HB 0723, Engrossed 1 2003
1	A bill to be entitled
2	An act relating to health insurance; amending s. 408.909,
3	F.S.; revising a definition; authorizing health flex plans
4	to limit coverage under certain circumstances; authorizing
5	a small business purchasing arrangement to limit
6	enrollment to certain residents; extending an expiration
7	date; creating s. 627.6042, F.S.; requiring policies of
8	insurers offering coverage of dependent children to
9	maintain such coverage until a child reaches age 25, under
10	certain circumstances; providing application; creating s.
11	627.60425, F.S.; providing limitations on certain binding
12	arbitration requirements; amending s. 627.6044, F.S.;
13	providing for payment of claims to nonnetwork providers
14	under specified conditions; providing a definition;
15	requiring the method used for determining payment of
16	claims to be included in filings; providing for
17	disclosure; amending s. 627.6415, F.S.; deleting an 18th
18	birthday age limitation on application of certain
19	dependent coverage requirements; amending s. 627.6475,
20	F.S.; revising risk-assuming carrier election requirements
21	and procedures; revising certain criteria and limitations
22	under the individual health reinsurance program; amending
23	s. 627.651, F.S.; correcting a cross reference; amending
24	s. 627.662, F.S.; revising a list of provisions applicable
25	to group, blanket, or franchise health insurance to
26	include use of specific methodology for payment of claims
27	provisions; amending s. 627.667, F.S.; deleting a
28	limitation on application of certain extension of benefits
29	provisions; amending s. 627.6692, F.S.; increasing a time
30	period for payment of premium to continue coverage under a
31	group health plan; amending s. 627.6699, F.S.; revising
32	definitions; revising coverage enrollment eligibility
33	criteria for small employers; revising small employer
34	carrier election requirements and procedures; revising
35	certain criteria and limitations under the small employer
36	health reinsurance program; amending ss. 627.911 and
37	627.9175, F.S.; applying certain information reporting
38	requirements to health maintenance organizations; revising
39	health insurance information requirements and criteria;
40	authorizing the department to adopt rules; deleting an
41	annual report requirement; amending s. 627.9403, F.S.;
42	deleting an exemption for limited benefit policies from a
43	long-term care insurance restriction relating to nursing
44	home care; amending s. 641.185, F.S.; correcting a cross
45	reference; amending s. 641.31, F.S.; specifying
46	nonapplication to certain contracts; requiring health
47	maintenance organizations offering coverage of dependent
48	children to maintain such coverage until a child reaches
49	age 25, under certain circumstances; providing
50	application; providing requirements for contract
51	termination and denial of a claim related to limiting age
52	attainment; amending s. 641.3101, F.S.; providing a
53	compliance requirement for health maintenance contracts
54	using a specific payment of claims methodology; creating
55	s. 641.31025, F.S.; requiring specific reasons for denial
56	of coverage under a health maintenance organization
57	contract; creating s. 641.31075, F.S.; imposing compliance
58	requirements upon health maintenance organization
59	replacements of other group health coverage with
60	organization coverage; amending s. 641.3111, F.S.;
61	deleting a limitation on certain extension of benefits
62	provisions upon group health maintenance contract
63	termination; imposing additional extension of benefits
64	requirements upon such termination; amending ss. 627.651,
65	641.2018, 641.3107, and 641.513, F.S.; correcting cross
66	references; providing an effective date.
67
68	Be It Enacted by the Legislature of the State of Florida:
69
70	Section 1. Paragraph (e) of subsection (2), subsection
71	(3), paragraph (c) of subsection (5), and subsection (10) of
72	section 408.909, Florida Statutes, are amended to read:
73	408.909 Health flex plans.--
74	(2) DEFINITIONS.--As used in this section, the term:
75	(e) "Health flex plan" means a health plan approved under
76	subsection (3) which guarantees payment for specified health
77	care coverage provided to the enrollee who purchases coverage
78	directly from the plan or through a small business purchasing
79	arrangement sponsored by a local government.
80	(3) PILOT PROGRAM.--The agency and the department shall
81	each approve or disapprove health flex plans that provide health
82	care coverage for eligible participants who reside in the three
83	areas of the state that have the highest number of uninsured
84	persons, as identified in the Florida Health Insurance Study
85	conducted by the agency and in Indian River County. A health
86	flex plan may limit or exclude benefits otherwise required by
87	law for insurers offering coverage in this state, may cap the
88	total amount of claims paid per year per enrollee, may limit the
89	number of enrollees or the term of coverage, or may take any
90	combination of those actions.
91	(a) The agency shall develop guidelines for the review of
92	applications for health flex plans and shall disapprove or
93	withdraw approval of plans that do not meet or no longer meet
94	minimum standards for quality of care and access to care.
95	(b) The department shall develop guidelines for the review
96	of health flex plan applications and shall disapprove or shall
97	withdraw approval of plans that:
98	1. Contain any ambiguous, inconsistent, or misleading
99	provisions or any exceptions or conditions that deceptively
100	affect or limit the benefits purported to be assumed in the
101	general coverage provided by the health flex plan;
102	2. Provide benefits that are unreasonable in relation to
103	the premium charged or contain provisions that are unfair or
104	inequitable or contrary to the public policy of this state, that
105	encourage misrepresentation, or that result in unfair
106	discrimination in sales practices; or
107	3. Cannot demonstrate that the health flex plan is
108	financially sound and that the applicant is able to underwrite
109	or finance the health care coverage provided.
110	(c) The agency and the department may adopt rules as
111	needed to administer this section.
112	(5) ELIGIBILITY.--Eligibility to enroll in an approved
113	health flex plan is limited to residents of this state who:
114	(c) Are not covered by a private insurance policy and are
115	not eligible for coverage through a public health insurance
116	program, such as Medicare or Medicaid, or another public health
117	care program, such as KidCare, and have not been covered at any
118	time during the past 6 months, except that a small business
119	purchasing arrangement sponsored by a local government may limit
120	enrollment to residents of this state who have not been covered
121	at any time during the past 12 months; and
122	(10) EXPIRATION.--This section expires July 1, 20082004.
123	Section 2. Section 627.6042, Florida Statutes, is created
124	to read:
125	627.6042 Dependent coverage.--
126	(1) If an insurer offers coverage that insures dependent
127	children of the policyholder or certificateholder, the policy
128	must insure a dependent child of the policyholder or
129	certificateholder at least until the end of the calendar year in
130	which the child reaches the age of 25, if the child meets all of
131	the following:
132	(a) The child is dependent upon the policyholder or
133	certificateholder for support.
134	(b) The child is living in the household of the
135	policyholder or certificateholder or the child is a full-time or
136	part-time student.
137	(2) Nothing in this section affects or preempts an
138	insurer's right to medically underwrite or charge the
139	appropriate premium.
140	Section 3. Section 627.60425, Florida Statutes, is created
141	to read:
142	627.60425 Binding arbitration requirement
143	limitations.--Notwithstanding any other provision of law, except
144	s. 624.155, an individual, blanket, group life, or group health
145	insurance policy; individual or group health maintenance
146	organization subscriber contract; prepaid limited health
147	organization subscriber contract; or any life or health
148	insurance policy or certificate delivered or issued for
149	delivery, including out-of-state group plans pursuant to s.
150	627.5515 or s. 627.6515 covering residents of this state, to any
151	resident of this state shall not require the submission of
152	disputes between the parties to the policy, contract, or plan to
153	binding arbitration unless the applicant has indicated that the
154	same policy, contract, or plan was offered and rejected without
155	arbitration and that the binding arbitration provision was fully
156	explained to the applicant and willingly accepted.
157	Section 4. Section 627.6044, Florida Statutes, is amended
158	to read:
159	627.6044 Use of a specific methodology for payment of
160	claims.--
161	(1) Each insurance policy that provides for payment of
162	claims to nonnetwork providers that is less than the payment of
163	the provider's billed charges to the insured, excluding
164	deductible, coinsurance, and copay amounts, shall:
165	(a) Provide benefits prior to deductible, coinsurance, and
166	copay amounts for using a nonnetwork provider that are at least
167	equal to the amount that would have been allowed had the insured
168	used a network provider but are not in excess of the actual
169	billed charges.
