HB 0145A 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
4	plans to limit coverage under certain circumstances;
5	authorizing a small business purchasing arrangement to
6	limit enrollment to certain residents; extending an
7	expiration date; creating s. 627.6042, F.S.; requiring
8	policies of insurers offering coverage of dependent
9	children to maintain such coverage until a child reaches
10	age 25, under certain circumstances; providing
11	application; creating s. 627.60425, F.S.; providing
12	limitations on certain binding arbitration requirements;
13	amending s. 627.6044, F.S.; providing for payment of
14	claims to nonnetwork providers under specified
15	conditions; providing a definition; requiring the method
16	used for determining payment of claims to be included in
17	filings; providing for disclosure; amending s. 627.6415,
18	F.S.; deleting an 18th birthday age limitation on
19	application of certain dependent coverage requirements;
20	amending s. 627.6475, F.S.; revising risk-assuming
21	carrier election requirements and procedures; revising
22	certain criteria and limitations under the individual
23	health reinsurance program; amending s. 627.651, F.S.;
24	correcting a cross reference; amending s. 627.662, F.S.;
25	revising a list of provisions applicable to group,
26	blanket, or franchise health insurance to include use of
27	specific methodology for payment of claims provisions;
28	amending s. 627.667, F.S.; deleting a limitation on
29	application of certain extension of benefits provisions;
30	amending s. 627.6692, F.S.; increasing a time period for
31	payment of premium to continue coverage under a group
32	health plan; amending s. 627.6699, F.S.; revising
33	definitions; revising coverage enrollment eligibility
34	criteria for small employers; revising small employer
35	carrier election requirements and procedures; revising
36	certain criteria and limitations under the small employer
37	health reinsurance program; amending ss. 627.911 and
38	627.9175, F.S.; applying certain information reporting
39	requirements to health maintenance organizations;
40	revising health insurance information requirements and
41	criteria; authorizing the department to adopt rules;
42	deleting an annual report requirement; amending s.
43	627.9403, F.S.; deleting an exemption for limited benefit
44	policies from a long-term care insurance restriction
45	relating to nursing home care; amending s. 641.185, F.S.;
46	correcting a cross reference; amending s. 641.31, F.S.;
47	specifying nonapplication to certain contracts; requiring
48	health maintenance organizations offering coverage of
49	dependent children to maintain such coverage until a
50	child reaches age 25, under certain circumstances;
51	providing application; providing requirements for
52	contract termination and denial of a claim related to
53	limiting age attainment; creating s. 641.31025, F.S.;
54	requiring specific reasons for denial of coverage under a
55	health maintenance organization contract; creating s.
56	641.31075, F.S.; imposing compliance requirements upon
57	health maintenance organization replacements of other
58	group health coverage with organization coverage;
59	amending s. 641.3111, F.S.; deleting a limitation on
60	certain extension of benefits provisions upon group
61	health maintenance contract termination; imposing
62	additional extension of benefits requirements upon such
63	termination; amending ss. 641.2018, 641.3107, and
64	641.513, F.S.; correcting cross references; providing for
65	construction of the act in pari materia with laws enacted
66	during the 2003 Regular Session of the Legislature;
67	providing an effective date.
68
69	Be It Enacted by the Legislature of the State of Florida:
70
71	Section 1. Paragraph (e) of subsection (2), subsection
72	(3), paragraph (c) of subsection (5), and subsection (10) of
73	section 408.909, Florida Statutes, are amended to read:
74	408.909 Health flex plans.--
75	(2) DEFINITIONS.--As used in this section, the term:
76	(e) "Health flex plan" means a health plan approved under
77	subsection (3) which guarantees payment for specified health
78	care coverage provided to the enrollee who purchases coverage
79	directly from the plan or through a small business purchasing
80	arrangement sponsored by a local government.
81	(3) PILOT PROGRAM.--The agency and the department shall
82	each approve or disapprove health flex plans that provide health
83	care coverage for eligible participants who reside in the three
84	areas of the state that have the highest number of uninsured
85	persons, as identified in the Florida Health Insurance Study
86	conducted by the agency and in Indian River County. A health
87	flex plan may limit or exclude benefits otherwise required by
88	law for insurers offering coverage in this state, may cap the
89	total amount of claims paid per year per enrollee, may limit the
90	number of enrollees or the term of coverage, or may take any
91	combination of those actions.
92	(a) The agency shall develop guidelines for the review of
93	applications for health flex plans and shall disapprove or
94	withdraw approval of plans that do not meet or no longer meet
95	minimum standards for quality of care and access to care.
96	(b) The department shall develop guidelines for the review
97	of health flex plan applications and shall disapprove or shall
98	withdraw approval of plans that:
99	1. Contain any ambiguous, inconsistent, or misleading
100	provisions or any exceptions or conditions that deceptively
101	affect or limit the benefits purported to be assumed in the
102	general coverage provided by the health flex plan;
103	2. Provide benefits that are unreasonable in relation to
104	the premium charged or contain provisions that are unfair or
105	inequitable or contrary to the public policy of this state, that
106	encourage misrepresentation, or that result in unfair
107	discrimination in sales practices; or
108	3. Cannot demonstrate that the health flex plan is
109	financially sound and that the applicant is able to underwrite
110	or finance the health care coverage provided.
111	(c) The agency and the department may adopt rules as
112	needed to administer this section.
113	(5) ELIGIBILITY.--Eligibility to enroll in an approved
114	health flex plan is limited to residents of this state who:
115	(c) Are not covered by a private insurance policy and are
116	not eligible for coverage through a public health insurance
117	program, such as Medicare or Medicaid, or another public health
118	care program, such as KidCare, and have not been covered at any
119	time during the past 6 months, except that a small business
120	purchasing arrangement sponsored by a local government may limit
121	enrollment to residents of this state who have not been covered
122	at any time during the past 12 months; and
123	(10) EXPIRATION.--This section expires July 1, 20082004.
124	Section 2. Section 627.6042, Florida Statutes, is created
125	to read:
126	627.6042 Dependent coverage.--
127	(1) If an insurer offers coverage that insures dependent
128	children of the policyholder or certificateholder, the policy
129	must insure a dependent child of the policyholder or
130	certificateholder at least until the end of the calendar year in
131	which the child reaches the age of 25, if the child meets all of
132	the following:
133	(a) The child is dependent upon the policyholder or
134	certificateholder for support.
135	(b) The child is living in the household of the
136	policyholder or certificateholder or the child is a full-time or
137	part-time student.
138	(2) Nothing in this section affects or preempts an
139	insurer's right to medically underwrite or charge the
140	appropriate premium.
141	Section 3. Section 627.60425, Florida Statutes, is created
142	to read:
143	627.60425 Binding arbitration requirement
144	limitations.--Notwithstanding any other provision of law, except
145	s. 624.155, an individual, blanket, group life, or group health
146	insurance policy; individual or group health maintenance
147	organization subscriber contract; prepaid limited health
148	organization subscriber contract; or any life or health
149	insurance policy or certificate delivered or issued for
150	delivery, including out-of-state group plans pursuant to s.
151	627.5515 or s. 627.6515 covering residents of this state, to any
152	resident of this state shall not require the submission of
153	disputes between the parties to the policy, contract, or plan to
154	binding arbitration unless the applicant has indicated that the
155	same policy, contract, or plan was offered and rejected without
156	arbitration and that the binding arbitration provision was fully
157	explained to the applicant and willingly accepted.
158	Section 4. Section 627.6044, Florida Statutes, is amended
159	to read:
160	627.6044 Use of a specific methodology for payment of
161	claims.--
162	(1) Each insurance policy that provides for payment of
163	claims to nonnetwork providers that is less than the payment of
164	the provider's billed charges to the insured, excluding
165	deductible, coinsurance, and copay amounts, shall:
166	(a) Provide benefits prior to deductible, coinsurance, and
167	copay amounts for using a nonnetwork provider that are at least
168	equal to the amount that would have been allowed had the insured
169	used a network provider but are not in excess of the actual
170	billed charges.
