Senate Bill sb2910
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Florida Senate - 2004 SB 2910
By Senator Peaden
2-1470-04
1 A bill to be entitled
2 An act relating to health care; creating the
3 Florida Health Insurance Plan to provide health
4 insurance for certain residents; providing for
5 a board to supervise and control the plan;
6 providing for a plan of operation to establish
7 operating procedures; providing powers of the
8 plan and of the board; providing for reports;
9 providing liability of the plan; providing for
10 audits; prescribing eligibility requirements;
11 prohibiting unfair referrals to the plan;
12 providing for a plan administrator and its term
13 limits and duties; providing for funding the
14 plan; prescribing benefits; providing annual
15 and cumulative maximum benefits; providing for
16 tax exemption; creating the Small Employers
17 Access Program; prescribing eligibility
18 requirements; providing for administration of
19 the program; providing qualifications and
20 duties of insurers; providing for reports;
21 prescribing benefits; providing for an advisory
22 council; creating a Statewide Electronic
23 Medical Records Advisory Panel and providing
24 its powers and duties; amending s. 381.026,
25 F.S.; requiring disclosure of certain financial
26 information to patients by health care
27 facilities or providers; amending s. 395.301,
28 F.S.; requiring disclosure of certain financial
29 information to patients of licensed hospitals
30 and similar facilities; amending s. 408.909,
31 F.S.; redefining the term "health flex plan
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1 entity"; revising guidelines for review of
2 health flex plan applications; amending s.
3 627.610, F.S.; revising applicability of
4 provisions relating to health insurance policy
5 and annuity contract forms; creating s.
6 627.64101, F.S.; requiring certain insurers to
7 make available coverage for disorders or
8 conditions involving speech, language,
9 swallowing, and hearing and hearing aid and
10 earmold benefits; creating s. 627.6421, F.S.;
11 requiring the offering of standardized
12 policies; amending s. 627.6487, F.S.;
13 redefining the term "eligible individual" for
14 purposes of guaranteed availability of
15 coverage; creating s. 627.66912, F.S.;
16 requiring certain insurers to make available
17 coverage for disorders or conditions involving
18 speech, language, swallowing, and hearing and
19 hearing aid and earmold benefits; amending s.
20 627.6699, F.S.; redefining the term "modified
21 community rating" for purposes of the Employee
22 Health Care Access Act; revising provisions
23 relating to premium rates; amending s. 636.003,
24 F.S.; redefining the term "prepaid limited
25 health service organization"; amending s.
26 641.31, F.S.; requiring certain health
27 maintenance organizations to make available
28 coverage for disorders or conditions involving
29 speech, language, swallowing, and hearing and
30 hearing aid and earmold benefits; providing
31 effective dates.
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1
2 WHEREAS, the Legislature finds that 2.8 million
3 Floridians do not have access to health insurance coverage,
4 and
5 WHEREAS, often this lack of health insurance coverage
6 is because premiums are not affordable, and
7 WHEREAS, the Legislature finds that many small
8 employers are unable to provide health insurance to their
9 employees because of rising health care premiums, and
10 WHEREAS, it is the intent of the Legislature to
11 stabilize Florida's health insurance markets and make them
12 more competitive, and
13 WHEREAS, it is the intent of the Legislature to provide
14 access to health coverage for more of Florida's small
15 employers, and
16 WHEREAS, it is the intent of the Legislature to provide
17 access to health coverage to Florida's uninsurables, and
18 WHEREAS, it is the intent of the Legislature to make
19 health insurance affordable by bringing about reductions in
20 costs to all of Florida's insureds, NOW, THEREFORE,
21
22 Be It Enacted by the Legislature of the State of Florida:
23
24 Section 1. There is created the Florida Health
25 Insurance Plan.
26 (1) DEFINITIONS.--As used in this section, the term:
27 (a) "Board" means the board of directors of the plan.
28 (b) "Governor" means the Governor of the State of
29 Florida.
30 (c) "Office" means the Office of Insurance Regulation
31 of the Financial Services Commission.
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1 (d) "Dependent" means a resident spouse or resident
2 unmarried child under the age of 19 years, a child who is a
3 student under the age of 25 years and who is financially
4 dependent upon the parent, or a child of any age who is
5 disabled and dependent upon the parent.
6 (e) "Director" means the Director of the Office of
7 Insurance Regulation.
8 (f) "Health insurance" means any hospital or medical
9 expense incurred policy, health maintenance organization
10 subscriber contract pursuant to chapter 641, Florida Statutes,
11 or any other health care plan or arrangement that pays for or
12 furnishes medical or health care services whether by insurance
13 or otherwise. The term does not include short term, accident,
14 dental-only, vision-only, fixed indemnity, limited benefit or
15 credit insurance, coverage issued as a supplement to liability
16 insurance, insurance arising out of a workers' compensation or
17 similar law, automobile medical-payment insurance, or
18 insurance under which benefits are payable with or without
19 regard to fault and which is statutorily required to be
20 contained in any liability insurance policy or equivalent
21 self-insurance.
22 (g) "Insurer" means any entity that provides health
23 insurance in this state. For purposes of this act, the term
24 includes an insurance company with a valid certificate in
25 accordance with chapter 624, Florida Statutes, or a health
26 maintenance organization with a valid certificate of authority
27 in accordance with parts I and III of chapter 641, Florida
28 Statutes; prepaid health clinic authorized to transact
29 business in this state pursuant to part II of chapter 641,
30 Florida Statutes; multiple employer welfare arrangement
31 authorized to transact business in this state pursuant to
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1 sections 624.436-624.45, Florida Statutes; or fraternal
2 benefit society providing health benefits to its members as
3 authorized pursuant to chapter 632, Florida Statutes.
4 (h) "Medicare" means coverage under both Parts A and B
5 of Title XVIII of the Social Security Act, 42 U.S.C. 1395 et
6 seq., as amended.
7 (i) "Medicaid" means coverage under Titles XIX and XXI
8 of the Social Security Act.
9 (j) "Participating insurer" means any insurer
10 providing health insurance to residents of this state.
11 (k) "Provider" means any physician, hospital, or other
12 institution, organization, or person that furnishes health
13 care services and is licensed or otherwise authorized to
14 practice in this state.
15 (l) "Plan" means the Florida Health Insurance Plan as
16 created in this section.
17 (m) "Plan of operation" means the articles, bylaws,
18 and operating rules and procedures adopted by the board
19 pursuant to this act.
20 (n) "Resident" means an individual who has been
21 legally domiciled in this state for a period of at least 30
22 days.
23 (2) OPERATION OF THE PLAN.--
24 (a) The plan shall be managed during full
25 implementation of this act by a three-member team appointed by
26 the Governor. The director shall head the team.
27 (b) Following full implementation, the plan shall
28 operate subject to the supervision and control of the board.
29 The board shall consist of the director or his or her
30 designated representative, who shall serve as a member of the
31 board and shall be its chairperson, and an additional eight
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1 members appointed by the Governor. A majority of the board
2 must be composed of individuals who are not representatives of
3 insurers or health care providers.
4 (c) The initial board members shall be appointed as
5 follows: one-third of the members to serve a term of 2 years
6 each; one-third of the members to serve a term of 3 years
7 each; and one-third of the members to serve a term of 4 years
8 each. Subsequent board members shall serve for a term of 3
9 years. A board member's term shall continue until his or her
10 successor is appointed.
