Amendment
Bill No. 0811

Amendment No. 455143

CHAMBER ACTION
Senate		House
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1	Representative(s) Farkas offered the following:
2
3	Amendment (with title amendment)
4	Between lines 58 and 59, insert:
5	Section 3.  Paragraph (l) of subsection (3) of section
6	408.05, Florida Statutes, is amended to read:
7	408.05  State Center for Health Statistics.--
8	(3)  COMPREHENSIVE HEALTH INFORMATION SYSTEM.--In order to
9	produce comparable and uniform health information and
10	statistics, the agency shall perform the following functions:
11	(l)  Develop, in conjunction with the State Comprehensive
12	Health Information System Advisory Council, and implement a
13	long-range plan for making available performance outcome and
14	financial data that will allow consumers to compare health care
15	services. The performance outcomes and financial data the agency
16	must make available shall include, but is not limited to,
17	pharmaceuticals, physicians, health care facilities, and health
18	plans and managed care entities. The agency shall submit the
19	initial plan to the Governor, the President of the Senate, and
20	the Speaker of the House of Representatives by January March 1,
21	2006 2005, and shall update the plan and report on the status of
22	its implementation annually thereafter. The agency shall also
23	make the plan and status report available to the public on its
24	Internet website. As part of the plan, the agency shall identify
25	the process and timeframes for implementation, any barriers to
26	implementation, and recommendations of changes in the law that
27	may be enacted by the Legislature to eliminate the barriers. As
28	preliminary elements of the plan, the agency shall:
29	1.  Make available performance outcome and patient charge
30	data collected from health care facilities pursuant to s.
31	408.061(1)(a) and (2). The agency shall determine which
32	conditions and procedures, performance outcomes, and patient
33	charge data to disclose based upon input from the council. When
34	determining which conditions and procedures are to be disclosed,
35	the council and the agency shall consider variation in costs,
36	variation in outcomes, and magnitude of variations and other
37	relevant information. When determining which performance
38	outcomes to disclose, the agency:
39	a.  Shall consider such factors as volume of cases; average
40	patient charges; average length of stay; complication rates;
41	mortality rates; and infection rates, among others, which shall
42	be adjusted for case mix and severity, if applicable.
43	b.  May consider such additional measures that are adopted
44	by the Centers for Medicare and Medicaid Studies, National
45	Quality Forum, the Joint Commission on Accreditation of
46	Healthcare Organizations, the Agency for Healthcare Research and
47	Quality, or a similar national entity that establishes standards
48	to measure the performance of health care providers, or by other
49	states.
50
51	When determining which patient charge data to disclose, the
52	agency shall consider such measures as average charge, average
53	net revenue per adjusted patient day, average cost per adjusted
54	patient day, and average cost per admission, among others.
55	2.  Make available performance measures, benefit design,
56	and premium cost data from health plans licensed pursuant to
57	chapter 627 or chapter 641. The agency shall determine which
58	performance outcome and member and subscriber cost data to
59	disclose, based upon input from the council. When determining
60	which data to disclose, the agency shall consider information
61	that may be required by either individual or group purchasers to
62	assess the value of the product, which may include membership
63	satisfaction, quality of care, current enrollment or membership,
64	coverage areas, accreditation status, premium costs, plan costs,
65	premium increases, range of benefits, copayments and
66	deductibles, accuracy and speed of claims payment, credentials
67	of physicians, number of providers, names of network providers,
68	and hospitals in the network. Health plans shall make available
69	to the agency any such data or information that is not currently
70	reported to the agency or the office.
71	3.  Determine the method and format for public disclosure
72	of data reported pursuant to this paragraph. The agency shall
73	make its determination based upon input from the Comprehensive
74	Health Information System Advisory Council. At a minimum, the
75	data shall be made available on the agency's Internet website in
76	a manner that allows consumers to conduct an interactive search
77	that allows them to view and compare the information for
78	specific providers. The website must include such additional
79	information as is determined necessary to ensure that the
80	website enhances informed decisionmaking among consumers and
81	health care purchasers, which shall include, at a minimum,
82	appropriate guidance on how to use the data and an explanation
83	of why the data may vary from provider to provider. The data
84	specified in subparagraph 1. shall be released no later than
85	January 1, 2006, for the reporting of infection rates, and no
86	later than October March 1, 2005, for mortality rates and
87	complication rates. The data specified in subparagraph 2. shall
88	be released no later than October March 1, 2006.
89	Section 4.  Paragraph (b) of subsection (3) of section
90	408.909, Florida Statutes, is amended to read:
91	408.909  Health flex plans.--
92	(3)  PROGRAM.--The agency and the office shall each approve
93	or disapprove health flex plans that provide health care
94	coverage for eligible participants. A health flex plan may limit
95	or exclude benefits otherwise required by law for insurers
96	offering coverage in this state, may cap the total amount of
97	claims paid per year per enrollee, may limit the number of
98	enrollees, or may take any combination of those actions. A
99	health flex plan offering may include the option of a
100	catastrophic plan supplementing the health flex plan.