171	(b) Where there are multiple network providers in the
172	geographical area in which the services were provided or, if
173	none, the closest geographic area, the carrier may use an
174	averaging method of the contracted amounts but not less than the
175	80th percentile of all network contracted amounts in the
176	geographic area.
177
178	For purposes of this subsection, the term "network providers"
179	means those providers for which an insured will not be
180	responsible for any balance payment for services provided by
181	such provider, excluding deductible, coinsurance, and copay
182	amountsbased on a specific methodology, including, but not
183	limited to, usual and customary charges, reasonable and
184	customary charges, or charges based upon the prevailing rate in
185	the community, shall specify the formula or criteria used by the
186	insurer in determining the amount to be paid.
187	(2) Each insurer issuing a policy that provides for
188	payment of claims based on a specific methodology shall provide
189	to an insured, upon her or his written request, an estimate of
190	the amount the insurer will pay for a particular medical
191	procedure or service. The estimate may be in the form of a range
192	of payments or an average payment and may specify that the
193	estimate is based on the assumption of a particular service
194	code. The insurer may require the insured to provide detailed
195	information regarding the procedure or service to be performed,
196	including the procedure or service code number provided by the
197	health care provider and the health care provider's estimated
198	charge.An insurer that provides an insured with a good faith
199	estimate is not bound by the estimate. However, a pattern of
200	providing estimates that vary significantly from the ultimate
201	insurance payment constitutes a violation of this code.
202	(3) The method used for determining the payment of claims
203	shall be included in filings made pursuant to s. 627.410(6) and
204	may not be changed unless such change is filed under s.
205	627.410(6).
206	(4) Any policy that provides that the insured is
207	responsible for the balance of a claim amount, excluding
208	deductible, coinsurance, and copay amounts, must disclose such
209	feature on the face of the policy or certificate and such
210	feature must be included in any outline of coverage provided to
211	the insured.
212	Section 5. Subsections (1) and (4) of section 627.6415,
213	Florida Statutes, are amended to read:
214	627.6415 Coverage for natural-born, adopted, and foster
215	children; children in insured's custodial care.--
216	(1) A health insurance policy that provides coverage for a
217	member of the family of the insured shall, as to the family
218	member's coverage, provide that the health insurance benefits
219	applicable to children of the insured also apply to an adopted
220	child or a foster child of the insured placed in compliance with
221	chapter 63, prior to the child's 18th birthday,from the moment
222	of placement in the residence of the insured. Except in the case
223	of a foster child, the policy may not exclude coverage for any
224	preexisting condition of the child. In the case of a newborn
225	child, coverage begins at the moment of birth if a written
226	agreement to adopt the child has been entered into by the
227	insured prior to the birth of the child, whether or not the
228	agreement is enforceable. This section does not require coverage
229	for an adopted child who is not ultimately placed in the
230	residence of the insured in compliance with chapter 63.
231	(4) In order to increase access to postnatal, infant, and
232	pediatric health care for all children placed in court-ordered
233	custody, including foster children, all health insurance
234	policies that provide coverage for a member of the family of the
235	insured shall, as to such family member's coverage, also provide
236	that the health insurance benefits applicable for children shall
237	be payable with respect to a foster child or other child in
238	court-ordered temporary or other custody of the insured, prior
239	to the child's 18th birthday.
240	Section 6. Paragraph (a) of subsection (5), paragraph (c)
241	of subsection (6), and paragraphs (b), (c), and (e) of
242	subsection (7) of section 627.6475, Florida Statutes, are
243	amended to read:
244	627.6475 Individual reinsurance pool.--
245	(5) ISSUER'S ELECTION TO BECOME A RISK-ASSUMING CARRIER.--
246	(a) Each health insurance issuer that offers individual
247	health insurance must elect to become a risk-assuming carrier or
248	a reinsuring carrier for purposes of this section. Each such
249	issuer must make an initial election, binding through December
250	31, 1999. The issuer's initial election must be made no later
251	than October 31, 1997. By October 31, 1997, all issuers must
252	file a final election, which is binding for 2 years, from
253	January 1, 1998, through December 31, 1999, after whichan
254	election that shall be binding indefinitely or until modified or
255	withdrawnfor a period of 5 years. The department may permit an
256	issuer to modify its election at any time for good cause shown,
257	after a hearing.
258	(6) ELECTION PROCESS TO BECOME A RISK-ASSUMING CARRIER.--
259	(c) The department shall provide public notice of an
260	issuer's filing adesignation of election under this subsection
261	to become a risk-assuming carrier and shall provide at least a
262	21-day period for public comment upon receipt of such filing
263	prior to making a decision on the election. The department shall
264	hold a hearing on the election at the request of the issuer.
265	(7) INDIVIDUAL HEALTH REINSURANCE PROGRAM.--
266	(b) A reinsuring carrier may reinsure with the program
267	coverage of an eligible individual, subject to each of the
268	following provisions:
269	1. A reinsuring carrier may reinsure an eligible
270	individual within 9060days after commencement of the coverage
271	of the eligible individual.
272	2. The program may not reimburse a participating carrier
273	with respect to the claims of a reinsured eligible individual
274	until the carrier has paid incurred claims of an amount equal to
275	the participating carrier’s selected deductible levelat least
276	$5,000 in a calendar year for benefits covered by the program.
277	In addition, the reinsuring carrier is responsible for 10
278	percent of the next $50,000 and 5 percent of the next $100,000
279	of incurred claims during a calendar year, and the program shall
280	reinsure the remainder.
281	3. The board shall annually adjust the initial level of
282	claims and the maximum limit to be retained by the carrier to
283	reflect increases in costs and utilization within the standard
284	market for health benefit plans within the state. The adjustment
285	may not be less than the annual change in the medical component
286	of the "Commerce Price Index for All Urban Consumers" of the
287	Bureau of Labor Statistics of the United States Department of
288	Labor, unless the board proposes and the department approves a
289	lower adjustment factor.
290	4. A reinsuring carrier may terminate reinsurance for all
291	reinsured eligible individuals on any plan anniversary.
292	5. The premium rate charged for reinsurance by the program
293	to a health maintenance organization that is approved by the
294	Secretary of Health and Human Services as a federally qualified
295	health maintenance organization pursuant to 42 U.S.C. s.
296	300e(c)(2)(A) and that, as such, is subject to requirements that
297	limit the amount of risk that may be ceded to the program, which
298	requirements are more restrictive than subparagraph 2., shall be
299	reduced by an amount equal to that portion of the risk, if any,
300	which exceeds the amount set forth in subparagraph 2., which may
301	not be ceded to the program.
302	6. The board may consider adjustments to the premium rates
303	charged for reinsurance by the program or carriers that use
304	effective cost-containment measures, including high-cost case
305	management, as defined by the board.
306	7. A reinsuring carrier shall apply its case-management
307	and claims-handling techniques, including, but not limited to,
308	utilization review, individual case management, preferred
309	provider provisions, other managed-care provisions, or methods
310	of operation consistently with both reinsured business and
311	nonreinsured business.
312	(c)1. The board, as part of the plan of operation, shall
313	establish a methodology for determining premium rates to be
314	charged by the program for reinsuring eligible individuals
315	pursuant to this section. The methodology must include a system
316	for classifying individuals which reflects the types of case
317	characteristics commonly used by carriers in this state. The
318	methodology must provide for the development of basic
319	reinsurance premium rates, which shall be multiplied by the
320	factors set for them in this paragraph to determine the premium
321	rates for the program. The basic reinsurance premium rates shall
322	be established by the board, subject to the approval of the
323	department, and shall be set at levels that reasonably
324	approximate gross premiums charged to eligible individuals for
325	individual health insurance by health insurance issuers. The
326	premium rates set by the board may vary by geographical area, as
327	determined under this section, to reflect differences in cost.
328	An eligible individual may be reinsured for a rate that is five
329	times the rate established by the board.
330	2. The board shall periodically review the methodology
331	established, including the system of classification and any
332	rating factors, to ensure that it reasonably reflects the claims
333	experience of the program. The board may propose changes to the
334	rates that are subject to the approval of the department.