170	(b) Where there are multiple network providers in the
171	geographical area in which the services were provided or, if
172	none, the closest geographic area, the carrier may use an
173	averaging method of the contracted amounts but not less than the
174	80th percentile of all network contracted amounts in the
175	geographic area.
176
177	For purposes of this subsection, the term "network providers"
178	means those providers for which an insured will not be
179	responsible for any balance payment for services provided by
180	such provider, excluding deductible, coinsurance, and copay
181	amountsbased on a specific methodology, including, but not
182	limited to, usual and customary charges, reasonable and
183	customary charges, or charges based upon the prevailing rate in
184	the community, shall specify the formula or criteria used by the
185	insurer in determining the amount to be paid.
186	(2) Each insurer issuing a policy that provides for
187	payment of claims based on a specific methodology shall provide
188	to an insured, upon her or his written request, an estimate of
189	the amount the insurer will pay for a particular medical
190	procedure or service. The estimate may be in the form of a range
191	of payments or an average payment and may specify that the
192	estimate is based on the assumption of a particular service
193	code. The insurer may require the insured to provide detailed
194	information regarding the procedure or service to be performed,
195	including the procedure or service code number provided by the
196	health care provider and the health care provider's estimated
197	charge.An insurer that provides an insured with a good faith
198	estimate is not bound by the estimate. However, a pattern of
199	providing estimates that vary significantly from the ultimate
200	insurance payment constitutes a violation of this code.
201	(3) The method used for determining the payment of claims
202	shall be included in filings made pursuant to s. 627.410(6) and
203	may not be changed unless such change is filed under s.
204	627.410(6).
205	(4) Any policy that provides that the insured is
206	responsible for the balance of a claim amount, excluding
207	deductible, coinsurance, and copay amounts, must disclose such
208	feature on the face of the policy or certificate and such
209	feature must be included in any outline of coverage provided to
210	the insured.
211	Section 5. Subsections (1) and (4) of section 627.6415,
212	Florida Statutes, are amended to read:
213	627.6415 Coverage for natural-born, adopted, and foster
214	children; children in insured's custodial care.--
215	(1) A health insurance policy that provides coverage for a
216	member of the family of the insured shall, as to the family
217	member's coverage, provide that the health insurance benefits
218	applicable to children of the insured also apply to an adopted
219	child or a foster child of the insured placed in compliance with
220	chapter 63, prior to the child's 18th birthday,from the moment
221	of placement in the residence of the insured. Except in the case
222	of a foster child, the policy may not exclude coverage for any
223	preexisting condition of the child. In the case of a newborn
224	child, coverage begins at the moment of birth if a written
225	agreement to adopt the child has been entered into by the
226	insured prior to the birth of the child, whether or not the
227	agreement is enforceable. This section does not require coverage
228	for an adopted child who is not ultimately placed in the
229	residence of the insured in compliance with chapter 63.
230	(4) In order to increase access to postnatal, infant, and
231	pediatric health care for all children placed in court-ordered
232	custody, including foster children, all health insurance
233	policies that provide coverage for a member of the family of the
234	insured shall, as to such family member's coverage, also provide
235	that the health insurance benefits applicable for children shall
236	be payable with respect to a foster child or other child in
237	court-ordered temporary or other custody of the insured, prior
238	to the child's 18th birthday.
239	Section 6. Paragraph (a) of subsection (5), paragraph (c)
240	of subsection (6), and paragraphs (b), (c), and (e) of
241	subsection (7) of section 627.6475, Florida Statutes, are
242	amended to read:
243	627.6475 Individual reinsurance pool.--
244	(5) ISSUER'S ELECTION TO BECOME A RISK-ASSUMING CARRIER.--
245	(a) Each health insurance issuer that offers individual
246	health insurance must elect to become a risk-assuming carrier or
247	a reinsuring carrier for purposes of this section. Each such
248	issuer must make an initial election, binding through December
249	31, 1999. The issuer's initial election must be made no later
250	than October 31, 1997. By October 31, 1997, all issuers must
251	file a final election, which is binding for 2 years, from
252	January 1, 1998, through December 31, 1999, after whichan
253	election that shall be binding indefinitely or until modified or
254	withdrawnfor a period of 5 years. The department may permit an
255	issuer to modify its election at any time for good cause shown,
256	after a hearing.
257	(6) ELECTION PROCESS TO BECOME A RISK-ASSUMING CARRIER.--
258	(c) The department shall provide public notice of an
259	issuer's filing adesignation of election under this subsection
260	to become a risk-assuming carrier and shall provide at least a
261	21-day period for public comment upon receipt of such filing
262	prior to making a decision on the election. The department shall
263	hold a hearing on the election at the request of the issuer.
264	(7) INDIVIDUAL HEALTH REINSURANCE PROGRAM.--
265	(b) A reinsuring carrier may reinsure with the program
266	coverage of an eligible individual, subject to each of the
267	following provisions:
268	1. A reinsuring carrier may reinsure an eligible
269	individual within 9060days after commencement of the coverage
270	of the eligible individual.
271	2. The program may not reimburse a participating carrier
272	with respect to the claims of a reinsured eligible individual
273	until the carrier has paid incurred claims of an amount equal to
274	the participating carrier’s selected deductible levelat least
275	$5,000 in a calendar year for benefits covered by the program.
276	In addition, the reinsuring carrier is responsible for 10
277	percent of the next $50,000 and 5 percent of the next $100,000
278	of incurred claims during a calendar year, and the program shall
279	reinsure the remainder.
280	3. The board shall annually adjust the initial level of
281	claims and the maximum limit to be retained by the carrier to
282	reflect increases in costs and utilization within the standard
283	market for health benefit plans within the state. The adjustment
284	may not be less than the annual change in the medical component
285	of the "Commerce Price Index for All Urban Consumers" of the
286	Bureau of Labor Statistics of the United States Department of
287	Labor, unless the board proposes and the department approves a
288	lower adjustment factor.
289	4. A reinsuring carrier may terminate reinsurance for all
290	reinsured eligible individuals on any plan anniversary.
291	5. The premium rate charged for reinsurance by the program
292	to a health maintenance organization that is approved by the
293	Secretary of Health and Human Services as a federally qualified
294	health maintenance organization pursuant to 42 U.S.C. s.
295	300e(c)(2)(A) and that, as such, is subject to requirements that
296	limit the amount of risk that may be ceded to the program, which
297	requirements are more restrictive than subparagraph 2., shall be
298	reduced by an amount equal to that portion of the risk, if any,
299	which exceeds the amount set forth in subparagraph 2., which may
300	not be ceded to the program.
301	6. The board may consider adjustments to the premium rates
302	charged for reinsurance by the program or carriers that use
303	effective cost-containment measures, including high-cost case
304	management, as defined by the board.
305	7. A reinsuring carrier shall apply its case-management
306	and claims-handling techniques, including, but not limited to,
307	utilization review, individual case management, preferred
308	provider provisions, other managed-care provisions, or methods
309	of operation consistently with both reinsured business and
310	nonreinsured business.
311	(c)1. The board, as part of the plan of operation, shall
312	establish a methodology for determining premium rates to be
313	charged by the program for reinsuring eligible individuals
314	pursuant to this section. The methodology must include a system
315	for classifying individuals which reflects the types of case
316	characteristics commonly used by carriers in this state. The
317	methodology must provide for the development of basic
318	reinsurance premium rates, which shall be multiplied by the
319	factors set for them in this paragraph to determine the premium
320	rates for the program. The basic reinsurance premium rates shall
321	be established by the board, subject to the approval of the
322	department, and shall be set at levels that reasonably
323	approximate gross premiums charged to eligible individuals for
324	individual health insurance by health insurance issuers. The
325	premium rates set by the board may vary by geographical area, as
326	determined under this section, to reflect differences in cost.
327	An eligible individual may be reinsured for a rate that is five
328	times the rate established by the board.
329	2. The board shall periodically review the methodology
330	established, including the system of classification and any
331	rating factors, to ensure that it reasonably reflects the claims
332	experience of the program. The board may propose changes to the
333	rates that are subject to the approval of the department.
334	(e)1. Before SeptemberMarch1 of each calendar year, the
335	board shall determine and report to the department the program
336	net loss in the individual account for the previous year,
337	including administrative expenses for that year and the incurred
338	losses for that year, taking into account investment income and
339	other appropriate gains and losses.