101	(b)  The office shall develop guidelines for the review of
102	health flex plan applications and provide regulatory oversight
103	of health flex plan advertisement and marketing procedures. The
104	office shall disapprove or shall withdraw approval of plans
105	that:
106	1.  Contain any ambiguous, inconsistent, or misleading
107	provisions or any exceptions or conditions that deceptively
108	affect or limit the benefits purported to be assumed in the
109	general coverage provided by the health flex plan;
110	2.  Provide benefits that are unreasonable in relation to
111	the premium charged or contain provisions that are unfair or
112	inequitable or contrary to the public policy of this state, that
113	encourage misrepresentation, or that result in unfair
114	discrimination in sales practices; or
115	3.  Cannot demonstrate that the health flex plan is
116	financially sound and that the applicant is able to underwrite
117	or finance the health care coverage provided; or
118	4.  Cannot demonstrate that the applicant and its
119	management are in compliance with the standards required
120	pursuant to s. 624.404(3).
121	Section 5.  Subsection (6) is added to section 627.413,
122	Florida Statutes, to read:
123	627.413  Contents of policies, in general;
124	identification.--
125	(6)  Notwithstanding any other provision of the Florida
126	Insurance Code that is in conflict with federal requirements for
127	a health savings account qualified high deductible health plan,
128	an insurer, or a health maintenance organization subject to part
129	I of chapter 641, which is authorized to issue health insurance
130	in this state may offer for sale an individual or group policy
131	or contract that provides for a high deductible plan that meets
132	the federal requirements of a health savings account plan and
133	which is offered in conjunction with a health savings account.
134	Section 6.  Subsection (2) of section 627.638, Florida
135	Statutes, is amended to read:
136	627.638  Direct payment for hospital, medical services.--
137	(2)  Whenever, in any health insurance claim form, an
138	insured specifically authorizes payment of benefits directly to
139	any recognized hospital, or physician, or dentist, the insurer
140	shall make such payment to the designated provider of such
141	services, unless otherwise provided in the insurance contract.
142	The insurance contract may not prohibit, and claims forms must
143	provide option for, the payment of benefits directly to a
144	licensed hospital, physician, or dentist for care provided
145	pursuant to s. 395.1041. The insurer may require written
146	attestation of assignment of benefits. Payment to the provider
147	from the insurer shall be no more than the amount that the
148	insurer would otherwise have paid without the assignment.
149	Section 7.  Section 627.6402, Florida Statutes, is amended
150	to read:
151	627.6402  Insurance rebates for healthy lifestyles.--
152	(1)  Any rate, rating schedule, or rating manual for an
153	individual health insurance policy filed with the office may
154	shall provide for an appropriate rebate of premiums paid in the
155	last calendar year when the individual covered by such plan is
156	enrolled in and maintains participation in any health wellness,
157	maintenance, or improvement program approved by the health plan.
158	The rebate may be based on premiums paid in the last calendar
159	year or the last policy year. The individual must provide
160	evidence of demonstrative maintenance or improvement of the
161	individual's health status as determined by assessments of
162	agreed-upon health status indicators between the individual and
163	the health insurer, including, but not limited to, reduction in
164	weight, body mass index, and smoking cessation. Any rebate
165	provided by the health insurer is presumed to be appropriate
166	unless credible data demonstrates otherwise, or unless such
167	rebate program requires the insured to incur costs to qualify
168	for the rebate which equal or exceed the value of the rebate,
169	but in no event shall the rebate not exceed 10 percent of paid
170	premiums.
171	(2)  The premium rebate authorized by this section shall be
172	effective for an insured on an annual basis, unless the
173	individual fails to maintain or improve his or her health status
174	while participating in an approved wellness program, or credible
175	evidence demonstrates that the individual is not participating
176	in the approved wellness program.
177	(3)  The program shall be available for all policies issued
178	on or after July 1, 2005.
179	Section 8.  Paragraph (b) of subsection (3) of section
180	627.6487, Florida Statutes, is amended to read:
181	627.6487  Guaranteed availability of individual health
182	insurance coverage to eligible individuals.--
183	(3)  For the purposes of this section, the term "eligible
184	individual" means an individual:
185	(b)  Who is not eligible for coverage under:
186	1.  A group health plan, as defined in s. 2791 of the
187	Public Health Service Act;
188	2.  A conversion policy or contract issued by an authorized
189	insurer or health maintenance organization under s. 627.6675 or
190	s. 641.3921, respectively, offered to an individual who is no
191	longer eligible for coverage under either an insured or self-
192	insured employer plan;
193	3.  Part A or part B of Title XVIII of the Social Security
194	Act; or
195	4.  A state plan under Title XIX of such act, or any
196	successor program, and does not have other health insurance
197	coverage; or
198	5.  The Florida Health Insurance Plan as specified in s.
199	627.64872 and such plan is accepting new enrollments. However, a
200	person whose previous coverage was under the Florida Health
201	Insurance Plan as specified in s. 627.64872 is not an eligible
202	individual as defined in s. 627.6487(3)(a);
203	Section 9.  Paragraphs (b), (c), and (n) of subsection (2)
204	and subsections (3), (6), (9), and (15) of section 627.64872,
205	Florida Statutes, are amended, subsection (20) of said section
206	is renumbered as subsection (21), and a new subsection (20) is
207	added to said section, to read:
208	627.64872  Florida Health Insurance Plan.--
209	(2)  DEFINITIONS.--As used in this section:
210	(b)  "Commissioner" means the Commissioner of Insurance
211	Regulation.
212	(c)  "Dependent" means a resident spouse or resident
213	unmarried child under the age of 19 years, a child who is a
214	student under the age of 25 years and who is financially
215	dependent upon the parent, or a child of any age who is disabled
216	and dependent upon the parent.
217	(c)  "Director" means the Director of the Office of
218	Insurance Regulation.
219	(n)  "Resident" means an individual who has been legally
220	domiciled in this state for a period of at least 6 months and
221	who physically resides in this state not less than 185 days per
222	year.