335	(e)1. Before SeptemberMarch1 of each calendar year, the
336	board shall determine and report to the department the program
337	net loss in the individual account for the previous year,
338	including administrative expenses for that year and the incurred
339	losses for that year, taking into account investment income and
340	other appropriate gains and losses.
341	2. Any net loss in the individual account for the year
342	shall be recouped by assessing the carriers as follows:
343	a. The operating losses of the program shall be assessed
344	in the following order subject to the specified limitations. The
345	first tier of assessments shall be made against reinsuring
346	carriers in an amount that may not exceed 5 percent of each
347	reinsuring carrier's premiums for individual health insurance.
348	If such assessments have been collected and additional moneys
349	are needed, the board shall make a second tier of assessments in
350	an amount that may not exceed 0.5 percent of each carrier's
351	health benefit plan premiums.
352	b. Except as provided in paragraph (f), risk-assuming
353	carriers are exempt from all assessments authorized pursuant to
354	this section. The amount paid by a reinsuring carrier for the
355	first tier of assessments shall be credited against any
356	additional assessments made.
357	c. The board shall equitably assess reinsuring carriers
358	for operating losses of the individual account based on market
359	share. The board shall annually assess each carrier a portion of
360	the operating losses of the individual account. The first tier
361	of assessments shall be determined by multiplying the operating
362	losses by a fraction, the numerator of which equals the
363	reinsuring carrier's earned premium pertaining to direct
364	writings of individual health insurance in the state during the
365	calendar year for which the assessment is levied, and the
366	denominator of which equals the total of all such premiums
367	earned by reinsuring carriers in the state during that calendar
368	year. The second tier of assessments shall be based on the
369	premiums that all carriers, except risk-assuming carriers,
370	earned on all health benefit plans written in this state. The
371	board may levy interim assessments against reinsuring carriers
372	to ensure the financial ability of the plan to cover claims
373	expenses and administrative expenses paid or estimated to be
374	paid in the operation of the plan for the calendar year prior to
375	the association's anticipated receipt of annual assessments for
376	that calendar year. Any interim assessment is due and payable
377	within 30 days after receipt by a carrier of the interim
378	assessment notice. Interim assessment payments shall be credited
379	against the carrier's annual assessment. Health benefit plan
380	premiums and benefits paid by a carrier that are less than an
381	amount determined by the board to justify the cost of collection
382	may not be considered for purposes of determining assessments.
383	d. Subject to the approval of the department, the board
384	shall adjust the assessment formula for reinsuring carriers that
385	are approved as federally qualified health maintenance
386	organizations by the Secretary of Health and Human Services
387	pursuant to 42 U.S.C. s. 300e(c)(2)(A) to the extent, if any,
388	that restrictions are placed on them which are not imposed on
389	other carriers.
390	3. Before SeptemberMarch1 of each year, the board shall
391	determine and file with the department an estimate of the
392	assessments needed to fund the losses incurred by the program in
393	the individual account for the previous calendar year.
394	4. If the board determines that the assessments needed to
395	fund the losses incurred by the program in the individual
396	account for the previous calendar year will exceed the amount
397	specified in subparagraph 2., the board shall evaluate the
398	operation of the program and report its findings and
399	recommendations to the department in the format established in
400	s. 627.6699(11) for the comparable report for the small employer
401	reinsurance program.
402	Section 7. Subsection (4) of section 627.651, Florida
403	Statutes, is amended to read:
404	627.651 Group contracts and plans of self-insurance must
405	meet group requirements.--
406	(4) This section does not apply to any plan which is
407	established or maintained by an individual employer in
408	accordance with the Employee Retirement Income Security Act of
409	1974, Pub. L. No. 93-406, or to a multiple-employer welfare
410	arrangement as defined in s. 624.437(1), except that a multiple-
411	employer welfare arrangement shall comply with ss. 627.419,
412	627.657, 627.6575, 627.6578, 627.6579, 627.6612, 627.66121,
413	627.66122, 627.6615, 627.6616, and 627.662(8)(7). This
414	subsection does not allow an authorized insurer to issue a group
415	health insurance policy or certificate which does not comply
416	with this part.
417	Section 8. Section 627.662, Florida Statutes, is amended
418	to read:
419	627.662 Other provisions applicable.--The following
420	provisions apply to group health insurance, blanket health
421	insurance, and franchise health insurance:
422	(1) Section 627.569, relating to use of dividends,
423	refunds, rate reductions, commissions, and service fees.
424	(2) Section 627.602(1)(f) and (2), relating to
425	identification numbers and statement of deductible provisions.
426	(3) Section 627.6044, relating to the use of specific
427	methodology for payment of claims.
428	(4)(3)Section 627.635, relating to excess insurance.
429	(5)(4)Section 627.638, relating to direct payment for
430	hospital or medical services.
431	(6)(5)Section 627.640, relating to filing and
432	classification of rates.
433	(7)(6)Section 627.613, relating to timely payment of
434	claims, or s. 627.6131, relating to payment of claims, whichever
435	is applicable.
436	(8)(7)Section 627.645(1), relating to denial of claims.
437	(9)(8)Section 627.6471, relating to preferred provider
438	organizations.
439	(10)(9)Section 627.6472, relating to exclusive provider
440	organizations.
441	(11)(10)Section 627.6473, relating to combined preferred
442	provider and exclusive provider policies.
443	(12)(11)Section 627.6474, relating to provider contracts.
444	Section 9. Subsection (6) of section 627.667, Florida
445	Statutes, is amended to read:
446	627.667 Extension of benefits.--
447	(6) This section also applies to holders of group
448	certificates which are renewed, delivered, or issued for
449	delivery to residents of this state under group policies
450	effectuated or delivered outside this state, unless a succeeding
451	carrier under a group policy has agreed to assume liability for
452	the benefits.
453	Section 10. Paragraph (e) of subsection (5) of section
454	627.6692, Florida Statutes, is amended to read:
455	627.6692 Florida Health Insurance Coverage Continuation
456	Act.--
457	(5) CONTINUATION OF COVERAGE UNDER GROUP HEALTH PLANS.--
458	(e)1. A covered employee or other qualified beneficiary
459	who wishes continuation of coverage must pay the initial premium
460	and elect such continuation in writing to the insurance carrier
461	issuing the employer's group health plan within 6330days after
462	receiving notice from the insurance carrier under paragraph (d).
463	Subsequent premiums are due by the grace period expiration date.
464	The insurance carrier or the insurance carrier's designee shall
465	process all elections promptly and provide coverage
466	retroactively to the date coverage would otherwise have
467	terminated. The premium due shall be for the period beginning on
468	the date coverage would have otherwise terminated due to the
469	qualifying event. The first premium payment must include the
470	coverage paid to the end of the month in which the first payment
471	is made. After the election, the insurance carrier must bill the
472	qualified beneficiary for premiums once each month, with a due
473	date on the first of the month of coverage and allowing a 30-day
474	grace period for payment.
475	2. Except as otherwise specified in an election, any
476	election by a qualified beneficiary shall be deemed to include
477	an election of continuation of coverage on behalf of any other
478	qualified beneficiary residing in the same household who would
479	lose coverage under the group health plan by reason of a
480	qualifying event. This subparagraph does not preclude a
481	qualified beneficiary from electing continuation of coverage on
482	behalf of any other qualified beneficiary.
483	Section 11. Paragraphs (g), (h), (i), and (u) of
484	subsection (3), paragraph (c) of subsection (5), paragraph (a)
485	of subsection (9), paragraph (d) of subsection (10), and
486	paragraphs (f), (g), (h), and (j) of subsection (11) of section
487	627.6699, Florida Statutes, are amended to read:
488	627.6699 Employee Health Care Access Act.--
489	(3) DEFINITIONS.--As used in this section, the term:
490	(g) "Dependent" means the spouse or child as described in
491	s. 627.6562 of an eligible employee, subject to the applicable
492	terms of the health benefit plan covering that employee.
493	(h) "Eligible employee" means an employee who works full
494	time, having a normal workweek of 25 or more hours, who is paid
495	wages or a salary at least equal to the federal minimum hourly
496	wage applicable to such employee,and who has met any applicable
497	waiting-period requirements or other requirements of this act.