11 (d) Vacancies in the board shall be filled by the
12 Governor. Board members may be removed by the Governor for
13 cause.
14 (e) Members shall not be compensated in their capacity
15 as board members but shall be reimbursed for reasonable
16 expenses incurred in the necessary performance of their duties
17 in accordance with section 112.061, Florida Statutes.
18 (f) The board shall submit to the Governor a plan of
19 operation for the plan and any amendments thereto necessary or
20 suitable to assure the fair, reasonable, and equitable
21 administration of the plan. The plan of operation shall ensure
22 that the plan qualifies to apply for any available funding
23 from the Federal Government which adds to the financial
24 viability of the plan. The plan of operation shall become
25 effective upon approval in writing by the Governor consistent
26 with the date on which the coverage under this act must be
27 made available. If the board fails to submit a suitable plan
28 of operation within 180 days after the appointment of the
29 board of directors, or at any time thereafter fails to submit
30 suitable amendments to the plan of operation, the office shall
31 adopt and promulgate such rules as are necessary or advisable
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1 to effectuate this section. Such rules shall continue in force
2 until modified by the office or superseded by a plan of
3 operation submitted by the board and approved by the Governor.
4 (3) PLAN OF OPERATION.--The plan of operation shall:
5 (a) Establish procedures for operation of the plan.
6 (b) Establish procedures for selecting an
7 administrator in accordance with subsection (13).
8 (c) Establish procedures to create a fund, under
9 management of the board, for administrative expenses.
10 (d) Establish procedures for the handling, accounting,
11 and auditing of assets, moneys, and claims of the plan and the
12 plan administrator.
13 (e) Develop and implement a program to publicize the
14 existence of the plan, the eligibility requirements, and
15 procedures for enrollment and to maintain public awareness of
16 the plan.
17 (f) Establish procedures under which applicants and
18 participants may have grievances reviewed by a grievance
19 committee appointed by the board. The grievances shall be
20 reported to the board after completion of the review, with the
21 committee's recommendation for grievance resolution. The board
22 shall retain all written grievances regarding the plan for at
23 least 3 years.
24 (g) Provide for other matters as are necessary and
25 proper for the execution of the board's powers, duties, and
26 obligations under this act.
27 (4) POWERS OF THE PLAN.--The plan shall have the
28 general powers and authority granted under the laws of this
29 state to health insurers and, in addition thereto, the
30 specific authority to:
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1 (a) Enter into such contracts as are necessary or
2 proper to carry out the provisions and purposes of this act,
3 including the authority, with the approval of the Governor, to
4 enter into contracts with similar plans of other states for
5 the joint performance of common administrative functions, or
6 with persons or other organizations for the performance of
7 administrative functions;
8 (b) Take any legal actions necessary or proper to
9 recover or collect assessments due the plan;
10 (c) Take such legal action as is necessary:
11 1. To avoid payment of improper claims against the
12 plan or the coverage provided by or through the plan;
13 2. To recover any amounts erroneously or improperly
14 paid by the plan;
15 3. To recover any amounts paid by the plan as a result
16 of mistake of fact or law; or
17 4. To recover other amounts due the plan.
18 (d) Establish and modify as appropriate, rates, rate
19 schedules, rate adjustments, expense allowances, agents'
20 referral fees, claim reserve formulas, and any other actuarial
21 functions appropriate to the operation of the plan. Rates and
22 rate schedules may be adjusted for appropriate factors such as
23 age, sex, and geographic variation in claim cost and shall
24 take into consideration appropriate factors in accordance with
25 established actuarial and underwriting practices;
26 (e) Issue policies of insurance in accordance with the
27 requirements of this act;
28 (f) Appoint appropriate legal, actuarial, investment,
29 and other committees as necessary to provide technical
30 assistance in the operation of the plan, develop and educate
31 its policyholders regarding health savings accounts (HSAs),
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1 policy and contract design, and any other function within the
2 authority of the plan;
3 (g) Borrow money to effect the purposes of the plan.
4 Any notes or other evidence of indebtedness of the plan not in
5 default shall be legal investments for insurers and may be
6 carried as admitted assets;
7 (h) Employ and fix the compensation of employees;
8 (i) Prepare and distribute certificate of eligibility
9 forms and enrollment instruction forms to insurance producers
10 and to the general public;
11 (j) Provide for reinsurance of risks incurred by the
12 plan;
13 (k) Provide for and employ cost containment measures
14 and requirements, including, but not limited to, preadmission
15 screening, second surgical opinion, concurrent utilization
16 review, and individual case management for the purpose of
17 making the plan more cost effective;
18 (l) Design, use, contract, or otherwise arrange for
19 the delivery of cost effective health care services, including
20 establishing or contracting with preferred provider
21 organizations, health maintenance organizations, and other
22 limited network provider arrangements; and
23 (m) Adopt such bylaws, policies, and procedures as are
24 necessary or convenient for the implementation of this act and
25 the operation of the plan.
26 (5) INTERIM REPORT.--No later than December 1, 2004,
27 the Transition Team shall submit a report to the Governor, the
28 President of the Senate, and the Speaker of the House of
29 Representatives, which includes an independent actuarial study
30 to determine, including, but not be limited to, the following
31 issues:
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1 1. The impact the creation of this plan will have on
2 the small group insurance market on premiums paid by insureds.
3 This shall include an estimate of the total anticipated
4 aggregate savings for all small employers in the state.
5 2. How many people the pool could reasonably cover at
6 various funding levels and specifically how many people the
7 pool could cover at each of those funding levels.
8 3. A recommendation as to the best source of funding
9 for the anticipated deficits of the pool.
10 (6) ANNUAL REPORT.--The board shall make an annual
11 report to the Governor, the President of the Senate, and the
12 Speaker of the House of Representatives. The report shall
13 summarize the activities of the plan in the preceding calendar
14 year, including the net written and earned premiums, plan
15 enrollment, the expense of administration, and the paid and
16 incurred losses.
17 (7) EVALUATION REPORT.--The board shall report to the
18 Governor, the President of the Senate, and the Speaker of the
19 House of Representatives 3 years after commencement of
20 operations of the plan whether or nor the plan has met the
21 intent of this act.
22 (8) LIABILITY OF THE PLAN.--Neither the board nor its
23 employees shall be liable for any obligations of the plan. No
24 member or employee of the board is liable, and no cause of
25 action of any nature may arise against them, for any act or
26 omission related to the performance of their powers and duties
27 under this act, unless such act or omission constitutes
28 willful or wanton misconduct. The board may provide in its
29 bylaws or rules for indemnification of, and legal
30 representation for, its members and employees.
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1 (9) AUDITED FINANCIAL STATEMENT.--No later than June 1
2 following the close of each calendar year the plan shall
3 submit to the Governor an audited financial statement,
4 prepared in accordance with Statutory Accounting Principles as
5 adopted by the National Association of Insurance
6 Commissioners.
7 (10) ADDITIONAL POWERS OF THE BOARD.--The board is
8 authorized to open up the plan to all eligible individual
9 persons as defined in subsection (11) for whom the estimated
10 loss ratio is 100 percent or less. The Governor may establish
11 additional powers and duties of the board to implement this
12 act.