223	(3)  BOARD OF DIRECTORS.--
224	(a)  The plan shall operate subject to the supervision and
225	control of the board. The board shall consist of the
226	commissioner director or his or her designated representative,
227	who shall serve as a member of the board and shall be its chair,
228	and an additional eight members, five of whom shall be appointed
229	by the Governor, at least two of whom shall be individuals not
230	representative of insurers or health care providers, one of whom
231	shall be appointed by the President of the Senate, one of whom
232	shall be appointed by the Speaker of the House of
233	Representatives, and one of whom shall be appointed by the Chief
234	Financial Officer.
235	(b)  The term to be served on the board by the commissioner
236	Director of the Office of Insurance Regulation shall be
237	determined by continued employment in such position. The
238	remaining initial board members shall serve for a period of time
239	as follows: two members appointed by the Governor and the
240	members appointed by the President of the Senate and the Speaker
241	of the House of Representatives shall serve a term of 2 years;
242	and three members appointed by the Governor and the Chief
243	Financial Officer shall serve a term of 4 years. Subsequent
244	board members shall serve for a term of 3 years. A board
245	member's term shall continue until his or her successor is
246	appointed.
247	(c)  Vacancies on the board shall be filled by the
248	appointing authority, such authority being the Governor, the
249	President of the Senate, the Speaker of the House of
250	Representatives, or the Chief Financial Officer. The appointing
251	authority may remove board members for cause.
252	(d)  The commissioner director, or his or her recognized
253	representative, shall be responsible for any organizational
254	requirements necessary for the initial meeting of the board
255	which shall take place no later than September 1, 2004.
256	(e)  Members shall not be compensated in their capacity as
257	board members but shall be reimbursed for reasonable expenses
258	incurred in the necessary performance of their duties in
259	accordance with s. 112.061.
260	(f)  The board shall submit to the Financial Services
261	Commission a plan of operation for the plan and any amendments
262	thereto necessary or suitable to ensure the fair, reasonable,
263	and equitable administration of the plan. The plan of operation
264	shall ensure that the plan qualifies to apply for any available
265	funding from the Federal Government that adds to the financial
266	viability of the plan. The plan of operation shall become
267	effective upon approval in writing by the Financial Services
268	Commission consistent with the date on which the coverage under
269	this section must be made available. If the board fails to
270	submit a suitable plan of operation within 1 year after
271	implementation the appointment of the board of directors, or at
272	any time thereafter fails to submit suitable amendments to the
273	plan of operation, the Financial Services Commission shall adopt
274	such rules as are necessary or advisable to effectuate the
275	provisions of this section. Such rules shall continue in force
276	until modified by the office or superseded by a plan of
277	operation submitted by the board and approved by the Financial
278	Services Commission.
279	(6)  INTERIM REPORT; ANNUAL REPORT.--
280	(a)  By no later than December 1, 2004, the board shall
281	report to the Governor, the President of the Senate, and the
282	Speaker of the House of Representatives the results of an
283	actuarial study conducted by the board to determine, including,
284	but not limited to:
285	1.  The impact the creation of the plan will have on the
286	small group insurance market and the individual market on
287	premiums paid by insureds. This shall include an estimate of the
288	total anticipated aggregate savings for all small employers in
289	the state.
290	2.  The number of individuals the pool could reasonably
291	cover at various funding levels, specifically, the number of
292	people the pool may cover at each of those funding levels.
293	3.  A recommendation as to the best source of funding for
294	the anticipated deficits of the pool.
295	4.  The effect on the individual and small group market by
296	including in the Florida Health Insurance Plan persons eligible
297	for coverage under s. 627.6487, as well as the cost of including
298	these individuals.
299
300	The board shall take no action to implement the Florida Health
301	Insurance Plan, other than the completion of the actuarial study
302	authorized in this paragraph, until funds are appropriated for
303	startup cost and any projected deficits.
304	(b)  No later than December 1, 2005, and annually
305	thereafter, the board shall submit to the Governor, the
306	President of the Senate, the Speaker of the House of
307	Representatives, and the substantive legislative committees of
308	the Legislature a report which includes an independent actuarial
309	study to determine, including, but not be limited to:
310	(a)1.  The impact the creation of the plan has on the small
311	group and individual insurance market, specifically on the
312	premiums paid by insureds. This shall include an estimate of the
313	total anticipated aggregate savings for all small employers in
314	the state.
315	(b)2.  The actual number of individuals covered at the
316	current funding and benefit level, the projected number of
317	individuals that may seek coverage in the forthcoming fiscal
318	year, and the projected funding needed to cover anticipated
319	increase or decrease in plan participation.
320	3.  A recommendation as to the best source of funding for
321	the anticipated deficits of the pool.
322	(c)4.  A summarization of the activities of the plan in the
323	preceding calendar year, including the net written and earned
324	premiums, plan enrollment, the expense of administration, and
325	the paid and incurred losses.
326	(d)5.  A review of the operation of the plan as to whether
327	the plan has met the intent of this section.
328	(9)  ELIGIBILITY.--
329	(a)  Any individual person who is and continues to be a
330	resident of this state shall be eligible for coverage under the
331	plan if:
332	1.  Evidence is provided that the person received notices
333	of rejection or refusal to issue substantially similar coverage
334	for health reasons from at least two health insurers or health
335	maintenance organizations. A rejection or refusal by an insurer
336	offering only stop-loss, excess of loss, or reinsurance coverage
337	with respect to the applicant shall not be sufficient evidence
338	under this paragraph;.