498	The term includes a self-employed individual, a sole proprietor,
499	a partner of a partnership, or an independent contractor, if the
500	sole proprietor, partner, or independent contractor is included
501	as an employee under a health benefit plan of a small employer,
502	but does not include a part-time, temporary, or substitute
503	employee.
504	(i) "Established geographic area" means the county or
505	counties, or any portion of a county or counties,within which
506	the carrier provides or arranges for health care services to be
507	available to its insureds, members, or subscribers.
508	(u) "Self-employed individual" means an individual or sole
509	proprietor who derives his or her income from a trade or
510	business carried on by the individual or sole proprietor which
511	necessitates that the individual file federal income tax forms
512	with supporting schedules and accompanying income reporting
513	forms or federal income tax extensions of time to file forms
514	with the Internal Revenue Service for the most recent tax year
515	results in taxable income as indicated on IRS Form 1040,
516	schedule C or F, and which generated taxable income in one of
517	the 2 previous years.
518	(5) AVAILABILITY OF COVERAGE.--
519	(c) Every small employer carrier must, as a condition of
520	transacting business in this state:
521	1. Beginning July 1, 2000, offer and issue all small
522	employer health benefit plans on a guaranteed-issue basis to
523	every eligible small employer, with 2 to 50 eligible employees,
524	that elects to be covered under such plan, agrees to make the
525	required premium payments, and satisfies the other provisions of
526	the plan. A rider for additional or increased benefits may be
527	medically underwritten and may only be added to the standard
528	health benefit plan. The increased rate charged for the
529	additional or increased benefit must be rated in accordance with
530	this section.
531	2. Beginning July 1, 2000, and until July 31, 2001, offer
532	and issue basic and standard small employer health benefit plans
533	on a guaranteed-issue basis to every eligible small employer
534	which is eligible for guaranteed renewal, has less than two
535	eligible employees, is not formed primarily for the purpose of
536	buying health insurance, elects to be covered under such plan,
537	agrees to make the required premium payments, and satisfies the
538	other provisions of the plan. A rider for additional or
539	increased benefits may be medically underwritten and may be
540	added only to the standard benefit plan. The increased rate
541	charged for the additional or increased benefit must be rated in
542	accordance with this section. For purposes of this subparagraph,
543	a person, his or her spouse, and his or her dependent children
544	shall constitute a single eligible employee if that person and
545	spouse are employed by the same small employer and either one
546	has a normal work week of less than 25 hours.
547	3.a.Beginning August 1, 2001, offer and issue basic and
548	standard small employer health benefit plans on a guaranteed-
549	issue basis, during a 31-day open enrollment period of August 1
550	through August 31 of each year, to every eligible small
551	employer, with fewer than two eligible employees, which small
552	employer is not formed primarily for the purpose of buying
553	health insurance and which elects to be covered under such plan,
554	agrees to make the required premium payments, and satisfies the
555	other provisions of the plan. Coverage provided under this sub-
556	subparagraphsubparagraphshall begin on October 1 of the same
557	year as the date of enrollment, unless the small employer
558	carrier and the small employer agree to a different date. A
559	rider for additional or increased benefits may be medically
560	underwritten and may only be added to the standard health
561	benefit plan. The increased rate charged for the additional or
562	increased benefit must be rated in accordance with this section.
563	For purposes of this sub-subparagraphsubparagraph, a person,
564	his or her spouse, and his or her dependent children constitute
565	a single eligible employee if that person and spouse are
566	employed by the same small employer and either that person or
567	his or her spouse has a normal work week of less than 25 hours.
568	b. Notwithstanding the restrictions set forth in sub-
569	subparagraph a., when a small employer group is losing coverage
570	because a carrier is exercising the provisions of s.
571	627.6571(3)(b) or s. 641.31074(3)(b), the eligible small
572	employer, as defined in sub-subparagraph a., shall be entitled
573	to enroll with another carrier offering small employer coverage
574	within 63 days after the notice of termination or the
575	termination date of the prior coverage, whichever is later.
576	Coverage provided under this sub-subparagraph shall begin
577	immediately upon enrollment unless the small employer carrier
578	and the small employer agree to a different date.
579	4. This paragraph does not limit a carrier's ability to
580	offer other health benefit plans to small employers if the
581	standard and basic health benefit plans are offered and
582	rejected.
583	(9) SMALL EMPLOYER CARRIER'S ELECTION TO BECOME A RISK-
584	ASSUMING CARRIER OR A REINSURING CARRIER.--
585	(a) A small employer carrier must elect to become either a
586	risk-assuming carrier or a reinsuring carrier. Each small
587	employer carrier must make an initial election, binding through
588	January 1, 1994. The carrier's initial election must be made no
589	later than October 31, 1992. By October 31, 1993, all small
590	employer carriers must file a final election, which is binding
591	for 2 years, from January 1, 1994, through December 31, 1995,
592	after which an election shall be binding for a period of 5
593	years.Any carrier that is not a small employer carrier on
594	October 31, 1992, and intends to become a small employer carrier
595	after October 31, 1992, must file its designation when it files
596	the forms and rates it intends to use for small employer group
597	health insurance; such designation shall be binding indefinitely
598	or until modified or withdrawnfor 2 years after the date of
599	approval of the forms and rates, and any subsequent designation
600	is binding for 5 years. The department may permit a carrier to
601	modify its election at any time for good cause shown, after a
602	hearing.
603	(10) ELECTION PROCESS TO BECOME A RISK-ASSUMING CARRIER.--
604	(d) The department shall provide public notice of a small
605	employer carrier's filing adesignation of election under
606	subsection (9) to become a risk-assuming carrier and shall
607	provide at least a 21-day period for public comment upon receipt
608	of such filingprior to making a decision on the election. The
609	department shall hold a hearing on the election at the request
610	of the carrier.
611	(11) SMALL EMPLOYER HEALTH REINSURANCE PROGRAM.--
612	(f) The program has the general powers and authority
613	granted under the laws of this state to insurance companies and
614	health maintenance organizations licensed to transact business,
615	except the power to issue health benefit plans directly to
616	groups or individuals. In addition thereto, the program has
617	specific authority to:
618	1. Enter into contracts as necessary or proper to carry
619	out the provisions and purposes of this act, including the
620	authority to enter into contracts with similar programs of other
621	states for the joint performance of common functions or with
622	persons or other organizations for the performance of
623	administrative functions.
624	2. Sue or be sued, including taking any legal action
625	necessary or proper for recovering any assessments and penalties
626	for, on behalf of, or against the program or any carrier.
627	3. Take any legal action necessary to avoid the payment of
628	improper claims against the program.
629	4. Issue reinsurance policies, in accordance with the
630	requirements of this act.
631	5. Establish rules, conditions, and procedures for
632	reinsurance risks under the program participation.
633	6. Establish actuarial functions as appropriate for the
634	operation of the program.
635	7. Assess participating carriers in accordance with
636	paragraph (j), and make advance interim assessments as may be
637	reasonable and necessary for organizational and interim
638	operating expenses. Interim assessments shall be credited as
639	offsets against any regular assessments due following the close
640	of the calendar year.
641	8. Appoint appropriate legal, actuarial, and other
642	committees as necessary to provide technical assistance in the
643	operation of the program, and in any other function within the
644	authority of the program.
645	9. Borrow money to effect the purposes of the program. Any
646	notes or other evidences of indebtedness of the program which
647	are not in default constitute legal investments for carriers and
648	may be carried as admitted assets.
649	10. To the extent necessary, increase the $5,000
650	deductible reinsurance requirement to adjust for the effects of
651	inflation. The program may evaluate the desirability of
652	establishing different levels of deductibles. If different
653	levels of deductibles are established, such levels and the
654	resulting premiums shall be approved by the department.