340	2. Any net loss in the individual account for the year
341	shall be recouped by assessing the carriers as follows:
342	a. The operating losses of the program shall be assessed
343	in the following order subject to the specified limitations. The
344	first tier of assessments shall be made against reinsuring
345	carriers in an amount that may not exceed 5 percent of each
346	reinsuring carrier's premiums for individual health insurance.
347	If such assessments have been collected and additional moneys
348	are needed, the board shall make a second tier of assessments in
349	an amount that may not exceed 0.5 percent of each carrier's
350	health benefit plan premiums.
351	b. Except as provided in paragraph (f), risk-assuming
352	carriers are exempt from all assessments authorized pursuant to
353	this section. The amount paid by a reinsuring carrier for the
354	first tier of assessments shall be credited against any
355	additional assessments made.
356	c. The board shall equitably assess reinsuring carriers
357	for operating losses of the individual account based on market
358	share. The board shall annually assess each carrier a portion of
359	the operating losses of the individual account. The first tier
360	of assessments shall be determined by multiplying the operating
361	losses by a fraction, the numerator of which equals the
362	reinsuring carrier's earned premium pertaining to direct
363	writings of individual health insurance in the state during the
364	calendar year for which the assessment is levied, and the
365	denominator of which equals the total of all such premiums
366	earned by reinsuring carriers in the state during that calendar
367	year. The second tier of assessments shall be based on the
368	premiums that all carriers, except risk-assuming carriers,
369	earned on all health benefit plans written in this state. The
370	board may levy interim assessments against reinsuring carriers
371	to ensure the financial ability of the plan to cover claims
372	expenses and administrative expenses paid or estimated to be
373	paid in the operation of the plan for the calendar year prior to
374	the association's anticipated receipt of annual assessments for
375	that calendar year. Any interim assessment is due and payable
376	within 30 days after receipt by a carrier of the interim
377	assessment notice. Interim assessment payments shall be credited
378	against the carrier's annual assessment. Health benefit plan
379	premiums and benefits paid by a carrier that are less than an
380	amount determined by the board to justify the cost of collection
381	may not be considered for purposes of determining assessments.
382	d. Subject to the approval of the department, the board
383	shall adjust the assessment formula for reinsuring carriers that
384	are approved as federally qualified health maintenance
385	organizations by the Secretary of Health and Human Services
386	pursuant to 42 U.S.C. s. 300e(c)(2)(A) to the extent, if any,
387	that restrictions are placed on them which are not imposed on
388	other carriers.
389	3. Before SeptemberMarch1 of each year, the board shall
390	determine and file with the department an estimate of the
391	assessments needed to fund the losses incurred by the program in
392	the individual account for the previous calendar year.
393	4. If the board determines that the assessments needed to
394	fund the losses incurred by the program in the individual
395	account for the previous calendar year will exceed the amount
396	specified in subparagraph 2., the board shall evaluate the
397	operation of the program and report its findings and
398	recommendations to the department in the format established in
399	s. 627.6699(11) for the comparable report for the small employer
400	reinsurance program.
401	Section 7. Subsection (4) of section 627.651, Florida
402	Statutes, is amended to read:
403	627.651 Group contracts and plans of self-insurance must
404	meet group requirements.--
405	(4) This section does not apply to any plan which is
406	established or maintained by an individual employer in
407	accordance with the Employee Retirement Income Security Act of
408	1974, Pub. L. No. 93-406, or to a multiple-employer welfare
409	arrangement as defined in s. 624.437(1), except that a multiple-
410	employer welfare arrangement shall comply with ss. 627.419,
411	627.657, 627.6575, 627.6578, 627.6579, 627.6612, 627.66121,
412	627.66122, 627.6615, 627.6616, and 627.662(8)(7). This
413	subsection does not allow an authorized insurer to issue a group
414	health insurance policy or certificate which does not comply
415	with this part.
416	Section 8. Section 627.662, Florida Statutes, is amended
417	to read:
418	627.662 Other provisions applicable.--The following
419	provisions apply to group health insurance, blanket health
420	insurance, and franchise health insurance:
421	(1) Section 627.569, relating to use of dividends,
422	refunds, rate reductions, commissions, and service fees.
423	(2) Section 627.602(1)(f) and (2), relating to
424	identification numbers and statement of deductible provisions.
425	(3) Section 627.6044, relating to the use of specific
426	methodology for payment of claims.
427	(4)(3)Section 627.635, relating to excess insurance.
428	(5)(4)Section 627.638, relating to direct payment for
429	hospital or medical services.
430	(6)(5)Section 627.640, relating to filing and
431	classification of rates.
432	(7)(6)Section 627.613, relating to timely payment of
433	claims, or s. 627.6131, relating to payment of claims, whichever
434	is applicable.
435	(8)(7)Section 627.645(1), relating to denial of claims.
436	(9)(8)Section 627.6471, relating to preferred provider
437	organizations.
438	(10)(9)Section 627.6472, relating to exclusive provider
439	organizations.
440	(11)(10)Section 627.6473, relating to combined preferred
441	provider and exclusive provider policies.
442	(12)(11)Section 627.6474, relating to provider contracts.
443	Section 9. Subsection (6) of section 627.667, Florida
444	Statutes, is amended to read:
445	627.667 Extension of benefits.--
446	(6) This section also applies to holders of group
447	certificates which are renewed, delivered, or issued for
448	delivery to residents of this state under group policies
449	effectuated or delivered outside this state, unless a succeeding
450	carrier under a group policy has agreed to assume liability for
451	the benefits.
452	Section 10. Paragraph (e) of subsection (5) of section
453	627.6692, Florida Statutes, is amended to read:
454	627.6692 Florida Health Insurance Coverage Continuation
455	Act.--
456	(5) CONTINUATION OF COVERAGE UNDER GROUP HEALTH PLANS.--
457	(e)1. A covered employee or other qualified beneficiary
458	who wishes continuation of coverage must pay the initial premium
459	and elect such continuation in writing to the insurance carrier
460	issuing the employer's group health plan within 6330days after
461	receiving notice from the insurance carrier under paragraph (d).
462	Subsequent premiums are due by the grace period expiration date.
463	The insurance carrier or the insurance carrier's designee shall
464	process all elections promptly and provide coverage
465	retroactively to the date coverage would otherwise have
466	terminated. The premium due shall be for the period beginning on
467	the date coverage would have otherwise terminated due to the
468	qualifying event. The first premium payment must include the
469	coverage paid to the end of the month in which the first payment
470	is made. After the election, the insurance carrier must bill the
471	qualified beneficiary for premiums once each month, with a due
472	date on the first of the month of coverage and allowing a 30-day
473	grace period for payment.
474	2. Except as otherwise specified in an election, any
475	election by a qualified beneficiary shall be deemed to include
476	an election of continuation of coverage on behalf of any other
477	qualified beneficiary residing in the same household who would
478	lose coverage under the group health plan by reason of a
479	qualifying event. This subparagraph does not preclude a
480	qualified beneficiary from electing continuation of coverage on
481	behalf of any other qualified beneficiary.
482	Section 11. Paragraphs (g), (h), (i), and (u) of
483	subsection (3), paragraph (c) of subsection (5), paragraph (a)
484	of subsection (9), paragraph (d) of subsection (10), and
485	paragraphs (f), (g), (h), and (j) of subsection (11) of section
486	627.6699, Florida Statutes, are amended to read:
487	627.6699 Employee Health Care Access Act.--
488	(3) DEFINITIONS.--As used in this section, the term:
489	(g) "Dependent" means the spouse or child as described in
490	s. 627.6562 of an eligible employee, subject to the applicable
491	terms of the health benefit plan covering that employee.
492	(h) "Eligible employee" means an employee who works full
493	time, having a normal workweek of 25 or more hours, who is paid
494	wages or a salary at least equal to the federal minimum hourly
495	wage applicable to such employee,and who has met any applicable
496	waiting-period requirements or other requirements of this act.
497	The term includes a self-employed individual, a sole proprietor,
498	a partner of a partnership, or an independent contractor, if the
499	sole proprietor, partner, or independent contractor is included
500	as an employee under a health benefit plan of a small employer,
501	but does not include a part-time, temporary, or substitute
502	employee.