339	2.  The person is enrolled in the Florida Comprehensive
340	Health Association as of the date the plan is implemented; or.
341	3.  Is an eligible individual as defined in s. 627.6487(3),
342	excluding s. 627.6487(3)(b)5.
343	(b)  Each resident dependent of a person who is eligible
344	for coverage under the plan shall also be eligible for such
345	coverage.
346	(c)  Except for individuals made eligible under
347	subparagraph (a)3., a person shall not be eligible for coverage
348	under the plan if:
349	1.  The person has or obtains health insurance coverage
350	substantially similar to or more comprehensive than a plan
351	policy, or would be eligible to obtain such coverage, unless a
352	person may maintain other coverage for the period of time the
353	person is satisfying any preexisting condition waiting period
354	under a plan policy or may maintain plan coverage for the period
355	of time the person is satisfying a preexisting condition waiting
356	period under another health insurance policy intended to replace
357	the plan policy;.
358	2.  The person is determined to be eligible for health care
359	benefits under Medicaid, Medicare, the state's children's health
360	insurance program, or any other federal, state, or local
361	government program that provides health benefits;
362	3.  The person voluntarily terminated plan coverage unless
363	12 months have elapsed since such termination;
364	4.  The person is an inmate or resident of a public
365	institution; or
366	5.  The person's premiums are paid for or reimbursed under
367	any government-sponsored program or by any government agency or
368	health care provider or by any health care provider sponsored or
369	affiliated organization.
370	(d)  Coverage shall cease:
371	1.  On the date a person is no longer a resident of this
372	state;
373	2.  On the date a person requests coverage to end;
374	3.  Upon the death of the covered person;
375	4.  On the date state law requires cancellation or
376	nonrenewal of the policy; or
377	5.  At the option of the plan, 30 days after the plan makes
378	any inquiry concerning the person's eligibility or place of
379	residence to which the person does not reply; or.
380	6.  Upon failure of the insured to pay for continued
381	coverage.
382	(e)  Except under the circumstances described in this
383	subsection, coverage of a person who ceases to meet the
384	eligibility requirements of this subsection shall be terminated
385	at the end of the policy period for which the necessary premiums
386	have been paid.
387	(15)  FUNDING OF THE PLAN.--
388	(a)  Premiums.--
389	1.  The plan shall establish premium rates for plan
390	coverage as provided in this section. Separate schedules of
391	premium rates based on age, sex, and geographical location may
392	apply for individual risks. Premium rates and schedules shall be
393	submitted to the office for approval prior to use.
394	2.  Initial rates for plan coverage shall be limited to no
395	more than 200 percent 300 percent of rates established for
396	individual standard risks as specified in s. 627.6675(3)(c).
397	Subject to the limits provided in this paragraph, subsequent
398	rates shall be established to provide fully for the expected
399	costs of claims, including recovery of prior losses, expenses of
400	operation, investment income of claim reserves, and any other
401	cost factors subject to the limitations described herein, but in
402	no event shall premiums exceed the 200-percent 300-percent rate
403	limitation provided in this section. Notwithstanding the 200-
404	percent 300-percent rate limitation, sliding scale premium
405	surcharges based upon the insured's income may apply to all
406	enrollees, except those made eligible for coverage by
407	subparagraph (9)(a)3.
408	3.  For the purposes of determining assessments under this
409	section, the term "health insurance" means any hospital and
410	medical expense incurred policy, minimum premium plan, stop-loss
411	coverage, health maintenance organization contract, prepaid
412	health clinic contract, multiple-employer welfare arrangement
413	contract, or fraternal benefit society health benefits contract,
414	whether sold as an individual or group policy or contract. The
415	term does not include a policy covering medical payment coverage
416	or personal injury protection coverage in a motor vehicle
417	policy, coverage issued as a supplement to liability insurance,
418	or workers' compensation.
419	(b)  Sources of additional revenue.--Any deficit incurred
420	by the plan may shall be primarily funded through amounts
421	appropriated by the Legislature from general revenue and other
422	appropriate sources, including, but not limited to, a portion of
423	the annual growth in existing net insurance premium taxes in an
424	amount not less than the anticipated losses and reserve
425	requirements for existing policyholders. General revenue sources
426	for the plan shall not exceed $5 million per year and are
427	subject to annual appropriation by the Legislature. The board
428	shall operate the plan in such a manner that the estimated cost
429	of providing health insurance during any fiscal year will not
430	exceed total income the plan expects to receive from policy
431	premiums and funds appropriated by the Legislature, including
432	any interest on investments. After determining the amount of
433	funds appropriated to the board for a fiscal year, the board
434	shall estimate the number of new policies it believes the plan
435	has the financial capacity to insure during that year so that
436	costs do not exceed income. The board shall take steps necessary
437	to ensure that plan enrollment does not exceed the number of
438	residents it has estimated it has the financial capacity to
439	insure.
440	(c)  In the event of inadequate funding, the board may
441	cancel existing policies on a nondiscriminatory basis as
442	necessary to remedy the situation. No policy may be canceled if
443	a covered individual is currently making a claim.