13 (11) ELIGIBILITY.--
14 (a) Any individual person who is and continues to be a
15 resident of this state is eligible for plan coverage if
16 evidence is provided of:
17 1. A notice of rejection or refusal to issue
18 substantially similar insurance for health reasons by one
19 insurer;
20 2. A refusal by an insurer to issue insurance except
21 at a rate exceeding the plan rate. A rejection or refusal by
22 an insurer offering only stoploss, excess of loss, or
23 reinsurance coverage with respect to the applicant is not
24 sufficient evidence under this paragraph; or
25 3. That person's eligibility for individual coverage
26 in accordance with the Health Insurance Accountability and
27 Portability Act (HIPAA).
28 (b) The board may promulgate a list of medical or
29 health conditions for which a person shall be eligible for
30 plan coverage without applying for health insurance pursuant
31 to paragraph (a). Persons who can demonstrate the existence or
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1 history of any medical or health conditions on the list
2 promulgated by the board shall not be required to provide the
3 evidence specified in paragraph (a). The list shall be
4 effective on the first day of the operation of the plan and
5 may be amended as appropriate.
6 (c) Each resident dependent of a person who is
7 eligible for plan coverage is also eligible for plan coverage.
8 (d) A person is not eligible for coverage under the
9 plan if:
10 1. The person has or obtains health insurance coverage
11 substantially similar to or more comprehensive than a plan
12 policy, or would be eligible to obtain coverage, unless a
13 person may maintain other coverage for the period of time the
14 person is satisfying any preexisting condition waiting period
15 under a plan policy, and may maintain plan coverage for the
16 period of time the person is satisfying a preexisting
17 condition waiting period under another health insurance policy
18 intended to replace the plan policy;
19 2. The person is determined to be eligible for health
20 care benefits under Medicaid or any other federal, state, or
21 local government program that provides health benefits;
22 3. The person has previously terminated plan coverage
23 unless 12 months have lapsed since such termination;
24 4. The plan has paid out $1 million in benefits on
25 behalf of the person;
26 5. The person is an inmate or resident of a public
27 institution; or
28 6. The person's premiums are paid for or reimbursed
29 under any government-sponsored program or by any government
30 agency or health care provider, except as an otherwise
31
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1 qualifying full-time employee, or dependent thereof, of a
2 government agency or health care provider.
3 (e) Coverage shall cease:
4 1. On the date a person is no longer a resident of
5 this state;
6 2. On the date a person requests coverage to end;
7 3. Upon the death of the covered person;
8 4. On the date state law requires cancellation of the
9 policy; or
10 5. At the option of the plan, 30 days after the plan
11 makes any inquiry concerning the person's eligibility or place
12 of residence to which the person does not reply.
13 (f) Except under the circumstances described in this
14 subsection, a person who ceases to meet the eligibility
15 requirements of this section may be terminated at the end of
16 the policy period for which the necessary premiums have been
17 paid.
18 (12) UNFAIR REFERRAL TO PLAN.--It shall constitute an
19 unfair trade practice for the purposes of part IX of chapter
20 626, Florida Statutes, or section 641.3901, Florida Statutes,
21 for an insurer, health maintenance organization, insurance
22 agent, insurance broker, or third-party administrator to refer
23 an individual employee to the plan, or arrange for an
24 individual employee to apply to the plan, for the purpose of
25 separating that employee from group health insurance coverage
26 provided in connection with the employee's employment.
27 (13) PLAN ADMINISTRATOR.--The board shall select
28 through a competitive bidding process a plan administrator to
29 administer the plan. The board shall evaluate bids submitted
30 based on criteria established by the board, which shall
31 include:
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1 (a) The plan administrator's proven ability to handle
2 health insurance coverage to individuals;
3 (b) The efficiency and timeliness of the plan
4 administrator's claim-processing procedures;
5 (c) An estimate of total charges for administering the
6 plan;
7 (d) The plan administrator's ability to apply
8 effective cost containment programs and procedures and to
9 administer the plan in a cost efficient manner; and
10 (e) The financial condition and stability of the plan
11 administrator.
12
13 The administrator shall be either an insurer, a health
14 maintenance organization or a third-party administrator, or
15 another organization duly authorized pursuant to the Florida
16 Insurance Code.
17 (14) ADMINISTRATOR TERM LIMITS.--The plan
18 administrator shall serve for a period specified in the
19 contract between the plan and the plan administrator, subject
20 to removal for cause and subject to any terms, conditions, and
21 limitations of the contract between the plan and the plan
22 administrator. At least 1 year before the expiration of each
23 period of service by a plan administrator, the board shall
24 invite eligible entities, including the current plan
25 administrator, to submit bids to serve as the plan
26 administrator. Selection of the plan administrator for each
27 succeeding period shall be made at least 6 months before the
28 end of the current period.
29 (15) DUTIES OF THE PLAN ADMINISTRATOR.--The plan
30 administrator shall perform such functions relating to the
31 plan as are assigned to it, including, but not limited to:
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1 (a) Determination of eligibility;
2 (b) Payment of claims;
3 (c) Establishment of a premium billing procedure for
4 collection of premiums from persons covered under the plan;
5 and
6 (d) Other necessary functions to assure timely payment
7 of benefits to covered persons under the plan.
8
9 The plan administer shall submit regular reports to the board
10 regarding the operation of the plan. The frequency, content,
11 and form of the reports shall be specified in the contract
12 between the board and the plan administrator. On March 1
13 following the close of each calendar year, the plan
14 administrator shall determine net written and earned premiums,
15 the expense of administration, and the paid and incurred
16 losses for the year and report this information to the board
17 and the Governor on a form prescribed by the Governor.
18 (16) PAYMENT OF THE PLAN ADMINISTRATOR.--The plan
19 administrator shall be paid as provided in the contract
20 between the plan and the plan administrator.
21 (17) FUNDING OF THE PLAN.--
22 (a) Premiums.--
23 1. The plan shall establish premium rates for plan
24 coverage as provided in subparagraph 2. Separate schedules of
25 premium rates based on age, sex, and geographical location may
26 apply for individual risks. Premium rates and schedules shall
27 be submitted to the office for approval before use.
28 2. The plan, in conjunction with the office, shall
29 determine a standard risk rate by considering the premium
30 rates charged by other insurers offering health insurance
31 coverage to individuals. The standard risk rate shall be
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1 established using reasonable actuarial techniques and shall
2 reflect anticipated experience and expenses for such coverage.
3 Initial rates for plan coverage shall not be less than 200
4 percent of rates established as applicable for individual
5 standard risks. The plan shall also develop a sliding scale
6 premium surcharge based upon the insured's income. Subject to
7 the limits provided in this paragraph, subsequent rates shall
8 be established to provide fully for the expected costs of
9 claims, including recovery of prior losses, expenses of
10 operation, investment income of claim reserves, and any other
11 cost factors subject to the limitations described herein.
12 (b) Sources of additional revenue.--Any deficit
13 incurred by the plan shall be funded through amounts
14 appropriated by the Legislature from general revenue sources,
15 including, but not limited to, a portion of the annual growth
16 in existing net insurance premium taxes. The board shall
17 operate the plan in such a manner that the estimated cost of
18 providing health insurance during any fiscal year will not
19 exceed total income the plan expects to receive from policy
20 premiums and funds appropriated by the Legislature, including
21 any interest on investments. After determining the amount of
22 funds appropriated to it for a fiscal year, the board shall
23 estimate the number of new policies it believes the plan has
24 the financial capacity to insure during that year so that
25 costs do not exceed income. The board shall take steps
26 necessary to assure that plan enrollment does not exceed the
27 number of residents it has estimated it has the financial
28 capacity to insure.
