinsurance and resulting premiums must be approved by the
674	department.
675	2. Except in the case of a late enrollee, a reinsuring
676	carrier may reinsure an eligible employee or dependent within 60
677	days after the commencement of the coverage of the small
678	employer. A newly employed eligible employee or dependent of a
679	small employer may be reinsured within 60 days after the
680	commencement of his or her coverage.
681	3. A small employer carrier may reinsure an entire
682	employer group within 60 days after the commencement of the
683	group's coverage under the plan. The carrier may choose to
684	reinsure newly eligible employees and dependents of the
685	reinsured group pursuant to subparagraph 1.
686	4. The program may evaluate the option of allowing a small
687	employer carrier to reinsure an entire employer group or an
688	eligible employee at the first or subsequent renewal date. Any
689	such option and the resulting premium must be approved by the
690	department.
691	5.4.The program may not reimburse a participating carrier
692	with respect to the claims of a reinsured employee or dependent
693	until the carrier has paid incurred claims of an amount equal to
694	the participating carrier’s selected deductible levelat least
695	$5,000 in a calendar year for benefits covered by the program.
696	In addition, the reinsuring carrier shall be responsible for 10
697	percent of the next $50,000 and 5 percent of the next $100,000
698	of incurred claims during a calendar year and the program shall
699	reinsure the remainder.
700	6.5.The board annually shall adjust the initial level of
701	claims and the maximum limit to be retained by the carrier to
702	reflect increases in costs and utilization within the standard
703	market for health benefit plans within the state. The adjustment
704	shall not be less than the annual change in the medical
705	component of the "Consumer Price Index for All Urban Consumers"
706	of the Bureau of Labor Statistics of the Department of Labor,
707	unless the board proposes and the department approves a lower
708	adjustment factor.
709	7.6.A small employer carrier may terminate reinsurance
710	for all reinsured employees or dependents on any plan
711	anniversary.
712	8.7.The premium rate charged for reinsurance by the
713	program to a health maintenance organization that is approved by
714	the Secretary of Health and Human Services as a federally
715	qualified health maintenance organization pursuant to 42 U.S.C.
716	s. 300e(c)(2)(A) and that, as such, is subject to requirements
717	that limit the amount of risk that may be ceded to the program,
718	which requirements are more restrictive than subparagraph 5.4.,
719	shall be reduced by an amount equal to that portion of the risk,
720	if any, which exceeds the amount set forth in subparagraph 5.4.
721	which may not be ceded to the program.
722	9.8.The board may consider adjustments to the premium
723	rates charged for reinsurance by the program for carriers that
724	use effective cost containment measures, including high-cost
725	case management, as defined by the board.
726	10.9.A reinsuring carrier shall apply its case-management
727	and claims-handling techniques, including, but not limited to,
728	utilization review, individual case management, preferred
729	provider provisions, other managed care provisions or methods of
730	operation, consistently with both reinsured business and
731	nonreinsured business.
732	(h)1. The board, as part of the plan of operation, shall
733	establish a methodology for determining premium rates to be
734	charged by the program for reinsuring small employers and
735	individuals pursuant to this section. The methodology shall
736	include a system for classification of small employers that
737	reflects the types of case characteristics commonly used by
738	small employer carriers in the state. The methodology shall
739	provide for the development of basic reinsurance premium rates,
740	which shall be multiplied by the factors set for them in this
741	paragraph to determine the premium rates for the program. The
742	basic reinsurance premium rates shall be established by the
743	board, subject to the approval of the department, and shall be
744	set at levels which reasonably approximate gross premiums
745	charged to small employers by small employer carriers for health
746	benefit plans with benefits similar to the standard and basic
747	health benefit plan. The premium rates set by the board may vary
748	by geographical area, as determined under this section, to
749	reflect differences in cost. The multiplying factors must be
750	established as follows:
751	a. The entire group may be reinsured for a rate that is
752	1.5 times the rate established by the board.
753	b. An eligible employee or dependent may be reinsured for
754	a rate that is 5 times the rate established by the board.