444	(20)  PROVIDER REIMBURSEMENT.--Notwithstanding any other
445	provision of law, the maximum reimbursement rate to health care
446	providers for all covered, medically necessary services shall be
447	100 percent of Medicare's allowed payment amount for that
448	particular provider and service. All licensed providers in this
449	state shall accept assignment of plan benefits and consider the
450	Medicare allowed payment amount as payment in full. By no later
451	than December 1, 2005, the board shall update the actuarial
452	study required by s. 627.64872(6), to include the impact of
453	alternative methods of actuarially sound risk adjusted provider
454	reimbursement methodologies, including capitated prepaid
455	arrangements, that take into account such factors as age, sex,
456	geographic variations, case mix, and access to specialty medical
457	care. The board shall submit the updated actuarial study to the
458	Governor, the President of the Senate, and the Speaker of the
459	House no later than December 1, 2005.
460	Section 10.  Section 627.65626, Florida Statutes, is
461	amended to read:
462	627.65626  Insurance rebates for healthy lifestyles.--
463	(1)  Any rate, rating schedule, or rating manual for a
464	health insurance policy, which provides creditable coverage as
465	defined in s. 627.6561(5), filed with the office shall provide
466	for an appropriate rebate of premiums paid in the last policy
467	year, contract year, or calendar year when the majority of
468	members of a health plan have enrolled and maintained
469	participation in any health wellness, maintenance, or
470	improvement program offered by the group policyholder and the
471	health plan employer. The rebate may be based upon premiums paid
472	in the last calendar year or policy year. The group employer
473	must provide evidence of demonstrative maintenance or
474	improvement of the enrollees' health status as determined by
475	assessments of agreed-upon health status indicators between the
476	policyholder employer and the health insurer, including, but not
477	limited to, reduction in weight, body mass index, and smoking
478	cessation. The group or health insurer may contract with an
479	independent third-party administrator to assemble and report the
480	health status required in this subsection between the
481	policyholder and the health insurer. Any rebate provided by the
482	health insurer is presumed to be appropriate unless credible
483	data demonstrates otherwise or unless such rebate program
484	requires the insured to incur costs to qualify for the rebate
485	which equal or exceed the value of the rebate, but in no event
486	shall the rebate not exceed 10 percent of paid premiums.
487	(2)  The premium rebate authorized by this section shall be
488	effective for an insured on an annual basis unless the number of
489	participating employees or members on the policy renewal
490	anniversary becomes less than the majority of the employees or
491	members eligible for participation in the wellness program.
492	(3)  The program shall be available for all policies issued
493	on or after July 1, 2005.
494	Section 11.  Paragraphs (d) and (j) of subsection (5) of
495	section 627.6692, Florida Statutes, are amended to read:
496	627.6692  Florida Health Insurance Coverage Continuation
497	Act.--
498	(5)  CONTINUATION OF COVERAGE UNDER GROUP HEALTH PLANS.--
499	(d)1.  A qualified beneficiary must give written notice to
500	the insurance carrier within 63 30 days after the occurrence of
501	a qualifying event. Unless otherwise specified in the notice, a
502	notice by any qualified beneficiary constitutes notice on behalf
503	of all qualified beneficiaries. The written notice must inform
504	the insurance carrier of the occurrence and type of the
505	qualifying event giving rise to the potential election by a
506	qualified beneficiary of continuation of coverage under the
507	group health plan issued by that insurance carrier, except that
508	in cases where the covered employee has been involuntarily
509	discharged, the nature of such discharge need not be disclosed.
510	The written notice must, at a minimum, identify the employer,
511	the group health plan number, the name and address of all
512	qualified beneficiaries, and such other information required by
513	the insurance carrier under the terms of the group health plan
514	or the commission by rule, to the extent that such information
515	is known by the qualified beneficiary.
516	2.  Within 14 days after the receipt of written notice
517	under subparagraph 1., the insurance carrier shall send each
518	qualified beneficiary by certified mail an election and premium
519	notice form, approved by the office, which form must provide for
520	the qualified beneficiary's election or nonelection of
521	continuation of coverage under the group health plan and the
522	applicable premium amount due after the election to continue
523	coverage. This subparagraph does not require separate mailing of
524	notices to qualified beneficiaries residing in the same
525	household, but requires a separate mailing for each separate
526	household.
527	(j)  Notwithstanding paragraph (b), if a qualified
528	beneficiary in the military reserve or National Guard has
529	elected to continue coverage and is thereafter called to active
530	duty and the coverage under the group plan is terminated by the
531	beneficiary or the carrier due to the qualified beneficiary
532	becoming eligible for TRICARE (the health care program provided
533	by the United States Defense Department), the 18-month period or
534	such other applicable maximum time period for which the
535	qualified beneficiary would otherwise be entitled to continue
536	coverage is tolled during the time that he or she is covered
537	under the TRICARE program. Within 63 30 days after the federal
538	TRICARE coverage terminates, the qualified beneficiary may elect
539	to continue coverage under the group health plan, retroactively
540	to the date coverage terminated under TRICARE, for the remainder
541	of the 18-month period or such other applicable time period,
542	subject to termination of coverage at the earliest of the
543	conditions specified in paragraph (b).
544	Section 12.  Paragraph (c) of subsection (5) and paragraphs
545	(b) and (j) of subsection (11) of section 627.6699, Florida
546	Statutes, are amended, and paragraph (o) is added to subsection
547	(11) of said section, to read:
548	627.6699  Employee Health Care Access Act.--
549	(5)  AVAILABILITY OF COVERAGE.--
550	(c)  Every small employer carrier must, as a condition of
551	transacting business in this state:
552	1.  Offer and issue all small employer health benefit plans
553	on a guaranteed-issue basis to every eligible small employer,
554	with 2 to 50 eligible employees, that elects to be covered under
555	such plan, agrees to make the required premium payments, and
556	satisfies the other provisions of the plan. A rider for
557	additional or increased benefits may be medically underwritten
558	and may only be added to the standard health benefit plan. The
559	increased rate charged for the additional or increased benefit
560	must be rated in accordance with this section.