29 (18) BENEFITS.--
30 (a) The benefits provided shall be the same as the
31 standard and basic plans for small employers as outlined in
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1 section 627.6699, Florida Statutes. The board may also
2 establish an option of alternative coverage such as
3 catastrophic coverage that includes a minimum level of primary
4 care coverage.
5 (b) In establishing the plan coverage, the board shall
6 take into consideration the levels of health insurance
7 provided in the state and such medical economic factors as are
8 deemed appropriate and adopt benefit levels, deductibles,
9 co-payments, coinsurance factors, exclusions and limitations
10 determined to be generally reflective of and commensurate with
11 health insurance provided through a representative number of
12 large employers in the state.
13 (c) The board may adjust any deductibles and
14 coinsurance factors annually according to the Medical
15 Component of the Consumer Price Index.
16 (d)1. Plan coverage shall exclude charges or expenses
17 incurred during the first 6 months following the effective
18 date of coverage for any condition for which medical advice,
19 care, or treatment was recommended or received during the
20 6-month period immediately preceding the effective date of
21 coverage.
22 2. Such preexisting condition exclusions shall be
23 waived to the extent that similar exclusions, if any, have
24 been satisfied under any prior health insurance coverage that
25 was involuntarily terminated, provided that application for
26 pool coverage is made not later than 63 days following such
27 involuntary termination; and, in such case, coverage in the
28 plan shall be effective from the date on which such prior
29 coverage was terminated and the applicant is not eligible for
30 continuation or conversion rights that would provide coverage
31 substantially similar to plan coverage.
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1 (19) NONDUPLICATION OF BENEFITS.--
2 (a) The plan shall be payer of last resort of benefits
3 whenever any other benefit or source of third-party payment is
4 available. Benefits otherwise payable under plan coverage
5 shall be reduced by all amounts paid or payable through any
6 other health insurance and by all hospital and medical expense
7 benefits paid or payable under any workers' compensation
8 coverage, automobile medical payment or liability insurance
9 whether provided on the basis of fault or nonfault, and by any
10 hospital or medical benefits paid or payable under or provided
11 pursuant to any state or federal law or program.
12 (b) The plan shall have a cause of action against an
13 eligible person for the recovery of the amount of benefits
14 paid that are not for covered expenses. Benefits due from the
15 plan may be reduced or refused as a set-off against any amount
16 recoverable under this paragraph.
17 (20) ANNUAL AND MAXIMUM BENEFITS.--Maximum benefits
18 shall be limited to $75,000 annually and $1 million per
19 lifetime.
20 (21) TAXATION.--The plan established pursuant to this
21 act shall be exempt from any and all taxes. The plan shall
22 apply for federal tax exemption.
23 Section 2. There is created The Small Employers Access
24 Program.
25 (1) DEFINITIONS.--As used in this section, the term:
26 (a) "Office" means the Office of Insurance Regulation
27 of the Department of Financial Services.
28 (b) "Insurer" means any entity that provides health
29 insurance in this state. For purposes of this section, the
30 term includes an insurance company holding a certificate of
31 authority pursuant to chapter 624, Florida Statutes, or a
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1 health maintenance organization holding a certificate of
2 authority pursuant to chapter 641, Florida Statutes, which
3 qualifies to provide coverage to small employer groups
4 pursuant to section 627.6699, Florida Statutes.
5 (c) "Participating insurer" means any insurer
6 providing health insurance to small employers which has been
7 selected by the office in accordance with this section for its
8 designated region.
9 (d) "Program" means the Small Employer Access Program
10 created by this section.
11 (e) "Fair Commission" means a commission structure
12 determined by the office and the insurers, which will carry
13 out the intent of this section.
14 (2) ELIGIBILITY.--
15 (a) Any small employer group up to 25 employees may
16 participate.
17 (b) Each dependent of a person eligible for coverage
18 is also eligible.
19 (c) Any municipality, county, school district, or
20 hospital located in a rural community as defined in section
21 288.0656(2)(b), Florida Statutes.
22 (d) A small employer group that ceases to meet the
23 eligibility requirements of this section may be terminated at
24 the end of the policy period for which the necessary premiums
25 have been paid.
26 (3) ADMINISTRATION.--The office shall by competitive
27 bid, in accordance with current state law, select an insurer
28 to provide coverage to small employers within established
29 geographical areas of this state. The office may develop
30 exclusive regions for the program similar to those used by the
31 Healthy Kids Corporation. However, the office is not precluded
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1 from developing, in conjunction with insurers, regions
2 different from those used by the Healthy Kids Corporation if
3 the office deems that such a region will carry out the
4 intentions of this act. The office shall evaluate bids
5 submitted based upon criteria established by the office, which
6 shall include, but are not limited to:
7 (a) The insurer's proven ability to provide health
8 insurance coverage to small employer groups;
9 (b) The efficiency and timeliness of the insurer's
10 claim-processing procedures;
11 (c) The insurer's ability to apply effective cost
12 containment programs and procedures and to administer the
13 program in a cost-efficient manner; and
14 (d) The financial condition and stability of the
15 insurer. The office may use any financial information
16 available to it through its regulatory duties to make this
17 evaluation.
18 (4) INSURER QUALIFICATIONS.--The insurer shall be a
19 duly authorized insurer or health maintenance organization.
20 (5) DUTIES OF THE INSURER.--The insurer shall develop
21 and implement a program to publicize the existence of the
22 program, the eligibility requirements, procedures for
23 enrollment, and
24 (a) Maintain employer awareness of the program.
25 (b) Demonstrate the ability to use delivery of cost
26 effective health care services.
27 (c) Encourage, educate, advise, and administer the
28 effective use of health savings accounts (HSAs) by covered
29 employees and dependents.
30 (d) Serve for a period specified in the contract
31 between the office and the insurer subject to removal for
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1 cause and subject to any terms, conditions, and limitations of
2 the contract between the office and the insurer as are
3 specified in the request for proposal.
4 (6) CONTRACT TERM.--The contract term shall not exceed
5 3 years. At least 6 months before the expiration of each
6 contract period, the office shall invite eligible entities,
7 including the current insurer, to submit bids to serve as the
8 insurer for a designated geographic area. Selection of the
9 insurer for the succeeding period must be made at least 3
10 months before the end of the current period.
11 (7) INSURER REPORTING REQUIREMENTS.--On March 1,
12 following the close of each calendar year, the insurer shall
13 determine net written and earned premiums, the expense of
14 administration, and the paid and incurred losses for the year
15 and report this information to the office on a form prescribed
16 by the office.
17 (8) APPLICATION REQUIREMENTS.--The insurer shall
18 permit or allow any licensed and duly appointed health
19 insurance agent residing in the designated region to submit
20 applications for coverage, and such agent shall be paid a fair
21 commission if coverage is written. The agency must be
22 appointed to at least one insurer.
23 (9) BENEFITS.--The benefits provided shall be the same
24 as the standard and basic plans for small employers as
25 outlined in section 627.6699, Florida Statutes, except that
26 the insurer, with the approval of the office, may also
27 establish an option of alternative coverage such as
28 catastrophic coverage that includes a minimum level of primary
29 care coverage or other such benefit plan, which will carry out
30 the intent of this act.
31
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1 (10) ANNUAL REPORTING.--The office shall make an
2 annual report to the Governor, the President of the Senate,
3 and the Speaker of the House of Representatives. The report
4 shall summarize the activities of the program in the preceding
5 calendar year, including the net written and earned premiums,
6 program enrollment, the expense of administration, and the
7 paid and incurred losses. The report shall be submitted no
8 later than March 15 following the close of the prior calendar
9 year.