655	(g) A reinsuring carrier may reinsure with the program
656	coverage of an eligible employee of a small employer, or any
657	dependent of such an employee, subject to each of the following
658	provisions:
659	1. With respect to a standard and basic health care plan,
660	the program maymustreinsure the level of coverage provided;
661	and, with respect to any other plan, the program maymust
662	reinsure the coverage up to, but not exceeding, the level of
663	coverage provided under the standard and basic health care plan.
664	As an alternative to reinsuring the level of coverage provided
665	under the standard and basic health care plan, the program may
666	develop alternate levels of reinsurance designed to coordinate
667	with a reinsuring carrier’s existing reinsurance. The levels of
668	reinsurance and resulting premiums must be approved by the
669	department.
670	2. Except in the case of a late enrollee, a reinsuring
671	carrier may reinsure an eligible employee or dependent within 60
672	days after the commencement of the coverage of the small
673	employer. A newly employed eligible employee or dependent of a
674	small employer may be reinsured within 60 days after the
675	commencement of his or her coverage.
676	3. A small employer carrier may reinsure an entire
677	employer group within 60 days after the commencement of the
678	group's coverage under the plan. The carrier may choose to
679	reinsure newly eligible employees and dependents of the
680	reinsured group pursuant to subparagraph 1.
681	4. The program may evaluate the option of allowing a small
682	employer carrier to reinsure an entire employer group or an
683	eligible employee at the first or subsequent renewal date. Any
684	such option and the resulting premium must be approved by the
685	department.
686	5.4.The program may not reimburse a participating carrier
687	with respect to the claims of a reinsured employee or dependent
688	until the carrier has paid incurred claims of an amount equal to
689	the participating carrier’s selected deductible levelat least
690	$5,000 in a calendar year for benefits covered by the program.
691	In addition, the reinsuring carrier shall be responsible for 10
692	percent of the next $50,000 and 5 percent of the next $100,000
693	of incurred claims during a calendar year and the program shall
694	reinsure the remainder.
695	6.5.The board annually shall adjust the initial level of
696	claims and the maximum limit to be retained by the carrier to
697	reflect increases in costs and utilization within the standard
698	market for health benefit plans within the state. The adjustment
699	shall not be less than the annual change in the medical
700	component of the "Consumer Price Index for All Urban Consumers"
701	of the Bureau of Labor Statistics of the Department of Labor,
702	unless the board proposes and the department approves a lower
703	adjustment factor.
704	7.6.A small employer carrier may terminate reinsurance
705	for all reinsured employees or dependents on any plan
706	anniversary.
707	8.7.The premium rate charged for reinsurance by the
708	program to a health maintenance organization that is approved by
709	the Secretary of Health and Human Services as a federally
710	qualified health maintenance organization pursuant to 42 U.S.C.
711	s. 300e(c)(2)(A) and that, as such, is subject to requirements
712	that limit the amount of risk that may be ceded to the program,
713	which requirements are more restrictive than subparagraph 5.4.,
714	shall be reduced by an amount equal to that portion of the risk,
715	if any, which exceeds the amount set forth in subparagraph 5.4.
716	which may not be ceded to the program.
717	9.8.The board may consider adjustments to the premium
718	rates charged for reinsurance by the program for carriers that
719	use effective cost containment measures, including high-cost
720	case management, as defined by the board.
721	10.9.A reinsuring carrier shall apply its case-management
722	and claims-handling techniques, including, but not limited to,
723	utilization review, individual case management, preferred
724	provider provisions, other managed care provisions or methods of
725	operation, consistently with both reinsured business and
726	nonreinsured business.
727	(h)1. The board, as part of the plan of operation, shall
728	establish a methodology for determining premium rates to be
729	charged by the program for reinsuring small employers and
730	individuals pursuant to this section. The methodology shall
731	include a system for classification of small employers that
732	reflects the types of case characteristics commonly used by
733	small employer carriers in the state. The methodology shall
734	provide for the development of basic reinsurance premium rates,
735	which shall be multiplied by the factors set for them in this
736	paragraph to determine the premium rates for the program. The
737	basic reinsurance premium rates shall be established by the
738	board, subject to the approval of the department, and shall be
739	set at levels which reasonably approximate gross premiums
740	charged to small employers by small employer carriers for health
741	benefit plans with benefits similar to the standard and basic
742	health benefit plan. The premium rates set by the board may vary
743	by geographical area, as determined under this section, to
744	reflect differences in cost. The multiplying factors must be
745	established as follows:
746	a. The entire group may be reinsured for a rate that is
747	1.5 times the rate established by the board.
748	b. An eligible employee or dependent may be reinsured for
749	a rate that is 5 times the rate established by the board.
750	2. The board periodically shall review the methodology
751	established, including the system of classification and any
752	rating factors, to assure that it reasonably reflects the claims
753	experience of the program. The board may propose changes to the
754	rates which shall be subject to the approval of the department.
755	(j)1. Before SeptemberMarch1 of each calendar year, the
756	board shall determine and report to the department the program
757	net loss for the previous year, including administrative
758	expenses for that year, and the incurred losses for the year,
759	taking into account investment income and other appropriate
760	gains and losses.
761	2. Any net loss for the year shall be recouped by
762	assessment of the carriers, as follows:
763	a. The operating losses of the program shall be assessed
764	in the following order subject to the specified limitations. The
765	first tier of assessments shall be made against reinsuring
766	carriers in an amount which shall not exceed 5 percent of each
767	reinsuring carrier's premiums from health benefit plans covering
768	small employers. If such assessments have been collected and
769	additional moneys are needed, the board shall make a second tier
770	of assessments in an amount which shall not exceed 0.5 percent
771	of each carrier's health benefit plan premiums. Except as
772	provided in paragraph (n), risk-assuming carriers are exempt
773	from all assessments authorized pursuant to this section. The
774	amount paid by a reinsuring carrier for the first tier of
775	assessments shall be credited against any additional assessments
776	made.
777	b. The board shall equitably assess carriers for operating
778	losses of the plan based on market share. The board shall
779	annually assess each carrier a portion of the operating losses
780	of the plan. The first tier of assessments shall be determined
781	by multiplying the operating losses by a fraction, the numerator
782	of which equals the reinsuring carrier's earned premium
783	pertaining to direct writings of small employer health benefit
784	plans in the state during the calendar year for which the
785	assessment is levied, and the denominator of which equals the
786	total of all such premiums earned by reinsuring carriers in the
787	state during that calendar year. The second tier of assessments
788	shall be based on the premiums that all carriers, except risk-
789	assuming carriers, earned on all health benefit plans written in
790	this state. The board may levy interim assessments against
791	carriers to ensure the financial ability of the plan to cover
792	claims expenses and administrative expenses paid or estimated to
793	be paid in the operation of the plan for the calendar year prior
794	to the association's anticipated receipt of annual assessments
795	for that calendar year. Any interim assessment is due and
796	payable within 30 days after receipt by a carrier of the interim
797	assessment notice. Interim assessment payments shall be credited
798	against the carrier's annual assessment. Health benefit plan
799	premiums and benefits paid by a carrier that are less than an
800	amount determined by the board to justify the cost of collection
801	may not be considered for purposes of determining assessments.
802	c. Subject to the approval of the department, the board
803	shall make an adjustment to the assessment formula for
804	reinsuring carriers that are approved as federally qualified
805	health maintenance organizations by the Secretary of Health and
806	Human Services pursuant to 42 U.S.C. s. 300e(c)(2)(A) to the
807	extent, if any, that restrictions are placed on them that are
808	not imposed on other small employer carriers.
809	3. Before SeptemberMarch1 of each year, the board shall
810	determine and file with the department an estimate of the
811	assessments needed to fund the losses incurred by the program in
812	the previous calendar year.
813	4. If the board determines that the assessments needed to
814	fund the losses incurred by the program in the previous calendar
815	year will exceed the amount specified in subparagraph 2., the
816	board shall evaluate the operation of the program and report its
817	findings, including any recommendations for changes to the plan
818	of operation, to the department within 24090days following the
819	end of the calendar year in which the losses were incurred. The
820	evaluation shall include an estimate of future assessments, the
821	administrative costs of the program, the appropriateness of the
822	premiums charged and the level of carrier retention under the
823	program, and the costs of coverage for small employers. If the
824	board fails to file a report with the department within 24090
825	days following the end of the applicable calendar year, the
826	department may evaluate the operations of the program and
827	implement such amendments to the plan of operation the
828	department deems necessary to reduce future losses and
829	assessments.