561	2.  In the absence of enrollment availability in the
562	Florida Health Insurance Plan, offer and issue basic and
563	standard small employer health benefit plans and a high
564	deductible plan that meets the requirements of a health savings
565	account plan or health reimbursement account as defined by
566	federal law, on a guaranteed-issue basis, during a 31-day open
567	enrollment period of August 1 through August 31 of each year, to
568	every eligible small employer, with fewer than two eligible
569	employees, which small employer is not formed primarily for the
570	purpose of buying health insurance and which elects to be
571	covered under such plan, agrees to make the required premium
572	payments, and satisfies the other provisions of the plan.
573	Coverage provided under this subparagraph shall begin on October
574	1 of the same year as the date of enrollment, unless the small
575	employer carrier and the small employer agree to a different
576	date. A rider for additional or increased benefits may be
577	medically underwritten and may only be added to the standard
578	health benefit plan. The increased rate charged for the
579	additional or increased benefit must be rated in accordance with
580	this section. For purposes of this subparagraph, a person, his
581	or her spouse, and his or her dependent children constitute a
582	single eligible employee if that person and spouse are employed
583	by the same small employer and either that person or his or her
584	spouse has a normal work week of less than 25 hours. Any right
585	to an open enrollment of health benefit coverage for groups of
586	fewer than two employees, pursuant to this section, shall remain
587	in full force and effect in the absence of the availability of
588	new enrollment into the Florida Health Insurance Plan.
589	3.  This paragraph does not limit a carrier's ability to
590	offer other health benefit plans to small employers if the
591	standard and basic health benefit plans are offered and
592	rejected.
593	(11)  SMALL EMPLOYER HEALTH REINSURANCE PROGRAM.--
594	(b)1.  The program shall operate subject to the supervision
595	and control of the board.
596	2.  Effective upon this act becoming a law, the board shall
597	consist of the director of the office or his or her designee,
598	who shall serve as the chairperson, and 13 additional members
599	who are representatives of carriers and insurance agents and are
600	appointed by the director of the office and serve as follows:
601	a.  Five members shall be representatives of health
602	insurers licensed under chapter 624 or chapter 641. Two members
603	shall be agents who are actively engaged in the sale of health
604	insurance. Four members shall be employers or representatives of
605	employers. One member shall be a person covered under an
606	individual health insurance policy issued by a licensed insurer
607	in this state. One member shall represent the Agency for Health
608	Care Administration and shall be recommended by the Secretary of
609	Health Care Administration. The director of the office shall
610	include representatives of small employer carriers subject to
611	assessment under this subsection. If two or more carriers elect
612	to be risk-assuming carriers, the membership must include at
613	least two representatives of risk-assuming carriers; if one
614	carrier is risk-assuming, one member must be a representative of
615	such carrier. At least one member must be a carrier who is
616	subject to the assessments, but is not a small employer carrier.
617	Subject to such restrictions, at least five members shall be
618	selected from individuals recommended by small employer carriers
619	pursuant to procedures provided by rule of the commission. Three
620	members shall be selected from a list of health insurance
621	carriers that issue individual health insurance policies. At
622	least two of the three members selected must be reinsuring
623	carriers. Two members shall be selected from a list of insurance
624	agents who are actively engaged in the sale of health insurance.
625	b.  A member appointed under this subparagraph shall serve
626	a term of 4 years and shall continue in office until the
627	member's successor takes office, except that, in order to
628	provide for staggered terms, the director of the office shall
629	designate two of the initial appointees under this subparagraph
630	to serve terms of 2 years and shall designate three of the
631	initial appointees under this subparagraph to serve terms of 3
632	years.
633	3.  The director of the office may remove a member for
634	cause.
635	4.  Vacancies on the board shall be filled in the same
636	manner as the original appointment for the unexpired portion of
637	the term.
638	5.  The director of the office may require an entity that
639	recommends persons for appointment to submit additional lists of
640	recommended appointees.
641	(j)1.  Before July March 1 of each calendar year, the board
642	shall determine and report to the office the program net loss
643	for the previous year, including administrative expenses for
644	that year, and the incurred losses for the year, taking into
645	account investment income and other appropriate gains and
646	losses.
647	2.  Any net loss for the year shall be recouped by
648	assessment of the carriers, as follows:
649	a.  The operating losses of the program shall be assessed
650	in the following order subject to the specified limitations. The
651	first tier of assessments shall be made against reinsuring
652	carriers in an amount which shall not exceed 5 percent of each
653	reinsuring carrier's premiums from health benefit plans covering
654	small employers. If such assessments have been collected and
655	additional moneys are needed, the board shall make a second tier
656	of assessments in an amount which shall not exceed 0.5 percent
657	of each carrier's health benefit plan premiums. Except as
658	provided in paragraph (n), risk-assuming carriers are exempt
659	from all assessments authorized pursuant to this section. The
660	amount paid by a reinsuring carrier for the first tier of
661	assessments shall be credited against any additional assessments
662	made.