10 (11) ADVISORY COUNCIL.--The office, in conjunction
11 with representatives of each of the regional insurers,
12 provider groups, and small employer representatives, and a
13 person designated by the Governor shall meet at least annually
14 to review the operations of the program, suggest improvements,
15 and recommend incentives to the Governor and the Legislature
16 which will encourage employer participation in the program.
17 Section 3. There is created a Statewide Electronic
18 Medical Records Advisory Panel to serve as a body of experts
19 to guide the Agency for Health Care Administration in the
20 development of policy related to electronic medical records
21 and the technology required for sharing clinical information
22 among caregivers.
23 (1) The agency shall provide staff support to the
24 panel and may enter into contracts as are necessary or proper
25 to carry out the provisions and purposes of this act,
26 assisting the advisory panel in the creation of the Electronic
27 Medical Records System.
28 (2) The advisory panel shall be appointed by the
29 Governor.
30 (3) The panel shall meet at least quarterly and advise
31 the Governor, the Legislature, and the agency regarding:
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1 (a) Public and private sector initiatives related to
2 electronic medical records and communication systems for the
3 sharing of clinical information among caregivers;
4 (b) Regulatory barriers that interfere with the
5 sharing of clinical information among caregivers;
6 (c) Investment incentives to promote the use of
7 recommended technologies by health care providers;
8 (d) Educational strategies to promote the use of
9 recommended technologies by health care providers; and
10 (e) Standards for public access to facilitate
11 transparency in pricing, costs, and quality.
12 (4) By November 30, 2004, and annually thereafter, the
13 advisory panel shall provide to the Office of the Governor,
14 the President of the Senate, and the Speaker of the House of
15 Representatives, a status report to include any
16 recommendations and an implementation plan to include, but not
17 limited to, estimated costs, capital investment requirements,
18 recommended investment incentives, initial committed provider
19 participation by region, standards of functionality and
20 features, marketing plan, and implementation schedules for key
21 components.
22 (5) Members of the advisory panel shall serve without
23 compensation but shall be entitled to receive reimbursement
24 for per diem and travel expenses as provided in section
25 112.061, Florida Statutes.
26 (6) The sum of $2 million is appropriated from the
27 General Revenue Fund to the Agency for Health Care
28 Administration for funding activities relative to the
29 Statewide Electronic Advisory Panel.
30 (7) Unless otherwise reenacted by the Legislature, the
31 advisory panel is abolished effective July 1, 2007.
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1 Section 4. Paragraph (c) of subsection (4) and
2 subsection (6) of section 381.026, Florida Statutes, are
3 amended to read:
4 381.026 Florida Patient's Bill of Rights and
5 Responsibilities.--
6 (4) RIGHTS OF PATIENTS.--Each health care facility or
7 provider shall observe the following standards:
8 (c) Financial information and disclosure.--
9 1. A patient has the right to be given, upon request,
10 by the responsible provider, his or her designee, or a
11 representative of the health care facility full information
12 and necessary counseling on the availability of known
13 financial resources for the patient's health care.
14 2. A health care provider or a health care facility
15 shall, upon request, disclose to each patient who is eligible
16 for Medicare, in advance of treatment, whether the health care
17 provider or the health care facility in which the patient is
18 receiving medical services accepts assignment under Medicare
19 reimbursement as payment in full for medical services and
20 treatment rendered in the health care provider's office or
21 health care facility.
22 3. A health care provider or a health care facility
23 shall, upon request, furnish a patient, prior to provision of
24 medical services, a reasonable estimate of charges for such
25 services. Such reasonable estimate shall not preclude the
26 health care provider or health care facility from exceeding
27 the estimate or making additional charges based on changes in
28 the patient's condition or treatment needs.
29 4. Each licensed facility not operated by the state
30 shall make available to the public on its Internet website or
31 by other electronic means package prices for each of the top
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1 50 most used elective inpatient and outpatient procedures. The
2 package pricing shall include all hospital-related services
3 and shall include separate estimates of costs for professional
4 fees charged by independent contractor physicians or physician
5 groups. The licensed facility shall also make available to the
6 public on its Internet website or by other electronic means
7 each of the top 50 most used inpatient and outpatient
8 procedures. Such list shall be updated quarterly. The facility
9 shall place a notice in the reception areas that such
10 information is available electronically and the website
11 address. The licensed facility may indicate that the package
12 pricing is based on a compilation of charges for the average
13 patient and that each patient's bill may vary from the average
14 depending upon the severity of illness and individual
15 resources consumed. The licensed facility may also indicate
16 that the package pricing is negotiable based upon the
17 patient's health plan and the ability to pay. The agency shall
18 develop rules for implementation of a uniform mechanism for
19 reporting this information on the facility's website.
20 5.4. A patient has the right to receive a copy of an
21 itemized bill upon request. A patient has a right to be given
22 an explanation of charges upon request.
23 (6) SUMMARY OF RIGHTS AND RESPONSIBILITIES.--Any
24 health care provider who treats a patient in an office or any
25 health care facility licensed under chapter 395 that provides
26 emergency services and care or outpatient services and care to
27 a patient, or admits and treats a patient, shall adopt and
28 make available to the patient, in writing, a statement of the
29 rights and responsibilities of patients, including the
30 following:
31
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1 SUMMARY OF THE FLORIDA PATIENT'S BILL
2 OF RIGHTS AND RESPONSIBILITIES
3
4 Florida law requires that your health care provider or
5 health care facility recognize your rights while you are
6 receiving medical care and that you respect the health care
7 provider's or health care facility's right to expect certain
8 behavior on the part of patients. You may request a copy of
9 the full text of this law from your health care provider or
10 health care facility. A summary of your rights and
11 responsibilities follows:
12 A patient has the right to be treated with courtesy and
13 respect, with appreciation of his or her individual dignity,
14 and with protection of his or her need for privacy.
15 A patient has the right to a prompt and reasonable
16 response to questions and requests.
17 A patient has the right to know who is providing
18 medical services and who is responsible for his or her care.
19 A patient has the right to know what patient support
20 services are available, including whether an interpreter is
21 available if he or she does not speak English.
22 A patient has the right to know what rules and
23 regulations apply to his or her conduct.
24 A patient has the right to be given by the health care
25 provider information concerning diagnosis, planned course of
26 treatment, alternatives, risks, and prognosis.
27 A patient has the right to refuse any treatment, except
28 as otherwise provided by law.
29 A patient has the right to be given, upon request, full
30 information and necessary counseling on the availability of
31 known financial resources for his or her care.
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1 A patient who is eligible for Medicare has the right to
2 know, upon request and in advance of treatment, whether the
3 health care provider or health care facility accepts the
4 Medicare assignment rate.
5 A patient has the right to receive, upon request, prior
6 to treatment, a reasonable estimate of charges for medical
7 care.
8 A patient has the right to receive, upon request, prior
9 to treatment, a reasonable estimate of charges for the
10 proposed service.
11 A patient has the right to receive a copy of a
12 reasonably clear and understandable, itemized bill and, upon
13 request, to have the charges explained.
14 A patient has the right to impartial access to medical
15 treatment or accommodations, regardless of race, national
16 origin, religion, handicap, or source of payment.
17 A patient has the right to treatment for any emergency
18 medical condition that will deteriorate from failure to
19 provide treatment.