755	2. The board periodically shall review the methodology
756	established, including the system of classification and any
757	rating factors, to assure that it reasonably reflects the claims
758	experience of the program. The board may propose changes to the
759	rates which shall be subject to the approval of the department.
760	(j)1. Before SeptemberMarch1 of each calendar year, the
761	board shall determine and report to the department the program
762	net loss for the previous year, including administrative
763	expenses for that year, and the incurred losses for the year,
764	taking into account investment income and other appropriate
765	gains and losses.
766	2. Any net loss for the year shall be recouped by
767	assessment of the carriers, as follows:
768	a. The operating losses of the program shall be assessed
769	in the following order subject to the specified limitations. The
770	first tier of assessments shall be made against reinsuring
771	carriers in an amount which shall not exceed 5 percent of each
772	reinsuring carrier's premiums from health benefit plans covering
773	small employers. If such assessments have been collected and
774	additional moneys are needed, the board shall make a second tier
775	of assessments in an amount which shall not exceed 0.5 percent
776	of each carrier's health benefit plan premiums. Except as
777	provided in paragraph (n), risk-assuming carriers are exempt
778	from all assessments authorized pursuant to this section. The
779	amount paid by a reinsuring carrier for the first tier of
780	assessments shall be credited against any additional assessments
781	made.
782	b. The board shall equitably assess carriers for operating
783	losses of the plan based on market share. The board shall
784	annually assess each carrier a portion of the operating losses
785	of the plan. The first tier of assessments shall be determined
786	by multiplying the operating losses by a fraction, the numerator
787	of which equals the reinsuring carrier's earned premium
788	pertaining to direct writings of small employer health benefit
789	plans in the state during the calendar year for which the
790	assessment is levied, and the denominator of which equals the
791	total of all such premiums earned by reinsuring carriers in the
792	state during that calendar year. The second tier of assessments
793	shall be based on the premiums that all carriers, except risk-
794	assuming carriers, earned on all health benefit plans written in
795	this state. The board may levy interim assessments against
796	carriers to ensure the financial ability of the plan to cover
797	claims expenses and administrative expenses paid or estimated to
798	be paid in the operation of the plan for the calendar year prior
799	to the association's anticipated receipt of annual assessments
800	for that calendar year. Any interim assessment is due and
801	payable within 30 days after receipt by a carrier of the interim
802	assessment notice. Interim assessment payments shall be credited
803	against the carrier's annual assessment. Health benefit plan
804	premiums and benefits paid by a carrier that are less than an
805	amount determined by the board to justify the cost of collection
806	may not be considered for purposes of determining assessments.
807	c. Subject to the approval of the department, the board
808	shall make an adjustment to the assessment formula for
809	reinsuring carriers that are approved as federally qualified
810	health maintenance organizations by the Secretary of Health and
811	Human Services pursuant to 42 U.S.C. s. 300e(c)(2)(A) to the
812	extent, if any, that restrictions are placed on them that are
813	not imposed on other small employer carriers.
814	3. Before SeptemberMarch1 of each year, the board shall
815	determine and file with the department an estimate of the
816	assessments needed to fund the losses incurred by the program in
817	the previous calendar year.
818	4. If the board determines that the assessments needed to
819	fund the losses incurred by the program in the previous calendar
820	year will exceed the amount specified in subparagraph 2., the
821	board shall evaluate the operation of the program and report its
822	findings, including any recommendations for changes to the plan
823	of operation, to the department within 24090days following the
824	end of the calendar year in which the losses were incurred. The
825	evaluation shall include an estimate of future assessments, the
826	administrative costs of the program, the appropriateness of the
827	premiums charged and the level of carrier retention under the
828	program, and the costs of coverage for small employers. If the
829	board fails to file a report with the department within 24090
830	days following the end of the applicable calendar year, the
831	department may evaluate the operations of the program and
832	implement such amendments to the plan of operation the
833	department deems necessary to reduce future losses and
834	assessments.