663	b.  The board shall equitably assess carriers for operating
664	losses of the plan based on market share. The board shall
665	annually assess each carrier a portion of the operating losses
666	of the plan. The first tier of assessments shall be determined
667	by multiplying the operating losses by a fraction, the numerator
668	of which equals the reinsuring carrier's earned premium
669	pertaining to direct writings of small employer health benefit
670	plans in the state during the calendar year for which the
671	assessment is levied, and the denominator of which equals the
672	total of all such premiums earned by reinsuring carriers in the
673	state during that calendar year. The second tier of assessments
674	shall be based on the premiums that all carriers, except risk-
675	assuming carriers, earned on all health benefit plans written in
676	this state. The board may levy interim assessments against
677	carriers to ensure the financial ability of the plan to cover
678	claims expenses and administrative expenses paid or estimated to
679	be paid in the operation of the plan for the calendar year prior
680	to the association's anticipated receipt of annual assessments
681	for that calendar year. Any interim assessment is due and
682	payable within 30 days after receipt by a carrier of the interim
683	assessment notice. Interim assessment payments shall be credited
684	against the carrier's annual assessment. Health benefit plan
685	premiums and benefits paid by a carrier that are less than an
686	amount determined by the board to justify the cost of collection
687	may not be considered for purposes of determining assessments.
688	c.  Subject to the approval of the office, the board shall
689	make an adjustment to the assessment formula for reinsuring
690	carriers that are approved as federally qualified health
691	maintenance organizations by the Secretary of Health and Human
692	Services pursuant to 42 U.S.C. s. 300e(c)(2)(A) to the extent,
693	if any, that restrictions are placed on them that are not
694	imposed on other small employer carriers.
695	3.  Before July March 1 of each year, the board shall
696	determine and file with the office an estimate of the
697	assessments needed to fund the losses incurred by the program in
698	the previous calendar year.
699	4.  If the board determines that the assessments needed to
700	fund the losses incurred by the program in the previous calendar
701	year will exceed the amount specified in subparagraph 2., the
702	board shall evaluate the operation of the program and report its
703	findings, including any recommendations for changes to the plan
704	of operation, to the office within 180 90 days following the end
705	of the calendar year in which the losses were incurred. The
706	evaluation shall include an estimate of future assessments, the
707	administrative costs of the program, the appropriateness of the
708	premiums charged and the level of carrier retention under the
709	program, and the costs of coverage for small employers. If the
710	board fails to file a report with the office within 180 90 days
711	following the end of the applicable calendar year, the office
712	may evaluate the operations of the program and implement such
713	amendments to the plan of operation the office deems necessary
714	to reduce future losses and assessments.
715	5.  If assessments exceed the amount of the actual losses
716	and administrative expenses of the program, the excess shall be
717	held as interest and used by the board to offset future losses
718	or to reduce program premiums. As used in this paragraph, the
719	term "future losses" includes reserves for incurred but not
720	reported claims.
721	6.  Each carrier's proportion of the assessment shall be
722	determined annually by the board, based on annual statements and
723	other reports considered necessary by the board and filed by the
724	carriers with the board.
725	7.  Provision shall be made in the plan of operation for
726	the imposition of an interest penalty for late payment of an
727	assessment.
728	8.  A carrier may seek, from the office, a deferment, in
729	whole or in part, from any assessment made by the board. The
730	office may defer, in whole or in part, the assessment of a
731	carrier if, in the opinion of the office, the payment of the
732	assessment would place the carrier in a financially impaired
733	condition. If an assessment against a carrier is deferred, in
734	whole or in part, the amount by which the assessment is deferred
735	may be assessed against the other carriers in a manner
736	consistent with the basis for assessment set forth in this
737	section. The carrier receiving such deferment remains liable to
738	the program for the amount deferred and is prohibited from
739	reinsuring any individuals or groups in the program if it fails
740	to pay assessments.
741	(o)  The board shall advise the office, the agency, the
742	department, and other executive and legislative entities on
743	health insurance issues. Specifically, the board shall:
744	1.  Provide a forum for stakeholders, consisting of
745	insurers, employers, agents, consumers, and regulators, in the
746	private health insurance market in this state.
747	2.  Review and recommend strategies to improve the
748	functioning of the health insurance markets in this state with a
749	specific focus on market stability, access, and pricing.
750	3.  Make recommendations to the office for legislation
751	addressing health insurance market issues and provide comments
752	on health insurance legislation proposed by the office.
753	4.  Meet at least three times each year. One meeting shall
754	be held to hear reports and to secure public comment on the
755	health insurance market, to develop any legislation needed to
756	address health insurance market issues, and to provide comments
757	on health insurance legislation proposed by the office.
758	5.  By September 1 each year, issue a report to the office
759	on the state of the health insurance market. The report shall
760	include recommendations for changes in the health insurance
761	market, results from implementation of previous recommendations
762	and information on health insurance markets.
763	Section 13.  Subsection (1) of section 641.27, Florida
764	Statutes, is amended to read:
765	641.27  Examination by the department.--
766	(1)  The office shall examine the affairs, transactions,
767	accounts, business records, and assets of any health maintenance
768	organization as often as it deems it expedient for the
769	protection of the people of this state, but not less frequently
770	than once every 5 3 years. In lieu of making its own financial
771	examination, the office may accept an independent certified
772	public accountant's audit report prepared on a statutory
773	accounting basis consistent with this part. However, except when
774	the medical records are requested and copies furnished pursuant
775	to s. 456.057, medical records of individuals and records of
776	physicians providing service under contract to the health
777	maintenance organization shall not be subject to audit, although
778	they may be subject to subpoena by court order upon a showing of
779	good cause. For the purpose of examinations, the office may
780	administer oaths to and examine the officers and agents of a
781	health maintenance organization concerning its business and
782	affairs. The examination of each health maintenance organization
783	by the office shall be subject to the same terms and conditions
784	as apply to insurers under chapter 624. In no event shall
785	expenses of all examinations exceed a maximum of $50,000 $20,000
786	for any 1-year period. Any rehabilitation, liquidation,
787	conservation, or dissolution of a health maintenance
788	organization shall be conducted under the supervision of the
789	department, which shall have all power with respect thereto
790	granted to it under the laws governing the rehabilitation,
791	liquidation, reorganization, conservation, or dissolution of
792	life insurance companies.