503	(i) "Established geographic area" means the county or
504	counties, or any portion of a county or counties,within which
505	the carrier provides or arranges for health care services to be
506	available to its insureds, members, or subscribers.
507	(u) "Self-employed individual" means an individual or sole
508	proprietor who derives his or her income from a trade or
509	business carried on by the individual or sole proprietor which
510	necessitates that the individual file federal income tax forms
511	with supporting schedules and accompanying income reporting
512	forms or federal income tax extensions of time to file forms
513	with the Internal Revenue Service for the most recent tax year
514	results in taxable income as indicated on IRS Form 1040,
515	schedule C or F, and which generated taxable income in one of
516	the 2 previous years.
517	(5) AVAILABILITY OF COVERAGE.--
518	(c) Every small employer carrier must, as a condition of
519	transacting business in this state:
520	1. Beginning July 1, 2000, offer and issue all small
521	employer health benefit plans on a guaranteed-issue basis to
522	every eligible small employer, with 2 to 50 eligible employees,
523	that elects to be covered under such plan, agrees to make the
524	required premium payments, and satisfies the other provisions of
525	the plan. A rider for additional or increased benefits may be
526	medically underwritten and may only be added to the standard
527	health benefit plan. The increased rate charged for the
528	additional or increased benefit must be rated in accordance with
529	this section.
530	2. Beginning July 1, 2000, and until July 31, 2001, offer
531	and issue basic and standard small employer health benefit plans
532	on a guaranteed-issue basis to every eligible small employer
533	which is eligible for guaranteed renewal, has less than two
534	eligible employees, is not formed primarily for the purpose of
535	buying health insurance, elects to be covered under such plan,
536	agrees to make the required premium payments, and satisfies the
537	other provisions of the plan. A rider for additional or
538	increased benefits may be medically underwritten and may be
539	added only to the standard benefit plan. The increased rate
540	charged for the additional or increased benefit must be rated in
541	accordance with this section. For purposes of this subparagraph,
542	a person, his or her spouse, and his or her dependent children
543	shall constitute a single eligible employee if that person and
544	spouse are employed by the same small employer and either one
545	has a normal work week of less than 25 hours.
546	3.a.Beginning August 1, 2001, offer and issue basic and
547	standard small employer health benefit plans on a guaranteed-
548	issue basis, during a 31-day open enrollment period of August 1
549	through August 31 of each year, to every eligible small
550	employer, with fewer than two eligible employees, which small
551	employer is not formed primarily for the purpose of buying
552	health insurance and which elects to be covered under such plan,
553	agrees to make the required premium payments, and satisfies the
554	other provisions of the plan. Coverage provided under this sub-
555	subparagraphsubparagraphshall begin on October 1 of the same
556	year as the date of enrollment, unless the small employer
557	carrier and the small employer agree to a different date. A
558	rider for additional or increased benefits may be medically
559	underwritten and may only be added to the standard health
560	benefit plan. The increased rate charged for the additional or
561	increased benefit must be rated in accordance with this section.
562	For purposes of this sub-subparagraphsubparagraph, a person,
563	his or her spouse, and his or her dependent children constitute
564	a single eligible employee if that person and spouse are
565	employed by the same small employer and either that person or
566	his or her spouse has a normal work week of less than 25 hours.
567	b. Notwithstanding the restrictions set forth in sub-
568	subparagraph a., when a small employer group is losing coverage
569	because a carrier is exercising the provisions of s.
570	627.6571(3)(b) or s. 641.31074(3)(b), the eligible small
571	employer, as defined in sub-subparagraph a., shall be entitled
572	to enroll with another carrier offering small employer coverage
573	within 63 days after the notice of termination or the
574	termination date of the prior coverage, whichever is later.
575	Coverage provided under this sub-subparagraph shall begin
576	immediately upon enrollment unless the small employer carrier
577	and the small employer agree to a different date.
578	4. This paragraph does not limit a carrier's ability to
579	offer other health benefit plans to small employers if the
580	standard and basic health benefit plans are offered and
581	rejected.
582	(9) SMALL EMPLOYER CARRIER'S ELECTION TO BECOME A RISK-
583	ASSUMING CARRIER OR A REINSURING CARRIER.--
584	(a) A small employer carrier must elect to become either a
585	risk-assuming carrier or a reinsuring carrier. Each small
586	employer carrier must make an initial election, binding through
587	January 1, 1994. The carrier's initial election must be made no
588	later than October 31, 1992. By October 31, 1993, all small
589	employer carriers must file a final election, which is binding
590	for 2 years, from January 1, 1994, through December 31, 1995,
591	after which an election shall be binding for a period of 5
592	years.Any carrier that is not a small employer carrier on
593	October 31, 1992, and intends to become a small employer carrier
594	after October 31, 1992, must file its designation when it files
595	the forms and rates it intends to use for small employer group
596	health insurance; such designation shall be binding indefinitely
597	or until modified or withdrawnfor 2 years after the date of
598	approval of the forms and rates, and any subsequent designation
599	is binding for 5 years. The department may permit a carrier to
600	modify its election at any time for good cause shown, after a
601	hearing.
602	(10) ELECTION PROCESS TO BECOME A RISK-ASSUMING CARRIER.--
603	(d) The department shall provide public notice of a small
604	employer carrier's filing adesignation of election under
605	subsection (9) to become a risk-assuming carrier and shall
606	provide at least a 21-day period for public comment upon receipt
607	of such filingprior to making a decision on the election. The
608	department shall hold a hearing on the election at the request
609	of the carrier.
610	(11) SMALL EMPLOYER HEALTH REINSURANCE PROGRAM.--
611	(f) The program has the general powers and authority
612	granted under the laws of this state to insurance companies and
613	health maintenance organizations licensed to transact business,
614	except the power to issue health benefit plans directly to
615	groups or individuals. In addition thereto, the program has
616	specific authority to:
617	1. Enter into contracts as necessary or proper to carry
618	out the provisions and purposes of this act, including the
619	authority to enter into contracts with similar programs of other
620	states for the joint performance of common functions or with
621	persons or other organizations for the performance of
622	administrative functions.
623	2. Sue or be sued, including taking any legal action
624	necessary or proper for recovering any assessments and penalties
625	for, on behalf of, or against the program or any carrier.
626	3. Take any legal action necessary to avoid the payment of
627	improper claims against the program.
628	4. Issue reinsurance policies, in accordance with the
629	requirements of this act.
630	5. Establish rules, conditions, and procedures for
631	reinsurance risks under the program participation.
632	6. Establish actuarial functions as appropriate for the
633	operation of the program.
634	7. Assess participating carriers in accordance with
635	paragraph (j), and make advance interim assessments as may be
636	reasonable and necessary for organizational and interim
637	operating expenses. Interim assessments shall be credited as
638	offsets against any regular assessments due following the close
639	of the calendar year.
640	8. Appoint appropriate legal, actuarial, and other
641	committees as necessary to provide technical assistance in the
642	operation of the program, and in any other function within the
643	authority of the program.
644	9. Borrow money to effect the purposes of the program. Any
645	notes or other evidences of indebtedness of the program which
646	are not in default constitute legal investments for carriers and
647	may be carried as admitted assets.
648	10. To the extent necessary, increase the $5,000
649	deductible reinsurance requirement to adjust for the effects of
650	inflation. The program may evaluate the desirability of
651	establishing different levels of deductibles. If different
652	levels of deductibles are established, such levels and the
653	resulting premiums shall be approved by the department.
654	(g) A reinsuring carrier may reinsure with the program
655	coverage of an eligible employee of a small employer, or any
656	dependent of such an employee, subject to each of the following
657	provisions:
658	1. With respect to a standard and basic health care plan,
659	the program maymustreinsure the level of coverage provided;
660	and, with respect to any other plan, the program maymust
661	reinsure the coverage up to, but not exceeding, the level of
662	coverage provided under the standard and basic health care plan.
663	As an alternative to reinsuring the level of coverage provided
664	under the standard and basic health care plan, the program may
665	develop alternate levels of reinsurance designed to coordinate
666	with a reinsuring carrier’s existing reinsurance. The levels of
667	reinsurance and resulting premiums must be approved by the
668	department.