835	5. If assessments exceed the amount of the actual losses
836	and administrative expenses of the program, the excess shall be
837	held as interest and used by the board to offset future losses
838	or to reduce program premiums. As used in this paragraph, the
839	term "future losses" includes reserves for incurred but not
840	reported claims.
841	6. Each carrier's proportion of the assessment shall be
842	determined annually by the board, based on annual statements and
843	other reports considered necessary by the board and filed by the
844	carriers with the board.
845	7. Provision shall be made in the plan of operation for
846	the imposition of an interest penalty for late payment of an
847	assessment.
848	8. A carrier may seek, from the commissioner, a deferment,
849	in whole or in part, from any assessment made by the board. The
850	department may defer, in whole or in part, the assessment of a
851	carrier if, in the opinion of the department, the payment of the
852	assessment would place the carrier in a financially impaired
853	condition. If an assessment against a carrier is deferred, in
854	whole or in part, the amount by which the assessment is deferred
855	may be assessed against the other carriers in a manner
856	consistent with the basis for assessment set forth in this
857	section. The carrier receiving such deferment remains liable to
858	the program for the amount deferred and is prohibited from
859	reinsuring any individuals or groups in the program if it fails
860	to pay assessments.
861	Section 12. Section 627.911, Florida Statutes, is amended
862	to read:
863	627.911 Scope of this part.--Any insurer or health
864	maintenance organizationtransacting insurance in this state
865	shall report information as required by this part.
866	Section 13. Section 627.9175, Florida Statutes, is amended
867	to read:
868	627.9175 Reports of information on health insurance.--
869	(1) Each authorized health insurer or health maintenance
870	organization shall submit annually to the department information
871	concerningas to policies of individual health insurance
872	coverage being issued or currently in force in this state. The
873	information shall include information related to premium, number
874	of policies, and covered lives for such policies and other
875	information necessary to analyze trends in enrollment, premiums,
876	and claim costs.
877	(2) The required information shall be broken down by
878	market segment, to include:
879	(a) Health insurance issuer, company, contact person, or
880	agent.
881	(b) All health insurance products issued or in force,
882	including, but not limited to:
883	1. Direct premiums earned.
884	2. Direct losses incurred.
885	3. Direct premiums earned for new business issued during
886	the year.
887	4. Number of policies.
888	5. Number of certificates.
889	6. Number of total covered lives.
890	(a) A summary of typical benefits, exclusions, and
891	limitations for each type of individual policy form currently
892	being issued in the state. The summary shall include, as
893	appropriate:
894	1. The deductible amount;
895	2. The coinsurance percentage;
896	3. The out-of-pocket maximum;
897	4. Outpatient benefits;
898	5. Inpatient benefits; and
899	6. Any exclusions for preexisting conditions.
900
901	The department shall determine other appropriate benefits,
902	exclusions, and limitations to be reported for inclusion in the
903	consumer's guide published pursuant to this section.
904	(b) A schedule of rates for each type of individual policy
905	form reflecting typical variations by age, sex, region of the
906	state, or any other applicable factor which is in use and is
907	determined to be appropriate for inclusion by the department.
908
909	The department shall provide by rule a uniform format for the
910	submission of this information in order to allow for meaningful
911	comparisons of premiums charged for comparable benefits.
912	(3) The department may adopt rules to administer this
913	section, including, but not limited to, rules governing
914	compliance and provisions implementing electronic methodologies
915	for use in furnishing such records or documents. The commission
916	may by rule specify a uniform format for the submission of this
917	information in order to allow for meaningful comparisonsshall
918	publish annually a consumer's guide which summarizes and
919	compares the information required to be reported under this
920	subsection.
921	(2)(a) Every insurer transacting health insurance in this
922	state shall report annually to the department, not later than
923	April 1, information relating to any measure the insurer has
924	implemented or proposes to implement during the next calendar
925	year for the purpose of containing health insurance costs or
926	cost increases. The reports shall identify each measure and the
927	forms to which the measure is applied, shall provide an
928	explanation as to how the measure is used, and shall provide an
929	estimate of the cost effect of the measure.