20 A patient has the right to know if medical treatment is
21 for purposes of experimental research and to give his or her
22 consent or refusal to participate in such experimental
23 research.
24 A patient has the right to express grievances regarding
25 any violation of his or her rights, as stated in Florida law,
26 through the grievance procedure of the health care provider or
27 health care facility which served him or her and to the
28 appropriate state licensing agency.
29 A patient is responsible for providing to the health
30 care provider, to the best of his or her knowledge, accurate
31 and complete information about present complaints, past
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1 illnesses, hospitalizations, medications, and other matters
2 relating to his or her health.
3 A patient is responsible for reporting unexpected
4 changes in his or her condition to the health care provider.
5 A patient is responsible for reporting to the health
6 care provider whether he or she comprehends a contemplated
7 course of action and what is expected of him or her.
8 A patient is responsible for following the treatment
9 plan recommended by the health care provider.
10 A patient is responsible for keeping appointments and,
11 when he or she is unable to do so for any reason, for
12 notifying the health care provider or health care facility.
13 A patient is responsible for his or her actions if he
14 or she refuses treatment or does not follow the health care
15 provider's instructions.
16 A patient is responsible for assuring that the
17 financial obligations of his or her health care are fulfilled
18 as promptly as possible.
19 A patient is responsible for following health care
20 facility rules and regulations affecting patient care and
21 conduct.
22 Section 5. Subsections (7) and (8) are added to
23 section 395.301, Florida Statutes, to read:
24 395.301 Itemized patient bill; form and content
25 prescribed by the agency.--
26 (7) Each licensed facility not operated by the state
27 shall make available to the public on its Internet website or
28 by other electronic means package prices for each of the top
29 50 most used elective inpatient and outpatient procedures. The
30 package pricing shall include all hospital-related services
31 and shall include separate estimates of costs for professional
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1 fees charged by independent contractor physicians or physician
2 groups. The licensed facility shall also make available to the
3 public on its Internet website or by other electronic means
4 the top 50 most used procedures in both the inpatient and
5 outpatient settings. The list shall be updated quarterly. The
6 facility shall place a notice in the reception areas that such
7 information is available electronically and the website
8 address. The licensed facility may indicate that the package
9 pricing is based on a compilation of charges for the average
10 patient and that each patient's bill may vary from the average
11 depending upon the severity of illness and individual
12 resources consumed. The licensed facility may also indicate
13 that the package pricing is negotiable based upon the
14 patient's health plan and the ability to pay. The agency shall
15 develop rules for implementation of a uniform mechanism for
16 reporting this information on the facility's website.
17 (8) Each licensed facility not operated by the state
18 shall, upon request of a prospective patient prior to the
19 provision of medical services, provide a reasonable estimate
20 of charges for the proposed service. Such estimate shall not
21 preclude the actual charges from exceeding the estimate based
22 on changes in the patient's medical condition or the treatment
23 needs of the patient as determined by the attending and
24 consulting physicians.
25 Section 6. Paragraph (f) of subsection (2) and
26 subsections (3) and (9) of section 408.909, Florida Statutes,
27 are amended to read:
28 408.909 Health flex plans.--
29 (2) DEFINITIONS.--As used in this section, the term:
30 (f) "Health flex plan entity" means a health insurer,
31 health maintenance organization,
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1 health-care-provider-sponsored organization, local government,
2 health care district, or other public or private
3 community-based organization, or public-private partnership
4 that develops and implements an approved health flex plan and
5 is responsible for administering the health flex plan and
6 paying all claims for health flex plan coverage by enrollees
7 of the health flex plan.
8 (3) PILOT PROGRAM.--The agency and the office shall
9 each approve or disapprove health flex plans that provide
10 health care coverage for eligible participants who reside in
11 the three areas of the state that have the highest number of
12 uninsured persons, as identified in the Florida Health
13 Insurance Study conducted by the agency and in Indian River
14 County. A health flex plan may limit or exclude benefits
15 otherwise required by law for insurers offering coverage in
16 this state, may cap the total amount of claims paid per year
17 per enrollee, may limit the number of enrollees, or may take
18 any combination of those actions.
19 (a) The agency shall develop guidelines for the review
20 of applications for health flex plans and shall disapprove or
21 withdraw approval of plans that do not meet or no longer meet
22 minimum standards for quality of care and access to care. The
23 agency shall ensure that the health flex plans follow
24 standardized grievance procedures similar to those required of
25 health maintenance organizations.
26 (b) The office shall develop guidelines for the review
27 of health flex plan applications and provide regulatory
28 oversight of health flex plan advertisement and marketing
29 procedures. The office shall disapprove or shall withdraw
30 approval of plans that:
31
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1 1. Contain any ambiguous, inconsistent, or misleading
2 provisions or any exceptions or conditions that deceptively
3 affect or limit the benefits purported to be assumed in the
4 general coverage provided by the health flex plan;
5 2. Provide benefits that are unreasonable in relation
6 to the premium charged or contain provisions that are unfair
7 or inequitable or contrary to the public policy of this state,
8 that encourage misrepresentation, or that result in unfair
9 discrimination in sales practices; or
10 3. Cannot demonstrate that the health flex plan is
11 financially sound and that the applicant is able to underwrite
12 or finance the health care coverage provided.
13 (c) The agency and the Financial Services Commission
14 may adopt rules as needed to administer this section.
15 (9) PROGRAM EVALUATION.--The agency and the office
16 shall evaluate the pilot program and its effect on the
17 entities that seek approval as health flex plans, on the
18 number of enrollees, and on the scope of the health care
19 coverage offered under a health flex plan; shall provide an
20 assessment of the health flex plans and their potential
21 applicability in other settings; shall use health flex plans
22 to gather more information to evaluate low-income consumer
23 driven benefit packages; and shall, by January 1, 2004,
24 jointly submit a report to the Governor, the President of the
25 Senate, and the Speaker of the House of Representatives.
26 Section 7. Paragraph (a) of subsection (6) of section
27 627.610, Florida Statutes, is amended to read:
28 627.410 Filing, approval of forms.--
29 (6)(a) An insurer shall not deliver or issue for
30 delivery or renew in this state any health insurance policy
31 form until it has filed with the office a copy of every
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1 applicable rating manual, rating schedule, change in rating
2 manual, and change in rating schedule; if rating manuals and
3 rating schedules are not applicable, the insurer must file
4 with the order applicable premium rates and any change in
5 applicable premium rates. This paragraph does not apply to
6 group health insurance policies, effectuated and delivered in
7 this state, insuring groups of 26 51 or more persons, except
8 for Medicare supplement insurance, long-term care insurance,
9 and any coverage under which the increase in claim costs over
10 the lifetime of the contract due to advancing age or duration
11 is prefunded in the premium.
12 Section 8. Section 627.64101, Florida Statutes, is
13 created to read:
14 627.64101 Optional coverage for speech, language,
15 swallowing, and hearing disorders.--
16 (1) Insurers issuing individual health insurance
17 policies in this state shall make available to the
18 policyholder as part of the application for any such policy of
19 insurance, for an appropriate additional premium, the benefits
20 or levels of benefits specified in the December 1999 Florida
21 Medicaid Therapy Services Handbook for genetic or congenital
22 disorders or conditions involving speech, language,
23 swallowing, and hearing and a hearing aid and earmolds benefit
24 at the level of benefits specified in the January 2001 Florida
25 Medicaid Hearing Services Handbook.
26 (2) This section does not apply to specified-accident,
27 specified-disease, hospital indemnity, limited benefit,
28 disability income, or long-term care insurance policies.