669	2. Except in the case of a late enrollee, a reinsuring
670	carrier may reinsure an eligible employee or dependent within 60
671	days after the commencement of the coverage of the small
672	employer. A newly employed eligible employee or dependent of a
673	small employer may be reinsured within 60 days after the
674	commencement of his or her coverage.
675	3. A small employer carrier may reinsure an entire
676	employer group within 60 days after the commencement of the
677	group's coverage under the plan. The carrier may choose to
678	reinsure newly eligible employees and dependents of the
679	reinsured group pursuant to subparagraph 1.
680	4. The program may evaluate the option of allowing a small
681	employer carrier to reinsure an entire employer group or an
682	eligible employee at the first or subsequent renewal date. Any
683	such option and the resulting premium must be approved by the
684	department.
685	5.4.The program may not reimburse a participating carrier
686	with respect to the claims of a reinsured employee or dependent
687	until the carrier has paid incurred claims of an amount equal to
688	the participating carrier’s selected deductible levelat least
689	$5,000 in a calendar year for benefits covered by the program.
690	In addition, the reinsuring carrier shall be responsible for 10
691	percent of the next $50,000 and 5 percent of the next $100,000
692	of incurred claims during a calendar year and the program shall
693	reinsure the remainder.
694	6.5.The board annually shall adjust the initial level of
695	claims and the maximum limit to be retained by the carrier to
696	reflect increases in costs and utilization within the standard
697	market for health benefit plans within the state. The adjustment
698	shall not be less than the annual change in the medical
699	component of the "Consumer Price Index for All Urban Consumers"
700	of the Bureau of Labor Statistics of the Department of Labor,
701	unless the board proposes and the department approves a lower
702	adjustment factor.
703	7.6.A small employer carrier may terminate reinsurance
704	for all reinsured employees or dependents on any plan
705	anniversary.
706	8.7.The premium rate charged for reinsurance by the
707	program to a health maintenance organization that is approved by
708	the Secretary of Health and Human Services as a federally
709	qualified health maintenance organization pursuant to 42 U.S.C.
710	s. 300e(c)(2)(A) and that, as such, is subject to requirements
711	that limit the amount of risk that may be ceded to the program,
712	which requirements are more restrictive than subparagraph 5.4.,
713	shall be reduced by an amount equal to that portion of the risk,
714	if any, which exceeds the amount set forth in subparagraph 5.4.
715	which may not be ceded to the program.
716	9.8.The board may consider adjustments to the premium
717	rates charged for reinsurance by the program for carriers that
718	use effective cost containment measures, including high-cost
719	case management, as defined by the board.
720	10.9.A reinsuring carrier shall apply its case-management
721	and claims-handling techniques, including, but not limited to,
722	utilization review, individual case management, preferred
723	provider provisions, other managed care provisions or methods of
724	operation, consistently with both reinsured business and
725	nonreinsured business.
726	(h)1. The board, as part of the plan of operation, shall
727	establish a methodology for determining premium rates to be
728	charged by the program for reinsuring small employers and
729	individuals pursuant to this section. The methodology shall
730	include a system for classification of small employers that
731	reflects the types of case characteristics commonly used by
732	small employer carriers in the state. The methodology shall
733	provide for the development of basic reinsurance premium rates,
734	which shall be multiplied by the factors set for them in this
735	paragraph to determine the premium rates for the program. The
736	basic reinsurance premium rates shall be established by the
737	board, subject to the approval of the department, and shall be
738	set at levels which reasonably approximate gross premiums
739	charged to small employers by small employer carriers for health
740	benefit plans with benefits similar to the standard and basic
741	health benefit plan. The premium rates set by the board may vary
742	by geographical area, as determined under this section, to
743	reflect differences in cost. The multiplying factors must be
744	established as follows:
745	a. The entire group may be reinsured for a rate that is
746	1.5 times the rate established by the board.
747	b. An eligible employee or dependent may be reinsured for
748	a rate that is 5 times the rate established by the board.
749	2. The board periodically shall review the methodology
750	established, including the system of classification and any
751	rating factors, to assure that it reasonably reflects the claims
752	experience of the program. The board may propose changes to the
753	rates which shall be subject to the approval of the department.
754	(j)1. Before SeptemberMarch1 of each calendar year, the
755	board shall determine and report to the department the program
756	net loss for the previous year, including administrative
757	expenses for that year, and the incurred losses for the year,
758	taking into account investment income and other appropriate
759	gains and losses.
760	2. Any net loss for the year shall be recouped by
761	assessment of the carriers, as follows:
762	a. The operating losses of the program shall be assessed
763	in the following order subject to the specified limitations. The
764	first tier of assessments shall be made against reinsuring
765	carriers in an amount which shall not exceed 5 percent of each
766	reinsuring carrier's premiums from health benefit plans covering
767	small employers. If such assessments have been collected and
768	additional moneys are needed, the board shall make a second tier
769	of assessments in an amount which shall not exceed 0.5 percent
770	of each carrier's health benefit plan premiums. Except as
771	provided in paragraph (n), risk-assuming carriers are exempt
772	from all assessments authorized pursuant to this section. The
773	amount paid by a reinsuring carrier for the first tier of
774	assessments shall be credited against any additional assessments
775	made.
776	b. The board shall equitably assess carriers for operating
777	losses of the plan based on market share. The board shall
778	annually assess each carrier a portion of the operating losses
779	of the plan. The first tier of assessments shall be determined
780	by multiplying the operating losses by a fraction, the numerator
781	of which equals the reinsuring carrier's earned premium
782	pertaining to direct writings of small employer health benefit
783	plans in the state during the calendar year for which the
784	assessment is levied, and the denominator of which equals the
785	total of all such premiums earned by reinsuring carriers in the
786	state during that calendar year. The second tier of assessments
787	shall be based on the premiums that all carriers, except risk-
788	assuming carriers, earned on all health benefit plans written in
789	this state. The board may levy interim assessments against
790	carriers to ensure the financial ability of the plan to cover
791	claims expenses and administrative expenses paid or estimated to
792	be paid in the operation of the plan for the calendar year prior
793	to the association's anticipated receipt of annual assessments
794	for that calendar year. Any interim assessment is due and
795	payable within 30 days after receipt by a carrier of the interim
796	assessment notice. Interim assessment payments shall be credited
797	against the carrier's annual assessment. Health benefit plan
798	premiums and benefits paid by a carrier that are less than an
799	amount determined by the board to justify the cost of collection
800	may not be considered for purposes of determining assessments.
801	c. Subject to the approval of the department, the board
802	shall make an adjustment to the assessment formula for
803	reinsuring carriers that are approved as federally qualified
804	health maintenance organizations by the Secretary of Health and
805	Human Services pursuant to 42 U.S.C. s. 300e(c)(2)(A) to the
806	extent, if any, that restrictions are placed on them that are
807	not imposed on other small employer carriers.
808	3. Before SeptemberMarch1 of each year, the board shall
809	determine and file with the department an estimate of the
810	assessments needed to fund the losses incurred by the program in
811	the previous calendar year.
812	4. If the board determines that the assessments needed to
813	fund the losses incurred by the program in the previous calendar
814	year will exceed the amount specified in subparagraph 2., the
815	board shall evaluate the operation of the program and report its
816	findings, including any recommendations for changes to the plan
817	of operation, to the department within 24090days following the
818	end of the calendar year in which the losses were incurred. The
819	evaluation shall include an estimate of future assessments, the
820	administrative costs of the program, the appropriateness of the
821	premiums charged and the level of carrier retention under the
822	program, and the costs of coverage for small employers. If the
823	board fails to file a report with the department within 24090
824	days following the end of the applicable calendar year, the
825	department may evaluate the operations of the program and
826	implement such amendments to the plan of operation the
827	department deems necessary to reduce future losses and
828	assessments.
829	5. If assessments exceed the amount of the actual losses
830	and administrative expenses of the program, the excess shall be
831	held as interest and used by the board to offset future losses
832	or to reduce program premiums. As used in this paragraph, the
833	term "future losses" includes reserves for incurred but not
834	reported claims.
835	6. Each carrier's proportion of the assessment shall be
836	determined annually by the board, based on annual statements and
837	other reports considered necessary by the board and filed by the
838	carriers with the board.
