Florida Senate - 2005 SENATOR AMENDMENT
Bill No. HB 811, 2nd Eng.
Barcode 670746
CHAMBER ACTION
Senate House
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11 Senator Fasano moved the following amendment:
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13 Senate Amendment (with title amendment)
14 Delete everything after the enacting clause
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16 and insert:
17 Section 1. Paragraph (l) of subsection (3) of section
18 408.05, Florida Statutes, is amended to read:
19 408.05 State Center for Health Statistics.--
20 (3) COMPREHENSIVE HEALTH INFORMATION SYSTEM.--In order
21 to produce comparable and uniform health information and
22 statistics, the agency shall perform the following functions:
23 (l) Develop, in conjunction with the State
24 Comprehensive Health Information System Advisory Council, and
25 implement a long-range plan for making available performance
26 outcome and financial data that will allow consumers to
27 compare health care services. The performance outcomes and
28 financial data the agency must make available shall include,
29 but is not limited to, pharmaceuticals, physicians, health
30 care facilities, and health plans and managed care entities.
31 The agency shall submit the initial plan to the Governor, the
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1 President of the Senate, and the Speaker of the House of
2 Representatives by January March 1, 2006 2005, and shall
3 update the plan and report on the status of its implementation
4 annually thereafter. The agency shall also make the plan and
5 status report available to the public on its Internet website.
6 As part of the plan, the agency shall identify the process and
7 timeframes for implementation, any barriers to implementation,
8 and recommendations of changes in the law that may be enacted
9 by the Legislature to eliminate the barriers. As preliminary
10 elements of the plan, the agency shall:
11 1. Make available performance outcome and patient
12 charge data collected from health care facilities pursuant to
13 s. 408.061(1)(a) and (2). The agency shall determine which
14 conditions and procedures, performance outcomes, and patient
15 charge data to disclose based upon input from the council.
16 When determining which conditions and procedures are to be
17 disclosed, the council and the agency shall consider variation
18 in costs, variation in outcomes, and magnitude of variations
19 and other relevant information. When determining which
20 performance outcomes to disclose, the agency:
21 a. Shall consider such factors as volume of cases;
22 average patient charges; average length of stay; complication
23 rates; mortality rates; and infection rates, among others,
24 which shall be adjusted for case mix and severity, if
25 applicable.
26 b. May consider such additional measures that are
27 adopted by the Centers for Medicare and Medicaid Studies,
28 National Quality Forum, the Joint Commission on Accreditation
29 of Healthcare Organizations, the Agency for Healthcare
30 Research and Quality, or a similar national entity that
31 establishes standards to measure the performance of health
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Bill No. HB 811, 2nd Eng.
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1 care providers, or by other states.
2
3 When determining which patient charge data to disclose, the
4 agency shall consider such measures as average charge, average
5 net revenue per adjusted patient day, average cost per
6 adjusted patient day, and average cost per admission, among
7 others.
8 2. Make available performance measures, benefit
9 design, and premium cost data from health plans licensed
10 pursuant to chapter 627 or chapter 641. The agency shall
11 determine which performance outcome and member and subscriber
12 cost data to disclose, based upon input from the council. When
13 determining which data to disclose, the agency shall consider
14 information that may be required by either individual or group
15 purchasers to assess the value of the product, which may
16 include membership satisfaction, quality of care, current
17 enrollment or membership, coverage areas, accreditation
18 status, premium costs, plan costs, premium increases, range of
19 benefits, copayments and deductibles, accuracy and speed of
20 claims payment, credentials of physicians, number of
21 providers, names of network providers, and hospitals in the
22 network. Health plans shall make available to the agency any
23 such data or information that is not currently reported to the
24 agency or the office.
25 3. Determine the method and format for public
26 disclosure of data reported pursuant to this paragraph. The
27 agency shall make its determination based upon input from the
28 Comprehensive Health Information System Advisory Council. At a
29 minimum, the data shall be made available on the agency's
30 Internet website in a manner that allows consumers to conduct
31 an interactive search that allows them to view and compare the
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Bill No. HB 811, 2nd Eng.