930	(b) The department shall promulgate forms to be used by
931	insurers in reporting information pursuant to this subsection
932	and shall utilize such forms to analyze the effects of health
933	care cost containment programs used by health insurers in this
934	state.
935	(c) The department shall analyze the data reported under
936	this subsection and shall annually make available to the public
937	a summary of its findings as to the types of cost containment
938	measures reported and the estimated effect of these measures.
939	Section 14. Section 627.9403, Florida Statutes, is amended
940	to read:
941	627.9403 Scope.--The provisions of this part shall apply
942	to long-term care insurance policies delivered or issued for
943	delivery in this state, and to policies delivered or issued for
944	delivery outside this state to the extent provided in s.
945	627.9406, by an insurer, a fraternal benefit society as defined
946	in s. 632.601, a health maintenance organization as defined in
947	s. 641.19, a prepaid health clinic as defined in s. 641.402, or
948	a multiple-employer welfare arrangement as defined in s.
949	624.437. A policy which is advertised, marketed, or offered as a
950	long-term care policy and as a Medicare supplement policy shall
951	meet the requirements of this part and the requirements of ss.
952	627.671-627.675 and, to the extent of a conflict, be subject to
953	the requirement that is more favorable to the policyholder or
954	certificateholder. The provisions of this part shall not apply
955	to a continuing care contract issued pursuant to chapter 651 and
956	shall not apply to guaranteed renewable policies issued prior to
957	October 1, 1988. Any limited benefit policy that limits coverage
958	to care in a nursing home or to one or more lower levels of care
959	required or authorized to be provided by this part or by
960	department rule must meet all requirements of this part that
961	apply to long-term care insurance policies, except ss.
962	627.9407(3)(c) and (d), (9), (10)(f), and (12) and 627.94073(2).
963	If the limited benefit policy does not provide coverage for care
964	in a nursing home, but does provide coverage for one or more
965	lower levels of care, the policy shall also be exempt from the
966	requirements of s. 627.9407(3)(d).
967	Section 15. Paragraph (b) of subsection (1) of section
968	641.185, Florida Statutes, is amended to read:
969	641.185 Health maintenance organization subscriber
970	protections.--
971	(1) With respect to the provisions of this part and part
972	III, the principles expressed in the following statements shall
973	serve as standards to be followed by the Department of Insurance
974	and the Agency for Health Care Administration in exercising
975	their powers and duties, in exercising administrative
976	discretion, in administrative interpretations of the law, in
977	enforcing its provisions, and in adopting rules:
978	(b) A health maintenance organization subscriber should
979	receive quality health care from a broad panel of providers,
980	including referrals, preventive care pursuant to s. 641.402(1),
981	emergency screening and services pursuant to ss. 641.31(13)(12)
982	and 641.513, and second opinions pursuant to s. 641.51.
983	Section 16. Subsections (9) through (17) of section
984	641.31, Florida Statutes, are amended to read:
985	641.31 Health maintenance contracts.--
986	(9)(a)1. If a health maintenance organization offers
987	coverage for dependent children of the subscriber, the contract
988	must cover a dependent child of the subscriber at least until
989	the end of the calendar year in which the child reaches the age
990	of 25, if the child meets all of the following:
991	a. The child is dependent upon the subscriber for support.
992	b. The child is living in the household of the subscriber,
993	or the child is a full-time or part-time student.
994	2. Nothing in this paragraph affects or preempts a health
995	maintenance organization's right to medically underwrite or
996	charge the appropriate premium.
997	(b)1. A contract that provides coverage for a family
998	member of the subscriber shall, as to such family member's
999	coverage, provide that benefits applicable to children of the
1000	subscriber also apply to an adopted child or a foster child of
1001	the subscriber placed in compliance with chapter 63 from the
1002	moment of placement in the residence of the subscriber. Except
1003	in the case of a foster child, the contract may not exclude
1004	coverage for any preexisting condition of the child. In the case
1005	of a newborn child, coverage begins at the moment of birth if a
1006	written agreement to adopt such child has been entered into by
1007	the subscriber prior to the birth of the child, whether or not
1008	the agreement is enforceable. This section does not require
1009	coverage for an adopted child who is not ultimately placed in
1010	the residence of the subscriber in compliance with chapter 63.