29 (3) Such optional coverage is not required to be
30 offered when substantially similar benefits are included in
31 the policy of insurance issued to the policyholder.
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1 (4) This section does not require or prohibit the use
2 of a provider network.
3 (5) This section does no prohibit an insurer from
4 requiring prior authorization for the benefits under this
5 section.
6 Section 9. Section 627.6421, Florida Statutes, is
7 created to read:
8 627.6421 Required standardized policy offering.--
9 (1) Beginning January 1, 2005, every authorized
10 insurer or health maintenance organization issuing a health
11 benefit plan as defined in s. 627.6699(3)(k) to individuals in
12 this state, including certificates of coverage offered to
13 individuals in this state as part of a group policy issued to
14 an association outside this state, must, as a condition of
15 transacting business in this state, offer to the prospective
16 individual insured or prospective subscriber a standard health
17 benefit plan and a basic health benefit plan as created
18 pursuant to s. 627.6699(12). Such health issuer shall offer a
19 standard health benefit plan or a basic health benefit plan to
20 every individual who meets the issuer's underwriting criteria,
21 agrees to make the required premium payments under such plan,
22 and agrees to satisfy the other provisions of the plan.
23 (2) If an individual rejects, in writing, the standard
24 health benefit plan and the basic health benefit plan, the
25 insurer or health maintenance organization may offer the
26 individual any other policy or contract filed and approved by
27 the state for issuance to individuals.
28 Section 10. Subsection (3) of section 627.6487,
29 Florida Statutes, is amended to read:
30 627.6487 Guaranteed availability of individual health
31 insurance coverage to eligible individuals.--
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1 (3) For the purposes of this section, the term
2 "eligible individual" means an individual:
3 (a)1. For whom, as of the date on which the individual
4 seeks coverage under this section, the aggregate of the
5 periods of creditable coverage, as defined in s. 627.6561(5)
6 and (6), is 18 or more months; and
7 2.a. Whose most recent prior creditable coverage was
8 under a group health plan, governmental plan, or church plan,
9 or health insurance coverage offered in connection with any
10 such plan; or
11 b. Whose most recent prior creditable coverage was
12 under an individual plan issued in this state by a health
13 insurer or health maintenance organization, which coverage is
14 terminated due to the insurer or health maintenance
15 organization becoming insolvent or discontinuing the offering
16 of all individual coverage in the State of Florida, or due to
17 the insured no longer living in the service area in the State
18 of Florida of the insurer or health maintenance organization
19 that provides coverage through a network plan in the State of
20 Florida;
21 (b) Who is not eligible for coverage under:
22 1. A group health plan, as defined in s. 2791 of the
23 Public Health Service Act;
24 2. A conversion policy or contract issued by an
25 authorized insurer or health maintenance organization under s.
26 627.6675 or s. 641.3921, respectively, offered to an
27 individual who is no longer eligible for coverage under either
28 an insured or self-insured employer plan;
29 3. Part A or part B of Title XVIII of the Social
30 Security Act; or
31
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1 4. A state plan under Title XIX of such act, or any
2 successor program, and does not have other health insurance
3 coverage; or
4 5. The Florida Health Insurance Plan as specified in
5 s. 627.64872 and such plan is accepting new enrollment;
6 (c) With respect to whom the most recent coverage
7 within the coverage period described in paragraph (a) was not
8 terminated based on a factor described in s. 627.6571(2)(a) or
9 (b), relating to nonpayment of premiums or fraud, unless such
10 nonpayment of premiums or fraud was due to acts of an employer
11 or person other than the individual;
12 (d) Who, having been offered the option of
13 continuation coverage under a COBRA continuation provision or
14 under s. 627.6692, elected such coverage; and
15 (e) Who, if the individual elected such continuation
16 provision, has exhausted such continuation coverage under such
17 provision or program.
18 Section 11. Section 627.66912, Florida Statutes, is
19 created to read:
20 627.66912 Optional coverage for speech, language,
21 swallowing, and hearing disorders.--
22 (1) Insures issuing group health insurance policies in
23 this stage shall make available to the policyholder as part of
24 the application for any such policy of insurance, for an
25 appropriate additional premium, the benefits or levels of
26 benefits specified in the December 1999 Florida Medicaid
27 Therapy Services Handbook for genetic or congenital disorders
28 or conditions involving speech, language, swallowing, and
29 hearing and a hearing aid and earmolds benefits at the level
30 of benefit specified in the January 2001 Florida Medicaid
31 Hearing Services Handbook.
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1 (2) This ection does not apply to specified-accident,
2 specified-disease, hospital indemnity, limited benefit,
3 disability income, or long-term care insurance policies.
4 (3) Such optional coverage is not required to be
5 offered when substantially similar benefits are included in
6 the policy of insurance issued to the policyholder.
7 (4) This section does not require or prohibit the use
8 of a provider network.
9 (5) This section does not prohibit an insurer from
10 requiring prior authorization for the benefits under this
11 section.
12 Section 12. Paragraph (n) of subsection (3) and
13 paragraph (b) of subsection (6) of section 627.6699, Florida
14 Statutes, are amended to read:
15 627.6699 Employee Health Care Access Act.--
16 (3) DEFINITIONS.--As used in this section, the term:
17 (n) "Modified community rating" means a method used to
18 develop carrier premiums which spreads financial risk across a
19 large population; allows the use of separate rating factors
20 for age, gender, family composition, tobacco usage, and
21 geographic area as determined under paragraph (5)(j); and
22 allows adjustments for: claims experience, health status, or
23 duration of coverage as permitted under subparagraph (6)(b)5.;
24 and administrative and acquisition expenses as permitted under
25 subparagraph (6)(b)5.
26 (6) RESTRICTIONS RELATING TO PREMIUM RATES.--
27 (b) For all small employer health benefit plans that
28 are subject to this section and are issued by small employer
29 carriers on or after January 1, 1994, premium rates for health
30 benefit plans subject to this section are subject to the
31 following:
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1 1. Small employer carriers must use a modified
2 community rating methodology in which the premium for each
3 small employer must be determined solely on the basis of the
4 eligible employee's and eligible dependent's gender, age,
5 family composition, tobacco use, or geographic area as
6 determined under paragraph (5)(j) and in which the premium may
7 be adjusted as permitted by this paragraph.
8 2. Rating factors related to age, gender, family
9 composition, tobacco use, or geographic location may be
10 developed by each carrier to reflect the carrier's experience.
11 The factors used by carriers are subject to office review and
12 approval.
13 3. Small employer carriers may not modify the rate for
14 a small employer for 12 months from the initial issue date or
15 renewal date, unless the composition of the group changes or
16 benefits are changed. However, a small employer carrier may
17 modify the rate one time prior to 12 months after the initial
18 issue date for a small employer who enrolls under a previously
19 issued group policy that has a common anniversary date for all
20 employers covered under the policy if:
21 a. The carrier discloses to the employer in a clear
22 and conspicuous manner the date of the first renewal and the
23 fact that the premium may increase on or after that date.
24 b. The insurer demonstrates to the office that
25 efficiencies in administration are achieved and reflected in
26 the rates charged to small employers covered under the policy.
