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