1011	2. A contract may require the subscriber to notify the
1012	health maintenance organization of the birth or placement of an
1013	adopted child within a specified time period of not less than 30
1014	days after the birth or placement in the residence of a child
1015	adopted by the subscriber. If timely notice is given, the health
1016	maintenance organization may not charge an additional premium
1017	for coverage of the child for the duration of the notice period.
1018	If timely notice is not given, the health maintenance
1019	organization may charge an additional premium from the date of
1020	birth or placement. If notice is given within 60 days after the
1021	birth or placement of the child, the health maintenance
1022	organization may not deny coverage for the child due to the
1023	failure of the subscriber to timely notify the health
1024	maintenance organization of the birth or placement of the child.
1025	3. If the contract does not require the subscriber to
1026	notify the health maintenance organization of the birth or
1027	placement of an adopted child within a specified time period,
1028	the health maintenance organization may not deny coverage for
1029	such child or retroactively charge the subscriber an additional
1030	premium for such child. However, the health maintenance
1031	organization may prospectively charge the subscriber an
1032	additional premium for the child if the health maintenance
1033	organization provides at least 45 days' notice of the additional
1034	premium required.
1035	4. In order to increase access to postnatal, infant, and
1036	pediatric health care for all children placed in court-ordered
1037	custody, including foster children, all health maintenance
1038	organization contracts that provide coverage for a family member
1039	of the subscriber shall, as to such family member's coverage,
1040	provide that benefits applicable for children shall be payable
1041	with respect to a foster child or other child in court-ordered,
1042	temporary, or other custody of the subscriber.
1043	(10) A contract that provides that coverage of a dependent
1044	child shall terminate upon attainment of the limiting age for
1045	dependent children specified in the contract shall also provide
1046	in substance that attainment of the limiting age does not
1047	terminate the coverage of the child while the child continues to
1048	be:
1049	(a) Incapable of self-sustaining employment by reason of
1050	mental retardation or physical handicap.
1051	(b) Chiefly dependent upon the subscriber for support and
1052	maintenance.
1053
1054	If a claim is denied under a contract for the stated reason that
1055	the child has attained the limiting age for dependent children
1056	specified in the contract, the notice of denial must state that
1057	the subscriber has the burden of establishing that the child
1058	continues to meet the criteria specified in paragraphs (a) and
1059	(b).All health maintenance contracts that provide coverage,
1060	benefits, or services for a member of the family of the
1061	subscriber must, as to such family member's coverage, benefits,
1062	or services, provide also that the coverage, benefits, or
1063	services applicable for children must be provided with respect
1064	to a newborn child of the subscriber, or covered family member
1065	of the subscriber, from the moment of birth. However, with
1066	respect to a newborn child of a covered family member other than
1067	the spouse of the insured or subscriber, the coverage for the
1068	newborn child terminates 18 months after the birth of the
1069	newborn child. The coverage, benefits, or services for newborn
1070	children must consist of coverage for injury or sickness,
1071	including the necessary care or treatment of medically diagnosed
1072	congenital defects, birth abnormalities, or prematurity, and
1073	transportation costs of the newborn to and from the nearest
1074	appropriate facility appropriately staffed and equipped to treat
1075	the newborn's condition, when such transportation is certified
1076	by the attending physician as medically necessary to protect the
1077	health and safety of the newborn child.
1078	(a) A contract may require the subscriber to notify the
1079	plan of the birth of a child within a time period, as specified
1080	in the contract, of not less than 30 days after the birth, or a
1081	contract may require the preenrollment of a newborn prior to
1082	birth. However, if timely notice is given, a plan may not charge
1083	an additional premium for additional coverage of the newborn
1084	child for not less than 30 days after the birth of the child. If
1085	timely notice is not given, the plan may charge an additional
1086	premium from the date of birth. If notice is given within 60
1087	days of the birth of the child, the contract may not deny
1088	coverage of the child due to failure of the subscriber to timely
1089	notify the plan of the birth of the child or to preenroll the
1090	child.