27 4. A carrier may issue a group health insurance policy
28 to a small employer health alliance or other group association
29 with rates that reflect a premium credit for expense savings
30 attributable to administrative activities being performed by
31 the alliance or group association if such expense savings are
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1 specifically documented in the insurer's rate filing and are
2 approved by the office. Any such credit may not be based on
3 different morbidity assumptions or on any other factor related
4 to the health status or claims experience of any person
5 covered under the policy. Nothing in this subparagraph exempts
6 an alliance or group association from licensure for any
7 activities that require licensure under the insurance code. A
8 carrier issuing a group health insurance policy to a small
9 employer health alliance or other group association shall
10 allow any properly licensed and appointed agent of that
11 carrier to market and sell the small employer health alliance
12 or other group association policy. Such agent shall be paid
13 the usual and customary commission paid to any agent selling
14 the policy.
15 5. Any adjustments in rates for claims experience,
16 health status, or duration of coverage may not be charged to
17 individual employees or dependents. For a small employer's
18 policy, such adjustments may not result in a rate for the
19 small employer which deviates more than 15 percent from the
20 carrier's approved rate. Any such adjustment must be applied
21 uniformly to the rates charged for all employees and
22 dependents of the small employer. A small employer carrier may
23 make an adjustment to a small employer's renewal premium, not
24 to exceed 10 percent annually, due to the claims experience,
25 health status, or duration of coverage of the employees or
26 dependents of the small employer. Semiannually, small group
27 carriers shall report information on forms adopted by rule by
28 the commission, to enable the office to monitor the
29 relationship of aggregate adjusted premiums actually charged
30 policyholders by each carrier to the premiums that would have
31 been charged by application of the carrier's approved modified
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1 community rates. If the aggregate resulting from the
2 application of such adjustment exceeds the premium that would
3 have been charged by application of the approved modified
4 community rate by 5 percent for the current reporting period,
5 the carrier shall limit the application of such adjustments
6 only to minus adjustments beginning not more than 60 days
7 after the report is sent to the office. For any subsequent
8 reporting period, if the total aggregate adjusted premium
9 actually charged does not exceed the premium that would have
10 been charged by application of the approved modified community
11 rate by 5 percent, the carrier may apply both plus and minus
12 adjustments. A small employer carrier may provide a credit to
13 a small employer's premium based on administrative and
14 acquisition expense differences resulting from the size of the
15 group. Group size administrative and acquisition expense
16 factors may be developed by each carrier to reflect the
17 carrier's experience and are subject to office review and
18 approval.
19 6. A small employer carrier rating methodology may
20 include separate rating categories for one dependent child,
21 for two dependent children, and for three or more dependent
22 children for family coverage of employees having a spouse and
23 dependent children or employees having dependent children
24 only. A small employer carrier may have fewer, but not
25 greater, numbers of categories for dependent children than
26 those specified in this subparagraph.
27 7. Small employer carriers may not use a composite
28 rating methodology to rate a small employer with fewer than 10
29 employees. For the purposes of this subparagraph, a "composite
30 rating methodology" means a rating methodology that averages
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1 the impact of the rating factors for age and gender in the
2 premiums charged to all of the employees of a small employer.
3 8.a. A carrier may separate the experience of small
4 employer groups with less than 2 eligible employees from the
5 experience of small employer groups with 2-50 eligible
6 employees for purposes of determining an alternative modified
7 community rating.
8 b. If a carrier separates the experience of small
9 employer groups as provided in sub-subparagraph a., the rate
10 to be charged to small employer groups of less than 2 eligible
11 employees may not exceed 150 percent of the rate determined
12 for small employer groups of 2-50 eligible employees. However,
13 the carrier may charge excess losses of the experience pool
14 consisting of small employer groups with less than 2 eligible
15 employees to the experience pool consisting of small employer
16 groups with 2-50 eligible employees so that all losses are
17 allocated and the 150-percent rate limit on the experience
18 pool consisting of small employer groups with less than 2
19 eligible employees is maintained. Notwithstanding s.
20 627.411(1), the rate to be charged to a small employer group
21 of fewer than 2 eligible employees, insured as of July 1,
22 2002, may be up to 125 percent of the rate determined for
23 small employer groups of 2-50 eligible employees for the first
24 annual renewal and 150 percent for subsequent annual renewals.
25 Section 13. Subsection (7) of section 636.003, Florida
26 Statutes, is amended to read:
27 636.003 Definitions.--As used in this act, the term:
28 (7) "Prepaid limited health service organization"
29 means any person, corporation, partnership, or any other
30 entity which, in return for a prepayment, undertakes to
31 provide or arrange for, or provide access to, the provision of
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1 a limited health service to enrollees through an exclusive
2 panel of providers or undertakes to provide access to any
3 discounted medical services. Prepaid limited health service
4 organization does not include:
5 (a) An entity otherwise authorized pursuant to the
6 laws of this state to indemnify for any limited health
7 service;
8 (b) A provider or entity when providing limited health
9 services pursuant to a contract with a prepaid limited health
10 service organization, a health maintenance organization, a
11 health insurer, or a self-insurance plan; or
12 (c) Any person who, in exchange for fees, dues,
13 charges or other consideration, provides access to a limited
14 health service provider without assuming any responsibility
15 for payment for the limited health service or any portion
16 thereof; or.
17 (d) Any plan or program of discounted medical services
18 for which fees, dues, charges, or other consideration paid to
19 the plan by consumers does not exceed $15 per month or $180
20 per year and which in its advertising and contracts:
21 1. Clearly indicates that the plan is not insurance,
22 that the plan is not obligated to pay any portion of the
23 discounted medical fees, and that the consumer is responsible
24 for paying the full amount of the discounted fees;
25 2. Does not use the term "affordable health care" or
26 "coverage," or any other term that misrepresents the nature of
27 the program; and
28 3. Requires a statement beside the provider network on
29 the discount card alerting the network providers and
30 facilities that the cardholder does not have insurance and is
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1 merely entitled to the network discount rate for services
2 provided.
3 Section 14. Subsection (40) is added to section
4 641.31, Florida Statutes, to read:
5 641.31 Health maintenance contracts.--
6 (40) Health maintenance organizations shall make
7 available to the contract holder as part of the application
8 for any such contract, for an appropriate additional premium,
9 the benefits or levels of benefits specified in the December
10 1999 Florida Medicaid Therapy Services Handbook for genetic or
11 congenital disorders or conditions involving speech, language,
12 swallowing, and hearing and a hearing aid and earmolds benefit
13 at the level of benefits specified in the January 2001 Florida
14 Medicaid Hearing Services Handbook.
15 (a) Such optional coverage is not required to be
16 offered when substantially similar benefits are included in
17 the contract issued to the subscriber.
18 (b) This section does not require or prohibit the use
19 of a provider network.
20 (c) This section does not prohibit an organization
21 from requiring prior authorization for the benefits under this
22 subsection.
23 (d) This subsection does not apply to health
24 maintenance organizations issuing individual coverage to fewer
25 than 50,000 members.
26 Section 15. Except for this section and sections 5, 8,
27 11, and 14, which shall take effect July 1, 2004, and
28 paragraph (17)(b) of section 1, which shall take effect July
29 1, 2005, this act shall take effect October 1, 2004.
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1 *****************************************
2 SENATE SUMMARY
3 Creates or revises a variety of provisions relating to
health care, including creating a Florida Health
4 Insurance Plan, a Small Employers Access Program, and a
Statewide Electronic Medical Records Advisory Panel.
5 Revises coverages that insurers must make available. (See
bill for details.)
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