839	7. Provision shall be made in the plan of operation for
840	the imposition of an interest penalty for late payment of an
841	assessment.
842	8. A carrier may seek, from the commissioner, a deferment,
843	in whole or in part, from any assessment made by the board. The
844	department may defer, in whole or in part, the assessment of a
845	carrier if, in the opinion of the department, the payment of the
846	assessment would place the carrier in a financially impaired
847	condition. If an assessment against a carrier is deferred, in
848	whole or in part, the amount by which the assessment is deferred
849	may be assessed against the other carriers in a manner
850	consistent with the basis for assessment set forth in this
851	section. The carrier receiving such deferment remains liable to
852	the program for the amount deferred and is prohibited from
853	reinsuring any individuals or groups in the program if it fails
854	to pay assessments.
855	Section 12. Section 627.911, Florida Statutes, is amended
856	to read:
857	627.911 Scope of this part.--Any insurer or health
858	maintenance organizationtransacting insurance in this state
859	shall report information as required by this part.
860	Section 13. Section 627.9175, Florida Statutes, is amended
861	to read:
862	627.9175 Reports of information on health insurance.--
863	(1) Each authorized health insurer or health maintenance
864	organization shall submit annually to the office, on or before
865	March 1 of each year, information concerningdepartment as to
866	policies of individual health insurance coverage being issued or
867	currently in force in this state. The information shall include
868	information related to premium, number of policies, and covered
869	lives for such policies and other information necessary to
870	analyze trends in enrollment, premiums, and claim costs.
871	(2) The required information shall be broken down by
872	market segment, to include:
873	(a) Health insurance issuer, company, contact person, or
874	agent.
875	(b) All health insurance products issued or in force,
876	including, but not limited to:
877	1. Direct premiums earned.
878	2. Direct losses incurred.
879	3. Direct premiums earned for new business issued during
880	the year.
881	4. Number of policies.
882	5. Number of certificates.
883	6. Number of total covered lives.
884	(a) A summary of typical benefits, exclusions, and
885	limitations for each type of individual policy form currently
886	being issued in the state. The summary shall include, as
887	appropriate:
888	1. The deductible amount;
889	2. The coinsurance percentage;
890	3. The out-of-pocket maximum;
891	4. Outpatient benefits;
892	5. Inpatient benefits; and
893	6. Any exclusions for preexisting conditions.
894
895	The department shall determine other appropriate benefits,
896	exclusions, and limitations to be reported for inclusion in the
897	consumer's guide published pursuant to this section.
898	(b) A schedule of rates for each type of individual policy
899	form reflecting typical variations by age, sex, region of the
900	state, or any other applicable factor which is in use and is
901	determined to be appropriate for inclusion by the department.
902
903	The department shall provide by rule a uniform format for the
904	submission of this information in order to allow for meaningful
905	comparisons of premiums charged for comparable benefits.
906	(3) The department may adopt rules to administer this
907	section, including, but not limited to, rules governing
908	compliance and provisions implementing electronic methodologies
909	for use in furnishing such records or documents. The commission
910	may by rule specify a uniform format for the submission of this
911	information in order to allow for meaningful comparisonsshall
912	publish annually a consumer's guide which summarizes and
913	compares the information required to be reported under this
914	subsection.
915	(2)(a) Every insurer transacting health insurance in this
916	state shall report annually to the department, not later than
917	April 1, information relating to any measure the insurer has
918	implemented or proposes to implement during the next calendar
919	year for the purpose of containing health insurance costs or
920	cost increases. The reports shall identify each measure and the
921	forms to which the measure is applied, shall provide an
922	explanation as to how the measure is used, and shall provide an
923	estimate of the cost effect of the measure.
924	(b) The department shall promulgate forms to be used by
925	insurers in reporting information pursuant to this subsection
926	and shall utilize such forms to analyze the effects of health
927	care cost containment programs used by health insurers in this
928	state.
929	(c) The department shall analyze the data reported under
930	this subsection and shall annually make available to the public
931	a summary of its findings as to the types of cost containment
932	measures reported and the estimated effect of these measures.
933	Section 14. Section 627.9403, Florida Statutes, is amended
934	to read:
935	627.9403 Scope.--The provisions of this part shall apply
936	to long-term care insurance policies delivered or issued for
937	delivery in this state, and to policies delivered or issued for
938	delivery outside this state to the extent provided in s.
939	627.9406, by an insurer, a fraternal benefit society as defined
940	in s. 632.601, a health maintenance organization as defined in
941	s. 641.19, a prepaid health clinic as defined in s. 641.402, or
942	a multiple-employer welfare arrangement as defined in s.
943	624.437. A policy which is advertised, marketed, or offered as a
944	long-term care policy and as a Medicare supplement policy shall
945	meet the requirements of this part and the requirements of ss.
946	627.671-627.675 and, to the extent of a conflict, be subject to
947	the requirement that is more favorable to the policyholder or
948	certificateholder. The provisions of this part shall not apply
949	to a continuing care contract issued pursuant to chapter 651 and
950	shall not apply to guaranteed renewable policies issued prior to
951	October 1, 1988. Any limited benefit policy that limits coverage
952	to care in a nursing home or to one or more lower levels of care
953	required or authorized to be provided by this part or by
954	department rule must meet all requirements of this part that
955	apply to long-term care insurance policies, except ss.
956	627.9407(3)(c) and (d), (9), (10)(f), and (12) and 627.94073(2).
957	If the limited benefit policy does not provide coverage for care
958	in a nursing home, but does provide coverage for one or more
959	lower levels of care, the policy shall also be exempt from the
960	requirements of s. 627.9407(3)(d).
961	Section 15. Paragraph (b) of subsection (1) of section
962	641.185, Florida Statutes, is amended to read:
963	641.185 Health maintenance organization subscriber
964	protections.--
965	(1) With respect to the provisions of this part and part
966	III, the principles expressed in the following statements shall
967	serve as standards to be followed by the Department of Insurance
968	and the Agency for Health Care Administration in exercising
969	their powers and duties, in exercising administrative
970	discretion, in administrative interpretations of the law, in
971	enforcing its provisions, and in adopting rules:
972	(b) A health maintenance organization subscriber should
973	receive quality health care from a broad panel of providers,
974	including referrals, preventive care pursuant to s. 641.402(1),
975	emergency screening and services pursuant to ss. 641.31(13)(12)
976	and 641.513, and second opinions pursuant to s. 641.51.
977	Section 16. Paragraph (d) of subsection (3) and
978	subsections (9) through (17) of section 641.31, Florida
979	Statutes, are amended to read:
980	641.31 Health maintenance contracts.--
981	(3)
982	(d) Any change in rates charged for the contract must be
983	filed with the department not less than 30 days in advance of
984	the effective date. At the expiration of such 30 days, the rate
985	filing shall be deemed approved unless prior to such time the
986	filing has been affirmatively approved or disapproved by order
987	of the department. The approval of the filing by the department
988	constitutes a waiver of any unexpired portion of such waiting
989	period. The department may extend by not more than an additional
990	15 days the period within which it may so affirmatively approve
991	or disapprove any such filing, by giving notice of such
992	extension before expiration of the initial 30-day period. At the
993	expiration of any such period as so extended, and in the absence
994	of such prior affirmative approval or disapproval, any such
995	filing shall be deemed approved. This paragraph does not apply
996	to group health maintenance organization contracts effectuated
997	and delivered in this state insuring groups of 51 or more
998	persons.
999	(9)(a)1. If a health maintenance organization offers
1000	coverage for dependent children of the subscriber, the contract
1001	must cover a dependent child of the subscriber at least until
1002	the end of the calendar year in which the child reaches the age
1003	of 23, if the child meets all of the following:
1004	a. The child is dependent upon the subscriber for support.
1005	b. The child is living in the household of the subscriber,
1006	or the child is a full-time or part-time student.
1007	2. Nothing in this paragraph affects or preempts a health
1008	maintenance organization's right to medically underwrite or
1009	charge the appropriate premium.