793	Section 14.  Subsection (40) of section 641.31, Florida
794	Statutes, is amended to read:
795	641.31  Health maintenance contracts.--
796	(40)(a)  Any group rate, rating schedule, or rating manual
797	for a health maintenance organization policy, which provides
798	creditable coverage as defined in s. 627.6561(5), filed with the
799	office shall provide for an appropriate rebate of premiums paid
800	in the last contract calendar year when the majority of the
801	members of a health individual covered by such plan are is
802	enrolled in and maintain maintains participation in any health
803	wellness, maintenance, or improvement program offered by the
804	group contract holder approved by the health plan. The group
805	individual must provide evidence of demonstrative maintenance or
806	improvement of his or her health status as determined by
807	assessments of agreed-upon health status indicators between the
808	group individual and the health insurer, including, but not
809	limited to, reduction in weight, body mass index, and smoking
810	cessation. Any rebate provided by the health maintenance
811	organization insurer is presumed to be appropriate unless
812	credible data demonstrates otherwise or unless such rebate
813	program requires the insured to incur costs to qualify for the
814	rebate which equal or exceed the value of the rebate, but in no
815	event shall the rebate not exceed 10 percent of paid premiums.
816	(b)  The premium rebate authorized by this section shall be
817	effective for a subscriber an insured on an annual basis, unless
818	the number of participating members on the contract renewal
819	anniversary becomes less than the majority of the members
820	eligible for participation in the wellness program individual
821	fails to maintain or improve his or her health status while
822	participating in an approved wellness program, or credible
823	evidence demonstrates that the individual is not participating
824	in the approved wellness program.
825	(c)  The program shall be available for all contracts
826	issued on or after July 1, 2005.
827	Section 15.  There is hereby appropriated $5 million from
828	the General Revenue Fund for fiscal year 2005-2006 to the
829	Florida Health Insurance Plan for the purposes of implementing
830	the plan.
831
832
833	================ T I T L E  A M E N D M E N T =============
834	Remove line 10 and insert:
835	circumstances; providing requirements; amending s. 408.05, F.S.;
836	changing the due date for a report from the Agency for Health
837	Care Administration regarding the State Center for Health
838	Statistics; changing the release dates for certain data
839	collected by the State Center for Health Statistics; amending s.
840	408.909, F.S.; providing an additional criterion for the Office
841	of Insurance Regulation to disapprove or withdraw approval of
842	health flex plans; amending s. 627.413, F.S.; authorizing
843	insurers and health maintenance organizations to offer policies
844	or contracts providing for a high deductible plan meeting
845	federal requirements and in conjunction with a health savings
846	account; amending s. 627.638, F.S.; providing certain contract
847	and claim form requirements for direct payment to certain
848	providers of emergency services and care; amending s. 627.6402,
849	F.S.; revising provisions for healthy lifestyle rebates for an
850	individual health insurance policy; providing exceptions;
851	providing application; amending s. 627.6487, F.S.; revising the
852	definition of the term "eligible individual" for purposes of
853	obtaining coverage in the Florida Health Insurance Plan;
854	amending s. 627.64872, F.S.; revising definitions; changing
855	references to the Director of the Office of Insurance Regulation
856	to the Commissioner of Insurance Regulation; deleting obsolete
857	language; providing additional eligibility criteria; reducing
858	premium rate limitations; revising requirements for sources of
859	additional revenue; authorizing the board to cancel policies
860	under inadequate funding conditions; providing a limitation;
861	defining the term "health insurance" for purposes of certain
862	assessments; providing an exclusion; specifying a maximum
863	provider reimbursement rate; requiring licensed providers to
864	accept assignment of plan benefits and consider certain payments
865	as payments in full; authorizing the board to update a required
866	actuarial study; providing study criteria; amending s.
867	627.65626, F.S.; revising criteria for healthy lifestyle rebates
868	for group and similar health insurance policies provided by
869	health insurers; authorizing group or health insurers to
870	contract with an independent third-party administrator for
871	certain purposes; providing exceptions; providing application;
872	amending s. 627.6692, F.S.; extending a time period within which
873	eligible employees may apply for continuation of coverage;
874	amending s. 627.6699, F.S.; revising availability of coverage
875	provision of the Employee Health Care Access Act; including high
876	deductible plans meeting federal health savings account plan
877	requirements; revising membership of the board of the small
878	employer health reinsurance program; revising certain reporting
879	dates relating to program losses and assessments; requiring the
880	board to advise executive and legislative entities on health
881	insurance issues; providing requirements; amending s. 641.27,
882	F.S.; increasing the interval at which the office examines
883	health maintenance organizations; deleting authorization for the
884	office to accept an audit report from a certified public
885	accountant in lieu of conducting its own examination; increasing
886	an expense limitation; amending s. 641.31, F.S.; revising
887	criteria for healthy lifestyle rebates for health maintenance
888	organizations; providing exceptions; providing application;
889	providing an appropriation; providing application; providing an

CODING: Words stricken are deletions; words underlined are additions.