1091	(b) If the contract does not require the subscriber to
1092	notify the plan of the birth of a child within a specified time
1093	period, the plan may not deny coverage of the child nor may it
1094	retroactively charge the subscriber an additional premium for
1095	the child; however, the contract may prospectively charge the
1096	member an additional premium for the child if the plan provides
1097	at least 45 days' notice of the additional charge.
1098	(11)(10)No alteration of any written application for any
1099	health maintenance contract shall be made by any person other
1100	than the applicant without his or her written consent, except
1101	that insertions may be made by the health maintenance
1102	organization, for administrative purposes only, in such manner
1103	as to indicate clearly that such insertions are not to be
1104	ascribed to the applicant.
1105	(12)(11)No contract shall contain any waiver of rights or
1106	benefits provided to or available to subscribers under the
1107	provisions of any law or rule applicable to health maintenance
1108	organizations.
1109	(13)(12)Each health maintenance contract, certificate, or
1110	member handbook shall state that emergency services and care
1111	shall be provided to subscribers in emergency situations not
1112	permitting treatment through the health maintenance
1113	organization's providers, without prior notification to and
1114	approval of the organization. Not less than 75 percent of the
1115	reasonable charges for covered services and supplies shall be
1116	paid by the organization, up to the subscriber contract benefit
1117	limits. Payment also may be subject to additional applicable
1118	copayment provisions, not to exceed $100 per claim. The health
1119	maintenance contract, certificate, or member handbook shall
1120	contain the definitions of "emergency services and care" and
1121	"emergency medical condition" as specified in s. 641.19(7) and
1122	(8), shall describe procedures for determination by the health
1123	maintenance organization of whether the services qualify for
1124	reimbursement as emergency services and care, and shall contain
1125	specific examples of what does constitute an emergency. In
1126	providing for emergency services and care as a covered service,
1127	a health maintenance organization shall be governed by s.
1128	641.513.
1129	(14)(13)In addition to the requirements of this section,
1130	with respect to a person who is entitled to have payments for
1131	health care costs made under Medicare, Title XVIII of the Social
1132	Security Act ("Medicare"), parts A and/or B:
1133	(a) The health maintenance organization shall mail or
1134	deliver notification to the Medicare beneficiary of the date of
1135	enrollment in the health maintenance organization within 10 days
1136	after receiving notification of enrollment approval from the
1137	United States Department of Health and Human Services, Health
1138	Care Financing Administration. When a Medicare beneficiary who
1139	is a subscriber of the health maintenance organization requests
1140	disenrollment from the organization, the organization shall mail
1141	or deliver to the beneficiary notice of the effective date of
1142	the disenrollment within 10 days after receipt of the written
1143	disenrollment request. The health maintenance organization shall
1144	forward the disenrollment request to the United States
1145	Department of Health and Human Services, Health Care Financing
1146	Administration, in a timely manner so as to effectuate the next
1147	available disenrollment date, as prescribed by such federal
1148	agency.
1149	(b) The health maintenance contract, certificate, or
1150	member handbook shall be delivered to the subscriber no later
1151	than the earlier of 10 working days after the health maintenance
1152	organization and the Health Care Financing Administration of the
1153	United States Department of Health and Human Services approve
1154	the subscriber's enrollment application or the effective date of
1155	coverage of the subscriber under the health maintenance
1156	contract. However, if notice from the Health Care Financing
1157	Administration of its approval of the subscriber's enrollment
1158	application is received by the health maintenance organization
1159	after the effective coverage date prescribed by the Health Care
1160	Financing Administration, the health maintenance organization
1161	shall deliver the contract, certificate, or member handbook to
1162	the subscriber within 10 days after receiving such notice. When
1163	a Medicare recipient is enrolled in a health maintenance
1164	organization program, the contract, certificate, or member
1165	handbook shall be accompanied by a health maintenance
1166	organization identification sticker with instruction to the
1167	Medicare beneficiary to place the sticker on the Medicare
1168	identification card.