1010	(b)1. A contract that provides coverage for a family
1011	member of the subscriber shall, as to such family member's
1012	coverage, provide that benefits applicable to children of the
1013	subscriber also apply to an adopted child or a foster child of
1014	the subscriber placed in compliance with chapter 63 from the
1015	moment of placement in the residence of the subscriber. Except
1016	in the case of a foster child, the contract may not exclude
1017	coverage for any preexisting condition of the child. In the case
1018	of a newborn child, coverage begins at the moment of birth if a
1019	written agreement to adopt such child has been entered into by
1020	the subscriber prior to the birth of the child, whether or not
1021	the agreement is enforceable. This section does not require
1022	coverage for an adopted child who is not ultimately placed in
1023	the residence of the subscriber in compliance with chapter 63.
1024	2. A contract may require the subscriber to notify the
1025	health maintenance organization of the birth or placement of an
1026	adopted child within a specified time period of not less than 30
1027	days after the birth or placement in the residence of a child
1028	adopted by the subscriber. If timely notice is given, the health
1029	maintenance organization may not charge an additional premium
1030	for coverage of the child for the duration of the notice period.
1031	If timely notice is not given, the health maintenance
1032	organization may charge an additional premium from the date of
1033	birth or placement. If notice is given within 60 days after the
1034	birth or placement of the child, the health maintenance
1035	organization may not deny coverage for the child due to the
1036	failure of the subscriber to timely notify the health
1037	maintenance organization of the birth or placement of the child.
1038	3. If the contract does not require the subscriber to
1039	notify the health maintenance organization of the birth or
1040	placement of an adopted child within a specified time period,
1041	the health maintenance organization may not deny coverage for
1042	such child or retroactively charge the subscriber an additional
1043	premium for such child. However, the health maintenance
1044	organization may prospectively charge the subscriber an
1045	additional premium for the child if the health maintenance
1046	organization provides at least 45 days' notice of the additional
1047	premium required.
1048	4. In order to increase access to postnatal, infant, and
1049	pediatric health care for all children placed in court-ordered
1050	custody, including foster children, all health maintenance
1051	organization contracts that provide coverage for a family member
1052	of the subscriber shall, as to such family member's coverage,
1053	provide that benefits applicable for children shall be payable
1054	with respect to a foster child or other child in court-ordered,
1055	temporary, or other custody of the subscriber.
1056	(10) A contract that provides that coverage of a dependent
1057	child shall terminate upon attainment of the limiting age for
1058	dependent children specified in the contract shall also provide
1059	in substance that attainment of the limiting age does not
1060	terminate the coverage of the child while the child continues to
1061	be:
1062	(a) Incapable of self-sustaining employment by reason of
1063	mental retardation or physical handicap.
1064	(b) Chiefly dependent upon the subscriber for support and
1065	maintenance.
1066
1067	If a claim is denied under a contract for the stated reason that
1068	the child has attained the limiting age for dependent children
1069	specified in the contract, the notice of denial must state that
1070	the subscriber has the burden of establishing that the child
1071	continues to meet the criteria specified in paragraphs (a) and
1072	(b).All health maintenance contracts that provide coverage,
1073	benefits, or services for a member of the family of the
1074	subscriber must, as to such family member's coverage, benefits,
1075	or services, provide also that the coverage, benefits, or
1076	services applicable for children must be provided with respect
1077	to a newborn child of the subscriber, or covered family member
1078	of the subscriber, from the moment of birth. However, with
1079	respect to a newborn child of a covered family member other than
1080	the spouse of the insured or subscriber, the coverage for the
1081	newborn child terminates 18 months after the birth of the
1082	newborn child. The coverage, benefits, or services for newborn
1083	children must consist of coverage for injury or sickness,
1084	including the necessary care or treatment of medically diagnosed
1085	congenital defects, birth abnormalities, or prematurity, and
1086	transportation costs of the newborn to and from the nearest
1087	appropriate facility appropriately staffed and equipped to treat
1088	the newborn's condition, when such transportation is certified
1089	by the attending physician as medically necessary to protect the
1090	health and safety of the newborn child.
1091	(a) A contract may require the subscriber to notify the
1092	plan of the birth of a child within a time period, as specified
1093	in the contract, of not less than 30 days after the birth, or a
1094	contract may require the preenrollment of a newborn prior to
1095	birth. However, if timely notice is given, a plan may not charge
1096	an additional premium for additional coverage of the newborn
1097	child for not less than 30 days after the birth of the child. If
1098	timely notice is not given, the plan may charge an additional
1099	premium from the date of birth. If notice is given within 60
1100	days of the birth of the child, the contract may not deny
1101	coverage of the child due to failure of the subscriber to timely
1102	notify the plan of the birth of the child or to preenroll the
1103	child.
1104	(b) If the contract does not require the subscriber to
1105	notify the plan of the birth of a child within a specified time
1106	period, the plan may not deny coverage of the child nor may it
1107	retroactively charge the subscriber an additional premium for
1108	the child; however, the contract may prospectively charge the
1109	member an additional premium for the child if the plan provides
1110	at least 45 days' notice of the additional charge.
1111	(11)(10)No alteration of any written application for any
1112	health maintenance contract shall be made by any person other
1113	than the applicant without his or her written consent, except
1114	that insertions may be made by the health maintenance
1115	organization, for administrative purposes only, in such manner
1116	as to indicate clearly that such insertions are not to be
1117	ascribed to the applicant.
1118	(12)(11)No contract shall contain any waiver of rights or
1119	benefits provided to or available to subscribers under the
1120	provisions of any law or rule applicable to health maintenance
1121	organizations.
1122	(13)(12)Each health maintenance contract, certificate, or
1123	member handbook shall state that emergency services and care
1124	shall be provided to subscribers in emergency situations not
1125	permitting treatment through the health maintenance
1126	organization's providers, without prior notification to and
1127	approval of the organization. Not less than 75 percent of the
1128	reasonable charges for covered services and supplies shall be
1129	paid by the organization, up to the subscriber contract benefit
1130	limits. Payment also may be subject to additional applicable
1131	copayment provisions, not to exceed $100 per claim. The health
1132	maintenance contract, certificate, or member handbook shall
1133	contain the definitions of "emergency services and care" and
1134	"emergency medical condition" as specified in s. 641.19(7) and
1135	(8), shall describe procedures for determination by the health
1136	maintenance organization of whether the services qualify for
1137	reimbursement as emergency services and care, and shall contain
1138	specific examples of what does constitute an emergency. In
1139	providing for emergency services and care as a covered service,
1140	a health maintenance organization shall be governed by s.
1141	641.513.
1142	(14)(13)In addition to the requirements of this section,
1143	with respect to a person who is entitled to have payments for
1144	health care costs made under Medicare, Title XVIII of the Social
1145	Security Act ("Medicare"), parts A and/or B:
1146	(a) The health maintenance organization shall mail or
1147	deliver notification to the Medicare beneficiary of the date of
1148	enrollment in the health maintenance organization within 10 days
1149	after receiving notification of enrollment approval from the
1150	United States Department of Health and Human Services, Health
1151	Care Financing Administration. When a Medicare beneficiary who
1152	is a subscriber of the health maintenance organization requests
1153	disenrollment from the organization, the organization shall mail
1154	or deliver to the beneficiary notice of the effective date of
1155	the disenrollment within 10 days after receipt of the written
1156	disenrollment request. The health maintenance organization shall
1157	forward the disenrollment request to the United States
1158	Department of Health and Human Services, Health Care Financing
1159	Administration, in a timely manner so as to effectuate the next
1160	available disenrollment date, as prescribed by such federal
1161	agency.
1162	(b) The health maintenance contract, certificate, or
1163	member handbook shall be delivered to the subscriber no later
1164	than the earlier of 10 working days after the health maintenance
1165	organization and the Health Care Financing Administration of the
1166	United States Department of Health and Human Services approve
1167	the subscriber's enrollment application or the effective date of
1168	coverage of the subscriber under the health maintenance
1169	contract. However, if notice from the Health Care Financing
1170	Administration of its approval of the subscriber's enrollment
1171	application is received by the health maintenance organization
1172	after the effective coverage date prescribed by the Health Care
1173	Financing Administration, the health maintenance organization
1174	shall deliver the contract, certificate, or member handbook to
1175	the subscriber within 10 days after receiving such notice. When
1176	a Medicare recipient is enrolled in a health maintenance
1177	organization program, the contract, certificate, or member
1178	handbook shall be accompanied by a health maintenance
1179	organization identification sticker with instruction to the
1180	Medicare beneficiary to place the sticker on the Medicare
1181	identification card.
