HB 0999 2003
1	A bill to be entitled
2	An act relating to out-of-state group, blanket, and
3	franchise health insurance policies; amending s. 627.6515,
4	F.S.; revising certain criteria relating to nonapplication
5	of certain provisions to certain group health insurance
6	policies; specifying application; providing exceptions;
7	requiring certain policies, forms, and rates to be filed
8	and approved before providing or renewing coverage of
9	certain persons; requiring review by the Office of
10	Insurance Regulation; requiring combination of certain
11	insurer experience under certain circumstances; providing
12	for enforcement authority of the office; providing
13	requirements, limitations, and prohibitions relating to
14	insurers, policies, and coverage; requiring the office to
15	adopt rules; authorizing the office to exempt certain
16	policies, documents, or forms from certain provisions
17	under certain circumstances; specifying application;
18	providing an effective date.
19
20	Be It Enacted by the Legislature of the State of Florida:
21
22	Section 1. Subsection (2) of section 627.6515, Florida
23	Statutes, is amended, and subsections (9), (10), (11), and (12)
24	are added to said section, to read:
25	627.6515 Out-of-state groups.--
26	(2) Except as specifically provided otherwise in this
27	part,this part does not apply to a group health insurance
28	policy issued or delivered outside this state under which a
29	resident of this state is provided coverage if the forms and
30	rates and changes to the forms and rates are subject to
31	mandatory review and approval by the insurance regulatory
32	authorities in the state of issue and:
33	(a) The policy is issued to an employee group the
34	composition of which is substantially as described in s.
35	627.653; a labor union group or association groupthe
36	composition of which is substantially as described in s.
37	627.654; an additional group the composition of which is
38	substantially as described in s. 627.656 other than a group as
39	described in s. 627.5565; a group insured under a blanket health
40	policy when the composition of the group is substantially in
41	compliance with s. 627.659; a group insured under a franchise
42	health policy issued prior to October 1, 2001,when the
43	composition of the group is substantially in compliance with s.
44	627.663; an association group that has been in existence at
45	least 5 years andto cover persons associated in any other
46	common group, which common group is formed and maintained by its
47	members primarily for purposes of a specific and substantial
48	single common interest such as, but not limited to, a single
49	profession, skilled trade, hobby, or age group, or a trust on
50	behalf of such a groupother than providing insurance; a group
51	that is established primarily for the purpose of providing group
52	insurance, provided the benefits are and remainreasonable in
53	relation to the premiums charged thereunder and the issuance of
54	the group policy has resulted, or will result, in economies of
55	administration; or a group of insurance agents of an insurer,
56	which insurer is the policyholder;
57	(b) Certificates evidencing coverage under the policy are
58	issued to residents of this state and contain in contrasting
59	color and not less than 10-point type the following statement:
60	"The benefits of the policy providing your coverage are governed
61	primarily by the law of a state other than Florida"; and
62	(c) The policy provides the benefits specified in ss.
63	627.419, 627.6574, 627.6575, 627.6579, 627.6612, 627.66121,
64	627.66122, 627.6613, 627.667, 627.6675, 627.6691, and 627.66911.
65	(9)(a) This subsection shall apply to all policies to
66	which subsection (1) or subsection (2) apply except:
67	1. A health benefit plan as defined in s. 627.6699(3)(k),
68	providing coverage solely to one or more small employers in
69	accordance with the requirements of s. 627.6699, as to which
70	plan there is compliance with the requirements of ss. 627.6699,
71	627.410, and 627.411 as if the plan and all insurance policies
72	related to the plan were issued and delivered in this state.
73	2. Policies providing coverage solely to employees or
74	their dependents of an employer with over 50 employees.
75	3. Policies providing only Medicare supplement insurance,
76	which are subject to part VIII of chapter 627.
77	4. Policies providing solely long-term care insurance,
78	which are subject to part XVIII of chapter 627.
79	5. Policies issued to one or more labor organizations as
80	defined in s. 447.02, none of which labor organizations
81	represents self-employed persons, to provide coverage solely to
82	members or dependents of members of the labor organization.
83	6. Policies issued to provide coverage to persons all of
84	whom are in a licensed profession, to provide insurance coverage
85	only to such licensed professionals, their employees, or their
86	dependents.
87	7. Policies providing coverage only to persons or
88	dependents of persons age 50 or over, provided the Office of
89	Insurance Regulation determines that the benefits under the
90	policy are reasonable in relation to the premiums charged under
91	the policy as demonstrated by being filed and approved pursuant
92	to ss. 627.410 and 627.411 and the issuance of the group policy
93	has resulted, or will result, in economies of administration.
94	8. Policies covering a group of insurance agents of an
95	insurer, which insurer is the policyholder.
96	9. Any other policy determined by order of the Office of
97	Insurance Regulation to be exempt from the requirements of
98	paragraphs (b) and (c), based upon and as long as the Office of
99	Insurance Regulation finds that the application of paragraphs
100	(b) and (c) to such policy is impractical and unnecessary for
101	the protection of the public.