1169	(15)(14)Whenever a subscriber of a health maintenance
1170	organization is also a Medicaid recipient, the health
1171	maintenance organization's coverage shall be primary to the
1172	recipient's Medicaid benefits and the organization shall be a
1173	third party subject to the provisions of s. 409.910(4).
1174	(16)(15)(a) All health maintenance contracts,
1175	certificates, and member handbooks shall contain the following
1176	provision:
1177
1178	"Grace Period: This contract has a (insert a number not less
1179	than 10) day grace period. This provision means that if any
1180	required premium is not paid on or before the date it is due, it
1181	may be paid during the following grace period. During the grace
1182	period, the contract will stay in force."
1183
1184	(b) The required provision of paragraph (a) shall not
1185	apply to certificates or member handbooks delivered to
1186	individual subscribers under a group health maintenance contract
1187	when the employer or other person who will hold the contract on
1188	behalf of the subscriber group pays the entire premium for the
1189	individual subscribers. However, such required provision shall
1190	apply to the group health maintenance contract.
1191	(17)(16)The contracts must clearly disclose the intent of
1192	the health maintenance organization as to the applicability or
1193	nonapplicability of coverage to preexisting conditions. If
1194	coverage of the contract is not to be applicable to preexisting
1195	conditions, the contract shall specify, in substance, that
1196	coverage pertains solely to accidental bodily injuries resulting
1197	from accidents occurring after the effective date of coverage
1198	and that sicknesses are limited to those which first manifest
1199	themselves subsequent to the effective date of coverage.
1200	(17) All health maintenance contracts that provide
1201	coverage for a member of the family of the subscriber, shall, as
1202	to such family member's coverage, provide that coverage,
1203	benefits, or services applicable for children shall be provided
1204	with respect to an adopted child of the subscriber, which child
1205	is placed in compliance with chapter 63, from the moment of
1206	placement in the residence of the subscriber. Such contracts may
1207	not exclude coverage for any preexisting condition of the child.
1208	In the case of a newborn child, coverage shall begin from the
1209	moment of birth if a written agreement to adopt such child has
1210	been entered into by the subscriber prior to the birth of the
1211	child, whether or not such agreement is enforceable. However,
1212	coverage for such child shall not be required in the event that
1213	the child is not ultimately placed in the residence of the
1214	subscriber in compliance with chapter 63.
1215	Section 17. Section 641.3101, Florida Statutes, is amended
1216	to read:
1217	641.3101 Additional contract contents.--
1218	(1)A health maintenance contract may contain additional
1219	provisions not inconsistent with this part which are:
1220	(a)(1)Necessary, on account of the manner in which the
1221	organization is constituted or operated, in order to state the
1222	rights and obligations of the parties to the contract; or
1223	(b)(2)Desired by the organization and neither prohibited
1224	by law nor in conflict with any provisions required to be
1225	included therein.
1226	(2) A health maintenance contract that uses a specific
1227	methodology for payment of claims shall comply with s. 627.6044.
1228	Section 18. Section 641.31025, Florida Statutes, is
1229	created to read:
1230	641.31025 Specific reasons for denial of coverage.--The
1231	denial of an application for a health maintenance organization
1232	contract must be accompanied by the specific reasons for the
1233	denial, including, but not limited to, the specific underwriting
1234	reasons, if applicable.
1235	Section 19. Section 641.31075, Florida Statutes, is
1236	created to read:
1237	641.31075 Replacement.--Any health maintenance
1238	organization that is replacing any other group health coverage
1239	with its group health maintenance coverage shall comply with s.
1240	627.666.