830	5. If assessments exceed the amount of the actual losses
831	and administrative expenses of the program, the excess shall be
832	held as interest and used by the board to offset future losses
833	or to reduce program premiums. As used in this paragraph, the
834	term "future losses" includes reserves for incurred but not
835	reported claims.
836	6. Each carrier's proportion of the assessment shall be
837	determined annually by the board, based on annual statements and
838	other reports considered necessary by the board and filed by the
839	carriers with the board.
840	7. Provision shall be made in the plan of operation for
841	the imposition of an interest penalty for late payment of an
842	assessment.
843	8. A carrier may seek, from the commissioner, a deferment,
844	in whole or in part, from any assessment made by the board. The
845	department may defer, in whole or in part, the assessment of a
846	carrier if, in the opinion of the department, the payment of the
847	assessment would place the carrier in a financially impaired
848	condition. If an assessment against a carrier is deferred, in
849	whole or in part, the amount by which the assessment is deferred
850	may be assessed against the other carriers in a manner
851	consistent with the basis for assessment set forth in this
852	section. The carrier receiving such deferment remains liable to
853	the program for the amount deferred and is prohibited from
854	reinsuring any individuals or groups in the program if it fails
855	to pay assessments.
856	Section 12. Section 627.911, Florida Statutes, is amended
857	to read:
858	627.911 Scope of this part.--Any insurer or health
859	maintenance organizationtransacting insurance in this state
860	shall report information as required by this part.
861	Section 13. Section 627.9175, Florida Statutes, is amended
862	to read:
863	627.9175 Reports of information on health insurance.--
864	(1) Each authorized health insurer or health maintenance
865	organization shall submit annually to the office, on or before
866	March 1 of each year, information concerningdepartment as to
867	policies of individual health insurance coverage being issued or
868	currently in force in this state. The information shall include
869	information related to premium, number of policies, and covered
870	lives for such policies and other information necessary to
871	analyze trends in enrollment, premiums, and claim costs.
872	(2) The required information shall be broken down by
873	market segment, to include:
874	(a) Health insurance issuer, company, contact person, or
875	agent.
876	(b) All health insurance products issued or in force,
877	including, but not limited to:
878	1. Direct premiums earned.
879	2. Direct losses incurred.
880	3. Direct premiums earned for new business issued during
881	the year.
882	4. Number of policies.
883	5. Number of certificates.
884	6. Number of total covered lives.
885	(a) A summary of typical benefits, exclusions, and
886	limitations for each type of individual policy form currently
887	being issued in the state. The summary shall include, as
888	appropriate:
889	1. The deductible amount;
890	2. The coinsurance percentage;
891	3. The out-of-pocket maximum;
892	4. Outpatient benefits;
893	5. Inpatient benefits; and
894	6. Any exclusions for preexisting conditions.
895
896	The department shall determine other appropriate benefits,
897	exclusions, and limitations to be reported for inclusion in the
898	consumer's guide published pursuant to this section.
899	(b) A schedule of rates for each type of individual policy
900	form reflecting typical variations by age, sex, region of the
901	state, or any other applicable factor which is in use and is
902	determined to be appropriate for inclusion by the department.
903
904	The department shall provide by rule a uniform format for the
905	submission of this information in order to allow for meaningful
906	comparisons of premiums charged for comparable benefits.
907	(3) The department may adopt rules to administer this
908	section, including, but not limited to, rules governing
909	compliance and provisions implementing electronic methodologies
910	for use in furnishing such records or documents. The commission
911	may by rule specify a uniform format for the submission of this
912	information in order to allow for meaningful comparisonsshall
913	publish annually a consumer's guide which summarizes and
914	compares the information required to be reported under this
915	subsection.
916	(2)(a) Every insurer transacting health insurance in this
917	state shall report annually to the department, not later than
918	April 1, information relating to any measure the insurer has
919	implemented or proposes to implement during the next calendar
920	year for the purpose of containing health insurance costs or
921	cost increases. The reports shall identify each measure and the
922	forms to which the measure is applied, shall provide an
923	explanation as to how the measure is used, and shall provide an
924	estimate of the cost effect of the measure.
925	(b) The department shall promulgate forms to be used by
926	insurers in reporting information pursuant to this subsection
927	and shall utilize such forms to analyze the effects of health
928	care cost containment programs used by health insurers in this
929	state.
930	(c) The department shall analyze the data reported under
931	this subsection and shall annually make available to the public
932	a summary of its findings as to the types of cost containment
933	measures reported and the estimated effect of these measures.
934	Section 14. Section 627.9403, Florida Statutes, is amended
935	to read:
936	627.9403 Scope.--The provisions of this part shall apply
937	to long-term care insurance policies delivered or issued for
938	delivery in this state, and to policies delivered or issued for
939	delivery outside this state to the extent provided in s.
940	627.9406, by an insurer, a fraternal benefit society as defined
941	in s. 632.601, a health maintenance organization as defined in
942	s. 641.19, a prepaid health clinic as defined in s. 641.402, or
943	a multiple-employer welfare arrangement as defined in s.
944	624.437. A policy which is advertised, marketed, or offered as a
945	long-term care policy and as a Medicare supplement policy shall
946	meet the requirements of this part and the requirements of ss.
947	627.671-627.675 and, to the extent of a conflict, be subject to
948	the requirement that is more favorable to the policyholder or
949	certificateholder. The provisions of this part shall not apply
950	to a continuing care contract issued pursuant to chapter 651 and
951	shall not apply to guaranteed renewable policies issued prior to
952	October 1, 1988. Any limited benefit policy that limits coverage
953	to care in a nursing home or to one or more lower levels of care
954	required or authorized to be provided by this part or by
955	department rule must meet all requirements of this part that
956	apply to long-term care insurance policies, except ss.
957	627.9407(3)(c) and (d), (9), (10)(f), and (12) and 627.94073(2).
958	If the limited benefit policy does not provide coverage for care
959	in a nursing home, but does provide coverage for one or more
960	lower levels of care, the policy shall also be exempt from the
961	requirements of s. 627.9407(3)(d).
962	Section 15. Paragraph (b) of subsection (1) of section
963	641.185, Florida Statutes, is amended to read:
964	641.185 Health maintenance organization subscriber
965	protections.--
966	(1) With respect to the provisions of this part and part
967	III, the principles expressed in the following statements shall
968	serve as standards to be followed by the Department of Insurance
969	and the Agency for Health Care Administration in exercising
970	their powers and duties, in exercising administrative
971	discretion, in administrative interpretations of the law, in
972	enforcing its provisions, and in adopting rules:
973	(b) A health maintenance organization subscriber should
974	receive quality health care from a broad panel of providers,
975	including referrals, preventive care pursuant to s. 641.402(1),
976	emergency screening and services pursuant to ss. 641.31(13)(12)
977	and 641.513, and second opinions pursuant to s. 641.51.
978	Section 16. Paragraph (d) of subsection (3) and
979	subsections (9) through (17) of section 641.31, Florida
980	Statutes, are amended to read:
981	641.31 Health maintenance contracts.--
982	(3)
983	(d) Any change in rates charged for the contract must be
984	filed with the department not less than 30 days in advance of
985	the effective date. At the expiration of such 30 days, the rate
986	filing shall be deemed approved unless prior to such time the
987	filing has been affirmatively approved or disapproved by order
988	of the department. The approval of the filing by the department
989	constitutes a waiver of any unexpired portion of such waiting
990	period. The department may extend by not more than an additional
991	15 days the period within which it may so affirmatively approve
992	or disapprove any such filing, by giving notice of such
993	extension before expiration of the initial 30-day period. At the
994	expiration of any such period as so extended, and in the absence
995	of such prior affirmative approval or disapproval, any such
996	filing shall be deemed approved. This paragraph does not apply
997	to group health maintenance organization contracts effectuated
998	and delivered in this state insuring groups of 51 or more
999	persons.