102	(b) The policy, related certificate and enrollment forms
103	used in this state, and rates and changes in rates shall be
104	filed and approved pursuant to ss. 627.410 and 627.411, prior to
105	providing or renewing coverage under such policy to any resident
106	of this state, as if the policy were issued and delivered in
107	this state, notwithstanding any provision to the contrary in ss.
108	627.401, 627.410, and 627.411 or other provision of this code,
109	and shall be reviewed by the Office of Insurance Regulation
110	pursuant to the standards set forth in ss. 627.410 and 627.411,
111	as supplemented by the provisions of paragraph (c).
112	(c)1.a. The experience of the insurer under all policies
113	and policy forms providing similar benefits shall be combined
114	for all rating purposes relating to the policy if:
115	(I) Any health-status-related factor is used by the
116	insurer in determining the initial or continued eligibility of
117	any individual applicant for any coverage under the policy;
118	(II) Any health-status-related factor is used in
119	determining the initial or continued eligibility of any
120	individual for membership in the group to whom or for the
121	benefit of whom the policy is issued; or
122	(III) Any health-status-related factor is used by or on
123	behalf of the group in determining the initial or continued
124	eligibility of any group member for participation by that group
125	member in the group insurance program.
126
127	For purposes of this paragraph, the term “health-status-related
128	factor” includes, but is not limited to, information relating to
129	an individual or dependent of the individual concerning medical
130	condition, receipt of medical care, individual or family health
131	history, genetic information, health insurance or disability
132	claims made, or absence from work due to sickness or other
133	disability.
134	b. For the purpose of enforcing this subparagraph, the
135	Office of Insurance Regulation shall adopt rules for use in
136	determining whether policies and policy forms provide similar
137	benefits, and the office’s authority and discretion in adopting
138	such rules shall be broadly construed towards the goal of
139	moderating premium increases in any one policy by maximizing the
140	size of the experience base upon which health insurers subject
141	to this subparagraph determine health insurance rates and
142	premiums.
143	2. The risk classification of an individual insured
144	assigned by the insurer at initiation of coverage of that
145	individual may not thereafter be changed at renewal or otherwise
146	while coverage of that individual is in force.
147	3. Durational rating, the practice of increasing premiums
148	paid by existing individual insureds based on the length of time
149	the individual insured has been covered under the policy, is
150	prohibited.
151	4. Premiums may only be increased for any individual
152	insured if increased for all individuals under the policy in all
153	rate classes and for all coverages, including riders, by the
154	same percentage amount.
155	5. Provisions in the policy relating to pre-existing
156	condition exclusions shall comply with the requirements of s.
157	627.6561 as if the policy were issued and delivered in this
158	state, provided that, notwithstanding any provision of s.
159	627.6561(5)(b), (c), or (d) to the contrary, the insurer shall
160	count as periods of prior creditable coverage for all purposes
161	all periods of coverage previously provided to the individual by
162	such insurer under any health insurance policy issued by such
163	insurer to or for the benefit of the same group as the policy
164	under which the individual seeks coverage.
165	6. The coverage of individuals under the policy shall be
166	guaranteed renewable at the option of the individuals, as long
167	as the master policy remains in force, except an insurer may
168	nonrenew an individual’s coverage for the reasons set forth in
169	s. 627.6425(2), provided:
170	a. If the membership of any individual in the group to
171	which or in relation to which the policy was issued is
172	terminated by the group directly or indirectly on the basis of
173	any health-status-related factor subsequent to the individual
174	obtaining coverage under the group policy, the individual shall
175	continue to be eligible for coverage under the policy under the
176	same terms, conditions, and rates as if a member of the group.
177	b. If a master policy is terminated, individual insureds
178	under the terminated policy shall, on a guaranteed-issue basis,
179	be offered coverage by the insurer under any other health
180	insurance then or within 90 days thereafter issued by the
181	insurer to or for the benefit of the same group as the
182	terminated policy and at the same risk classification which the
183	individual was assigned under the terminated policy. Insurers
184	shall provide printed notice to individuals whose coverage is
185	terminated due to the termination of a master policy of their
186	rights under this sub-subparagraph prior to termination of their
187	coverage under the terminated policy.
188	7. The policy shall provide that individuals having in
189	force any health insurance coverage under any other policy
190	issued to the same group and providing similar benefits may
191	transfer their coverage to such policy on a guaranteed-issue
192	basis and at the same risk classification as assigned by the
193	insurer under the policy from which they seek transferral.
194	(10) The Office of Insurance Regulation shall adopt rules
195	implementing this section.
196	(11) The Office of Insurance Regulation may, by order,
197	exempt from the requirements of subsections (4) and (5) as long
198	as the office deems proper any policy, insurance document, or
199	form or type thereof as specified in such order to which the
200	department determines subsections (4) and (5) may not
201	practicably be applied or the enforcement of which are, in the
202	office’s opinion, not desirable or necessary for the protection
203	of the public.
204	(12) Subsections (4), (5), (9), and (11) apply to policies
205	to which subsections (1) and (2) apply. Subsections (3), (6),
206	(7), and (8) apply only to policies to which subsection (2)
207	applies.
208	Section 2. This act shall take effect upon becoming a law.