1241	Section 20. Subsection (1) of section 641.3111, Florida
1242	Statutes, is amended to read:
1243	641.3111 Extension of benefits.--
1244	(1) Every group health maintenance contract shall provide
1245	that termination of the contract shall be without prejudice to
1246	any continuous loss which commenced while the contract was in
1247	force, but any extension of benefits beyond the period the
1248	contract was in force may be predicated upon the continuous
1249	total disability of the subscriber and may be limited to payment
1250	for the treatment of a specific accident or illness incurred
1251	while the subscriber was a member. The extension is required
1252	regardless of whether the group contract holder or other entity
1253	secures replacement coverage from a new insurer or health
1254	maintenance organization or foregoes the provision of coverage.
1255	The required provision must provide for continuation of contract
1256	benefits in connection with the treatment of a specific accident
1257	or illness incurred while the contract was in effect.Such
1258	extension of benefits may be limited to the occurrence of the
1259	earliest of the following events:
1260	(a) The expiration of 12 months.
1261	(b) Such time as the member is no longer totally disabled.
1262	(c) A succeeding carrier elects to provide replacement
1263	coverage without limitation as to the disability condition.
1264	(d) The maximum benefits payable under the contract have
1265	been paid.
1266	Section 21. Subsection (4) of section 627.651, Florida
1267	Statutes, is amended to read:
1268	627.651 Group contracts and plans of self-insurance must
1269	meet group requirements.--
1270	(4) This section does not apply to any plan which is
1271	established or maintained by an individual employer in
1272	accordance with the Employee Retirement Income Security Act of
1273	1974, Pub. L. No. 93-406, or to a multiple-employer welfare
1274	arrangement as defined in s. 624.437(1), except that a multiple-
1275	employer welfare arrangement shall comply with ss. 627.419,
1276	627.657, 627.6575, 627.6578, 627.6579, 627.6612, 627.66121,
1277	627.66122, 627.6615, 627.6616, and 627.662(8)(7). This
1278	subsection does not allow an authorized insurer to issue a group
1279	health insurance policy or certificate which does not comply
1280	with this part.
1281	Section 22. Subsection (1) of section 641.2018, Florida
1282	Statutes, is amended to read:
1283	641.2018 Limited coverage for home health care
1284	authorized.--
1285	(1) Notwithstanding other provisions of this chapter, a
1286	health maintenance organization may issue a contract that limits
1287	coverage to home health care services only. The organization and
1288	the contract shall be subject to all of the requirements of this
1289	part that do not require or otherwise apply to specific benefits
1290	other than home care services. To this extent, all of the
1291	requirements of this part apply to any organization or contract
1292	that limits coverage to home care services, except the
1293	requirements for providing comprehensive health care services as
1294	provided in ss. 641.19(4), (12), and (13), and 641.31(1), except
1295	ss. 641.31(9),(13)(12), (17),(18), (19), (20), (21), and (24)
1296	and 641.31095.
1297	Section 23. Section 641.3107, Florida Statutes, is amended
1298	to read:
1299	641.3107 Delivery of contract.--Unless delivered upon
1300	execution or issuance, a health maintenance contract,
1301	certificate of coverage, or member handbook shall be mailed or
1302	delivered to the subscriber or, in the case of a group health
1303	maintenance contract, to the employer or other person who will
1304	hold the contract on behalf of the subscriber group within 10
1305	working days from approval of the enrollment form by the health
1306	maintenance organization or by the effective date of coverage,
1307	whichever occurs first. However, if the employer or other person
1308	who will hold the contract on behalf of the subscriber group
1309	requires retroactive enrollment of a subscriber, the
1310	organization shall deliver the contract, certificate, or member
1311	handbook to the subscriber within 10 days after receiving notice
1312	from the employer of the retroactive enrollment. This section
1313	does not apply to the delivery of those contracts specified in
1314	s. 641.31(14)(13).
1315	Section 24. Subsection (4) of section 641.513, Florida
1316	Statutes, is amended to read:
1317	641.513 Requirements for providing emergency services and
1318	care.--
1319	(4) A subscriber may be charged a reasonable copayment, as
1320	provided in s. 641.31(13)(12), for the use of an emergency room.
1321	Section 25. This act shall take effect upon becoming a
1322	law.