1182	(15)(14)Whenever a subscriber of a health maintenance
1183	organization is also a Medicaid recipient, the health
1184	maintenance organization's coverage shall be primary to the
1185	recipient's Medicaid benefits and the organization shall be a
1186	third party subject to the provisions of s. 409.910(4).
1187	(16)(15)(a) All health maintenance contracts,
1188	certificates, and member handbooks shall contain the following
1189	provision:
1190
1191	"Grace Period: This contract has a (insert a number not less
1192	than 10) day grace period. This provision means that if any
1193	required premium is not paid on or before the date it is due, it
1194	may be paid during the following grace period. During the grace
1195	period, the contract will stay in force."
1196
1197	(b) The required provision of paragraph (a) shall not
1198	apply to certificates or member handbooks delivered to
1199	individual subscribers under a group health maintenance contract
1200	when the employer or other person who will hold the contract on
1201	behalf of the subscriber group pays the entire premium for the
1202	individual subscribers. However, such required provision shall
1203	apply to the group health maintenance contract.
1204	(17)(16)The contracts must clearly disclose the intent of
1205	the health maintenance organization as to the applicability or
1206	nonapplicability of coverage to preexisting conditions. If
1207	coverage of the contract is not to be applicable to preexisting
1208	conditions, the contract shall specify, in substance, that
1209	coverage pertains solely to accidental bodily injuries resulting
1210	from accidents occurring after the effective date of coverage
1211	and that sicknesses are limited to those which first manifest
1212	themselves subsequent to the effective date of coverage.
1213	(17) All health maintenance contracts that provide
1214	coverage for a member of the family of the subscriber, shall, as
1215	to such family member's coverage, provide that coverage,
1216	benefits, or services applicable for children shall be provided
1217	with respect to an adopted child of the subscriber, which child
1218	is placed in compliance with chapter 63, from the moment of
1219	placement in the residence of the subscriber. Such contracts may
1220	not exclude coverage for any preexisting condition of the child.
1221	In the case of a newborn child, coverage shall begin from the
1222	moment of birth if a written agreement to adopt such child has
1223	been entered into by the subscriber prior to the birth of the
1224	child, whether or not such agreement is enforceable. However,
1225	coverage for such child shall not be required in the event that
1226	the child is not ultimately placed in the residence of the
1227	subscriber in compliance with chapter 63.
1228	Section 17. Section 641.3101, Florida Statutes, is amended
1229	to read:
1230	641.3101 Additional contract contents.--
1231	(1)A health maintenance contract may contain additional
1232	provisions not inconsistent with this part which are:
1233	(a)(1)Necessary, on account of the manner in which the
1234	organization is constituted or operated, in order to state the
1235	rights and obligations of the parties to the contract; or
1236	(b)(2)Desired by the organization and neither prohibited
1237	by law nor in conflict with any provisions required to be
1238	included therein.
1239	(2) A health maintenance contract that uses a specific
1240	methodology for payment of claims shall comply with s. 627.6044.
1241	Section 18. Section 641.31025, Florida Statutes, is
1242	created to read:
1243	641.31025 Specific reasons for denial of coverage.--The
1244	denial of an application for a health maintenance organization
1245	contract must be accompanied by the specific reasons for the
1246	denial, including, but not limited to, the specific underwriting
1247	reasons, if applicable.
1248	Section 19. Section 641.31075, Florida Statutes, is
1249	created to read:
1250	641.31075 Replacement.--Any health maintenance
1251	organization that is replacing any other group health coverage
1252	with its group health maintenance coverage shall comply with s.
1253	627.666.
1254	Section 20. Subsections (1) and (3) of section 641.3111,
1255	Florida Statutes, are amended to read:
1256	641.3111 Extension of benefits.--
1257	(1) Every group health maintenance contract shall provide
1258	that termination of the contract shall be without prejudice to
1259	any continuous loss which commenced while the contract was in
1260	force, but any extension of benefits beyond the period the
1261	contract was in force may be predicated upon the continuous
1262	total disability of the subscriber and may be limited to payment
1263	for the treatment of a specific accident or illness incurred
1264	while the subscriber was a member. The extension is required
1265	regardless of whether the group contract holder or other entity
1266	secures replacement coverage from a new insurer or health
1267	maintenance organization or foregoes the provision of coverage.
1268	The required provision must provide for continuation of contract
1269	benefits in connection with the treatment of a specific accident
1270	or illness incurred while the contract was in effect.Such
1271	extension of benefits may be limited to the occurrence of the
1272	earliest of the following events:
1273	(a) The expiration of 12 months.
1274	(b) Such time as the member is no longer totally disabled.
1275	(c) A succeeding carrier elects to provide replacement
1276	coverage without limitation as to the disability condition.
1277	(c)(d)The maximum benefits payable under the contract
1278	have been paid.
1279	(3) In the case of maternity coverage, when not covered by
1280	the succeeding carrier,a reasonable extension of benefits or
1281	accrued liability provision is required, which provision
1282	provides for continuation of the contract benefits in connection
1283	with maternity expenses for a pregnancy that commenced while the
1284	policy was in effect. The extension shall be for the period of
1285	that pregnancy and shall not be based upon total disability.
1286	Section 21. Subsection (4) of section 627.651, Florida
1287	Statutes, is amended to read:
1288	627.651 Group contracts and plans of self-insurance must
1289	meet group requirements.--
1290	(4) This section does not apply to any plan which is
1291	established or maintained by an individual employer in
1292	accordance with the Employee Retirement Income Security Act of
1293	1974, Pub. L. No. 93-406, or to a multiple-employer welfare
1294	arrangement as defined in s. 624.437(1), except that a multiple-
1295	employer welfare arrangement shall comply with ss. 627.419,
1296	627.657, 627.6575, 627.6578, 627.6579, 627.6612, 627.66121,
1297	627.66122, 627.6615, 627.6616, and 627.662(8)(7). This
1298	subsection does not allow an authorized insurer to issue a group
1299	health insurance policy or certificate which does not comply
1300	with this part.
1301	Section 22. Subsection (1) of section 641.2018, Florida
1302	Statutes, is amended to read:
1303	641.2018 Limited coverage for home health care
1304	authorized.--
1305	(1) Notwithstanding other provisions of this chapter, a
1306	health maintenance organization may issue a contract that limits
1307	coverage to home health care services only. The organization and
1308	the contract shall be subject to all of the requirements of this
1309	part that do not require or otherwise apply to specific benefits
1310	other than home care services. To this extent, all of the
1311	requirements of this part apply to any organization or contract
1312	that limits coverage to home care services, except the
1313	requirements for providing comprehensive health care services as
1314	provided in ss. 641.19(4), (12), and (13), and 641.31(1), except
1315	ss. 641.31(9),(13)(12), (17),(18), (19), (20), (21), and (24)
1316	and 641.31095.
1317	Section 23. Section 641.3107, Florida Statutes, is amended
1318	to read:
1319	641.3107 Delivery of contract.--Unless delivered upon
1320	execution or issuance, a health maintenance contract,
1321	certificate of coverage, or member handbook shall be mailed or
1322	delivered to the subscriber or, in the case of a group health
1323	maintenance contract, to the employer or other person who will
1324	hold the contract on behalf of the subscriber group within 10
1325	working days from approval of the enrollment form by the health
1326	maintenance organization or by the effective date of coverage,
1327	whichever occurs first. However, if the employer or other person
1328	who will hold the contract on behalf of the subscriber group
1329	requires retroactive enrollment of a subscriber, the
1330	organization shall deliver the contract, certificate, or member
1331	handbook to the subscriber within 10 days after receiving notice
1332	from the employer of the retroactive enrollment. This section
1333	does not apply to the delivery of those contracts specified in
1334	s. 641.31(14)(13).
1335	Section 24. Subsection (4) of section 641.513, Florida
1336	Statutes, is amended to read:
1337	641.513 Requirements for providing emergency services and
1338	care.--
1339	(4) A subscriber may be charged a reasonable copayment, as
1340	provided in s. 641.31(13)(12), for the use of an emergency room.
1341	Section 25. This act shall take effect upon becoming a
1342	law.