HOUSE AMENDMENT Bill No. HB 999 CS
1	CHAMBER ACTION
2	Senate House
3	.
4	.
5	.
6
7
8
9
10
11
12	Representative Stargel offered the following:
13
14	Amendment
15	Remove line(s) 46-70, and insert:
16
17	2.a. Effectuated and delivered outside this state, but
18	covering residents of this state, except for policies issued to
19	provide coverage to groups of persons all of whom are in the
20	same or functionally related licensed professions, and providing
21	coverage only to such licensed professionals, their employees or
22	their dependents, if the insurer meets the requirements of s.
23	627.6515, files its rates with the Office of Insurance
24	Regulation for information purposes only, and the filing of
25	rates is accompanied by an actuarial certification that the loss
26	ratios for the certificates delivered or issued for delivery in
27	this state meet or exceed a lifetime loss ratio for incurred
28	claims to earned premium of 65 percent for group policies, and
29	certificates reflecting coverage thereunder, issued on or after
30	the effective date of this act.
31	b. If an insurer issues policies which are not provider
32	network-based, they shall file with the Office of Insurance
33	Regulation for information purposes only, and accompanied by an
34	actuarial certification, that the loss ratios for certificates
35	delivered or issued for delivery in this state meet or exceed a
36	loss ratio of 60 percent for the first 2 years of coverage for
37	incurred claims. After the first 2 complete years of coverage,
38	such policies will be subject to the 65-percent loss ratio as
39	set forth in this section.
40	c. For the purposes of this subparagraph, incurred claims
41	may include, at the company’s discretion, costs that do not
42	result in increasing the loss ratio by more than 5 percent which
43	are expenses that serve to reduce the number of health services
44	provided or the cost of such services. Examples of cost
45	containment expenses are:
46	(I) Case management activities;
47	(II) Utilization review;
48	(III) Detection and prevention of payment for fraudulent
49	request for reimbursement;
50	(IV) Network access fees to Preferred Provider
51	Organizations and other network-based health plans, including
52	prescription drug networks; and
53	(V) Consumer education solely relating to health
54	improvement and relying on the direct involvement of health
55	personnel, which would include smoking cessation and disease
56	management programs and other programs that involve hands on
57	medical education.
58
59	The 65 percent loss ratio does not apply to accidental death,
60	accidental death and dismemberment, accident-only, vision-only,
61	dental only, hospital indemnity, hospital accident, cancer,
62	specified disease, disability income insurance, or similar
63	supplemental plans provided under a separate policy,
64	certificate, or contract of insurance, which cannot duplicate
65	coverage under an underlying health plan and are specifically
66	designed to fill gaps in the underlying health plan, coinsurance
67	or deductibles; coverage issued as a supplement to liability
68	insurance; worker’s compensation or similar insurance; or
69	automobile medical payment insurance.
70	d. As used in this subparagraph, the actuarial
71	certification shall be made by a qualified actuary who is a
72	member of the Society of Actuaries or the American Academy of
73	Actuaries and who is qualified in the area of health insurance.
74	For purposes of this subparagraph, group health insurance policy
75	means any hospital or medical policy, hospital or medical
76	service plan contract, or health maintenance organization
77	subscriber contract. The term does not include accidental death,
78	accidental death and dismemberment, accident-only, vision-only,
79	dental-only, hospital indemnity, hospital accident, cancer,
80	specified disease, limited-benefit, disability income insurance,
81	or similar supplemental plans provided under a separate policy,
82	certificate, or contract of insurance, which cannot duplicate
83	coverage under an underlying health plan and are specifically
84	designed to fill gaps in the underlying health plan,
85	coinsurance, or deductibles; coverage issued as a supplement to
86	liability insurance; worker's compensation, or similar
87	insurance; or automobile medical-payment insurance.