1000	(9)(a)1. If a health maintenance organization offers
1001	coverage for dependent children of the subscriber, the contract
1002	must cover a dependent child of the subscriber at least until
1003	the end of the calendar year in which the child reaches the age
1004	of 23, if the child meets all of the following:
1005	a. The child is dependent upon the subscriber for support.
1006	b. The child is living in the household of the subscriber,
1007	or the child is a full-time or part-time student.
1008	2. Nothing in this paragraph affects or preempts a health
1009	maintenance organization's right to medically underwrite or
1010	charge the appropriate premium.
1011	(b)1. A contract that provides coverage for a family
1012	member of the subscriber shall, as to such family member's
1013	coverage, provide that benefits applicable to children of the
1014	subscriber also apply to an adopted child or a foster child of
1015	the subscriber placed in compliance with chapter 63 from the
1016	moment of placement in the residence of the subscriber. Except
1017	in the case of a foster child, the contract may not exclude
1018	coverage for any preexisting condition of the child. In the case
1019	of a newborn child, coverage begins at the moment of birth if a
1020	written agreement to adopt such child has been entered into by
1021	the subscriber prior to the birth of the child, whether or not
1022	the agreement is enforceable. This section does not require
1023	coverage for an adopted child who is not ultimately placed in
1024	the residence of the subscriber in compliance with chapter 63.
1025	2. A contract may require the subscriber to notify the
1026	health maintenance organization of the birth or placement of an
1027	adopted child within a specified time period of not less than 30
1028	days after the birth or placement in the residence of a child
1029	adopted by the subscriber. If timely notice is given, the health
1030	maintenance organization may not charge an additional premium
1031	for coverage of the child for the duration of the notice period.
1032	If timely notice is not given, the health maintenance
1033	organization may charge an additional premium from the date of
1034	birth or placement. If notice is given within 60 days after the
1035	birth or placement of the child, the health maintenance
1036	organization may not deny coverage for the child due to the
1037	failure of the subscriber to timely notify the health
1038	maintenance organization of the birth or placement of the child.
1039	3. If the contract does not require the subscriber to
1040	notify the health maintenance organization of the birth or
1041	placement of an adopted child within a specified time period,
1042	the health maintenance organization may not deny coverage for
1043	such child or retroactively charge the subscriber an additional
1044	premium for such child. However, the health maintenance
1045	organization may prospectively charge the subscriber an
1046	additional premium for the child if the health maintenance
1047	organization provides at least 45 days' notice of the additional
1048	premium required.
1049	4. In order to increase access to postnatal, infant, and
1050	pediatric health care for all children placed in court-ordered
1051	custody, including foster children, all health maintenance
1052	organization contracts that provide coverage for a family member
1053	of the subscriber shall, as to such family member's coverage,
1054	provide that benefits applicable for children shall be payable
1055	with respect to a foster child or other child in court-ordered,
1056	temporary, or other custody of the subscriber.
1057	(10) A contract that provides that coverage of a dependent
1058	child shall terminate upon attainment of the limiting age for
1059	dependent children specified in the contract shall also provide
1060	in substance that attainment of the limiting age does not
1061	terminate the coverage of the child while the child continues to
1062	be:
1063	(a) Incapable of self-sustaining employment by reason of
1064	mental retardation or physical handicap.
1065	(b) Chiefly dependent upon the subscriber for support and
1066	maintenance.
1067
1068	If a claim is denied under a contract for the stated reason that
1069	the child has attained the limiting age for dependent children
1070	specified in the contract, the notice of denial must state that
1071	the subscriber has the burden of establishing that the child
1072	continues to meet the criteria specified in paragraphs (a) and
1073	(b).All health maintenance contracts that provide coverage,
1074	benefits, or services for a member of the family of the
1075	subscriber must, as to such family member's coverage, benefits,
1076	or services, provide also that the coverage, benefits, or
1077	services applicable for children must be provided with respect
1078	to a newborn child of the subscriber, or covered family member
1079	of the subscriber, from the moment of birth. However, with
1080	respect to a newborn child of a covered family member other than
1081	the spouse of the insured or subscriber, the coverage for the
1082	newborn child terminates 18 months after the birth of the
1083	newborn child. The coverage, benefits, or services for newborn
1084	children must consist of coverage for injury or sickness,
1085	including the necessary care or treatment of medically diagnosed
1086	congenital defects, birth abnormalities, or prematurity, and
1087	transportation costs of the newborn to and from the nearest
1088	appropriate facility appropriately staffed and equipped to treat
1089	the newborn's condition, when such transportation is certified
1090	by the attending physician as medically necessary to protect the
1091	health and safety of the newborn child.
1092	(a) A contract may require the subscriber to notify the
1093	plan of the birth of a child within a time period, as specified
1094	in the contract, of not less than 30 days after the birth, or a
1095	contract may require the preenrollment of a newborn prior to
1096	birth. However, if timely notice is given, a plan may not charge
1097	an additional premium for additional coverage of the newborn
1098	child for not less than 30 days after the birth of the child. If
1099	timely notice is not given, the plan may charge an additional
1100	premium from the date of birth. If notice is given within 60
1101	days of the birth of the child, the contract may not deny
1102	coverage of the child due to failure of the subscriber to timely
1103	notify the plan of the birth of the child or to preenroll the
1104	child.
1105	(b) If the contract does not require the subscriber to
1106	notify the plan of the birth of a child within a specified time
1107	period, the plan may not deny coverage of the child nor may it
1108	retroactively charge the subscriber an additional premium for
1109	the child; however, the contract may prospectively charge the
1110	member an additional premium for the child if the plan provides
1111	at least 45 days' notice of the additional charge.
1112	(11)(10)No alteration of any written application for any
1113	health maintenance contract shall be made by any person other
1114	than the applicant without his or her written consent, except
1115	that insertions may be made by the health maintenance
1116	organization, for administrative purposes only, in such manner
1117	as to indicate clearly that such insertions are not to be
1118	ascribed to the applicant.
1119	(12)(11)No contract shall contain any waiver of rights or
1120	benefits provided to or available to subscribers under the
1121	provisions of any law or rule applicable to health maintenance
1122	organizations.
1123	(13)(12)Each health maintenance contract, certificate, or
1124	member handbook shall state that emergency services and care
1125	shall be provided to subscribers in emergency situations not
1126	permitting treatment through the health maintenance
1127	organization's providers, without prior notification to and
1128	approval of the organization. Not less than 75 percent of the
1129	reasonable charges for covered services and supplies shall be
1130	paid by the organization, up to the subscriber contract benefit
1131	limits. Payment also may be subject to additional applicable
1132	copayment provisions, not to exceed $100 per claim. The health
1133	maintenance contract, certificate, or member handbook shall
1134	contain the definitions of "emergency services and care" and
1135	"emergency medical condition" as specified in s. 641.19(7) and
1136	(8), shall describe procedures for determination by the health
1137	maintenance organization of whether the services qualify for
1138	reimbursement as emergency services and care, and shall contain
1139	specific examples of what does constitute an emergency. In
1140	providing for emergency services and care as a covered service,
1141	a health maintenance organization shall be governed by s.
1142	641.513.
1143	(14)(13)In addition to the requirements of this section,
1144	with respect to a person who is entitled to have payments for
1145	health care costs made under Medicare, Title XVIII of the Social
1146	Security Act ("Medicare"), parts A and/or B:
1147	(a) The health maintenance organization shall mail or
1148	deliver notification to the Medicare beneficiary of the date of
1149	enrollment in the health maintenance organization within 10 days
1150	after receiving notification of enrollment approval from the
1151	United States Department of Health and Human Services, Health
1152	Care Financing Administration. When a Medicare beneficiary who
1153	is a subscriber of the health maintenance organization requests
1154	disenrollment from the organization, the organization shall mail
1155	or deliver to the beneficiary notice of the effective date of
1156	the disenrollment within 10 days after receipt of the written
1157	disenrollment request. The health maintenance organization shall
1158	forward the disenrollment request to the United States
1159	Department of Health and Human Services, Health Care Financing
1160	Administration, in a timely manner so as to effectuate the next
1161	available disenrollment date, as prescribed by such federal
1162	agency.
1163	(b) The health maintenance contract, certificate, or
1164	member handbook shall be delivered to the subscriber no later
1165	than the earlier of 10 working days after the health maintenance
1166	organization and the Health Care Financing Administration of the
1167	United States Department of Health and Human Services approve
1168	the subscriber's enrollment application or the effective date of
1169	coverage of the subscriber under the health maintenance
1170	contract. However, if notice from the Health Care Financing
1171	Administration of its approval of the subscriber's enrollment
1172	application is received by the health maintenance organization
1173	after the effective coverage date prescribed by the Health Care
1174	Financing Administration, the health maintenance organization
1175	shall deliver the contract, certificate, or member handbook to
1176	the subscriber within 10 days after receiving such notice. When
1177	a Medicare recipient is enrolled in a health maintenance
1178	organization program, the contract, certificate, or member
1179	handbook shall be accompanied by a health maintenance
1180	organization identification sticker with instruction to the
1181	Medicare beneficiary to place the sticker on the Medicare
1182	identification card.
1183	(15)(14)Whenever a subscriber of a health maintenance
1184	organization is also a Medicaid recipient, the health
1185	maintenance organization's coverage shall be primary to the
1186	recipient's Medicaid benefits and the organization shall be a
1187	third party subject to the provisions of s. 409.910(4).
1188	(16)(15)(a) All health maintenance contracts,
1189	certificates, and member handbooks shall contain the following
1190	provision:
1191
1192	"Grace Period: This contract has a (insert a number not less
1193	than 10) day grace period. This provision means that if any
1194	required premium is not paid on or before the date it is due, it
1195	may be paid during the following grace period. During the grace
1196	period, the contract will stay in force."
1197
1198	(b) The required provision of paragraph (a) shall not
1199	apply to certificates or member handbooks delivered to
1200	individual subscribers under a group health maintenance contract
1201	when the employer or other person who will hold the contract on
1202	behalf of the subscriber group pays the entire premium for the
1203	individual subscribers. However, such required provision shall
1204	apply to the group health maintenance contract.
1205	(17)(16)The contracts must clearly disclose the intent of
1206	the health maintenance organization as to the applicability or
1207	nonapplicability of coverage to preexisting conditions. If
1208	coverage of the contract is not to be applicable to preexisting
1209	conditions, the contract shall specify, in substance, that
1210	coverage pertains solely to accidental bodily injuries resulting
1211	from accidents occurring after the effective date of coverage
1212	and that sicknesses are limited to those which first manifest
1213	themselves subsequent to the effective date of coverage.
1214	(17) All health maintenance contracts that provide
1215	coverage for a member of the family of the subscriber, shall, as
1216	to such family member's coverage, provide that coverage,
1217	benefits, or services applicable for children shall be provided
1218	with respect to an adopted child of the subscriber, which child
1219	is placed in compliance with chapter 63, from the moment of
1220	placement in the residence of the subscriber. Such contracts may
1221	not exclude coverage for any preexisting condition of the child.
1222	In the case of a newborn child, coverage shall begin from the
1223	moment of birth if a written agreement to adopt such child has
1224	been entered into by the subscriber prior to the birth of the
1225	child, whether or not such agreement is enforceable. However,
1226	coverage for such child shall not be required in the event that
1227	the child is not ultimately placed in the residence of the
1228	subscriber in compliance with chapter 63.
1229	Section 17. Section 641.31025, Florida Statutes, is
1230	created to read:
1231	641.31025 Specific reasons for denial of coverage.--The
1232	denial of an application for a health maintenance organization
1233	contract must be accompanied by the specific reasons for the
1234	denial, including, but not limited to, the specific underwriting
1235	reasons, if applicable.
1236	Section 18. Section 641.31075, Florida Statutes, is
1237	created to read:
1238	641.31075 Replacement.--Any health maintenance
1239	organization that is replacing any other group health coverage
1240	with its group health maintenance coverage shall comply with s.
1241	627.666.
1242	Section 19. Subsections (1) and (3) of section 641.3111,
1243	Florida Statutes, are amended to read:
1244	641.3111 Extension of benefits.--
1245	(1) Every group health maintenance contract shall provide
1246	that termination of the contract shall be without prejudice to
1247	any continuous loss which commenced while the contract was in
1248	force, but any extension of benefits beyond the period the
1249	contract was in force may be predicated upon the continuous
1250	total disability of the subscriber and may be limited to payment
1251	for the treatment of a specific accident or illness incurred
1252	while the subscriber was a member. The extension is required
1253	regardless of whether the group contract holder or other entity
1254	secures replacement coverage from a new insurer or health
1255	maintenance organization or foregoes the provision of coverage.
1256	The required provision must provide for continuation of contract
1257	benefits in connection with the treatment of a specific accident
1258	or illness incurred while the contract was in effect.Such
1259	extension of benefits may be limited to the occurrence of the
1260	earliest of the following events:
1261	(a) The expiration of 12 months.
1262	(b) Such time as the member is no longer totally disabled.
1263	(c) A succeeding carrier elects to provide replacement
1264	coverage without limitation as to the disability condition.
1265	(c)(d)The maximum benefits payable under the contract
1266	have been paid.
1267	(3) In the case of maternity coverage, when not covered by
1268	the succeeding carrier,a reasonable extension of benefits or
1269	accrued liability provision is required, which provision
1270	provides for continuation of the contract benefits in connection
1271	with maternity expenses for a pregnancy that commenced while the
1272	policy was in effect. The extension shall be for the period of
1273	that pregnancy and shall not be based upon total disability.
1274	Section 20. Subsection (1) of section 641.2018, Florida
1275	Statutes, is amended to read:
1276	641.2018 Limited coverage for home health care
1277	authorized.--
1278	(1) Notwithstanding other provisions of this chapter, a
1279	health maintenance organization may issue a contract that limits
1280	coverage to home health care services only. The organization and
1281	the contract shall be subject to all of the requirements of this
1282	part that do not require or otherwise apply to specific benefits
1283	other than home care services. To this extent, all of the
1284	requirements of this part apply to any organization or contract
1285	that limits coverage to home care services, except the
1286	requirements for providing comprehensive health care services as
1287	provided in ss. 641.19(4), (12), and (13), and 641.31(1), except
1288	ss. 641.31(9),(13)(12), (17),(18), (19), (20), (21), and (24)
1289	and 641.31095.
1290	Section 21. Section 641.3107, Florida Statutes, is amended
1291	to read:
1292	641.3107 Delivery of contract.--Unless delivered upon
1293	execution or issuance, a health maintenance contract,
1294	certificate of coverage, or member handbook shall be mailed or
1295	delivered to the subscriber or, in the case of a group health
1296	maintenance contract, to the employer or other person who will
1297	hold the contract on behalf of the subscriber group within 10
1298	working days from approval of the enrollment form by the health
1299	maintenance organization or by the effective date of coverage,
1300	whichever occurs first. However, if the employer or other person
1301	who will hold the contract on behalf of the subscriber group
1302	requires retroactive enrollment of a subscriber, the
1303	organization shall deliver the contract, certificate, or member
1304	handbook to the subscriber within 10 days after receiving notice
1305	from the employer of the retroactive enrollment. This section
1306	does not apply to the delivery of those contracts specified in
1307	s. 641.31(14)(13).
1308	Section 22. Subsection (4) of section 641.513, Florida
1309	Statutes, is amended to read:
1310	641.513 Requirements for providing emergency services and
1311	care.--
1312	(4) A subscriber may be charged a reasonable copayment, as
1313	provided in s. 641.31(13)(12), for the use of an emergency room.
1314	Section 23. If any law amended by this act was also
1315	amended by a law enacted at the 2003 Regular Session of the
1316	Legislature, such laws shall be construed as if they had been
1317	enacted at the same session of the Legislature, and full effect
1318	shall be given to each if possible.
1319	Section 24. This act shall take effect upon becoming a
1320	law.