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1 information for specific providers. The website must include
2 such additional information as is determined necessary to
3 ensure that the website enhances informed decisionmaking among
4 consumers and health care purchasers, which shall include, at
5 a minimum, appropriate guidance on how to use the data and an
6 explanation of why the data may vary from provider to
7 provider. The data specified in subparagraph 1. shall be
8 released no later than January 1, 2006, for the reporting of
9 infection rates, and no later than October 1, 2005, for
10 mortality rates and complication rates March 1, 2005. The data
11 specified in subparagraph 2. shall be released no later than
12 October March 1, 2006.
13 Section 2. Paragraph (b) of subsection (3) of section
14 408.909, Florida Statutes, is amended to read:
15 408.909 Health flex plans.--
16 (3) PROGRAM.--The agency and the office shall each
17 approve or disapprove health flex plans that provide health
18 care coverage for eligible participants. A health flex plan
19 may limit or exclude benefits otherwise required by law for
20 insurers offering coverage in this state, may cap the total
21 amount of claims paid per year per enrollee, may limit the
22 number of enrollees, or may take any combination of those
23 actions. A health flex plan offering may include the option of
24 a catastrophic plan supplementing the health flex plan.
25 (b) The office shall develop guidelines for the review
26 of health flex plan applications and provide regulatory
27 oversight of health flex plan advertisement and marketing
28 procedures. The office shall disapprove or shall withdraw
29 approval of plans that:
30 1. Contain any ambiguous, inconsistent, or misleading
31 provisions or any exceptions or conditions that deceptively
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1 affect or limit the benefits purported to be assumed in the
2 general coverage provided by the health flex plan;
3 2. Provide benefits that are unreasonable in relation
4 to the premium charged or contain provisions that are unfair
5 or inequitable or contrary to the public policy of this state,
6 that encourage misrepresentation, or that result in unfair
7 discrimination in sales practices; or
8 3. Cannot demonstrate that the health flex plan is
9 financially sound and that the applicant is able to underwrite
10 or finance the health care coverage provided; or
11 4. Cannot demonstrate that the applicant and its
12 management are in compliance with the standards required under
13 s. 624.404(3).
14 Section 3. Subsection (6) is added to section 627.413,
15 Florida Statutes, to read:
16 627.413 Contents of policies, in general;
17 identification.--
18 (6) Notwithstanding any other provision of the Florida
19 Insurance Code that is in conflict with federal requirements
20 for a health savings account qualified high-deductible health
21 plan, an insurer, or a health maintenance organization subject
22 to part I of chapter 641, which is authorized to issue health
23 insurance in this state may offer for sale an individual or
24 group policy or contract that provides for a high-deductible
25 plan that meets the federal requirements of a health savings
26 account plan and which is offered in conjunction with a health
27 savings account.
28 Section 4. Subsection (2) of section 627.638, Florida
29 Statutes, is amended to read:
30 627.638 Direct payment for hospital, medical
31 services.--
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1 (2) Whenever, in any health insurance claim form, an
2 insured specifically authorizes payment of benefits directly
3 to any recognized hospital, or physician, or dentist, the
4 insurer shall make such payment to the designated provider of
5 such services, unless otherwise provided in the insurance
6 contract. The insurance contract may not prohibit, and claims
7 forms must provide an option for, the payment of benefits
8 directly to a licensed hospital, physician, or dentist for
9 care provided pursuant to s. 395.1041. The insurer may require
10 written attestation of assignment of benefits. Payment to the
11 provider from the insurer may not be more than the amount that
12 the insurer would otherwise have paid without the assignment.
13 Section 5. Section 627.6402, Florida Statutes, is
14 amended to read:
15 627.6402 Insurance rebates for healthy lifestyles.--
16 (1) Any rate, rating schedule, or rating manual for an
17 individual health insurance policy filed with the office may
18 shall provide for an appropriate rebate of premiums paid in
19 the last calendar year when the individual covered by such
20 plan is enrolled in and maintains participation in any health
21 wellness, maintenance, or improvement program approved by the
22 health plan. The rebate may be based on premiums paid in the
23 last calendar year or the last policy year. The individual
24 must provide evidence of demonstrative maintenance or
25 improvement of the individual's health status as determined by
26 assessments of agreed-upon health status indicators between
27 the individual and the health insurer, including, but not
28 limited to, reduction in weight, body mass index, and smoking
29 cessation. Any rebate provided by the health insurer is
30 presumed to be appropriate unless credible data demonstrates
31 otherwise, or unless such rebate program requires the insured
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1 to incur costs to qualify for the rebate which equal or exceed
2 the value of the rebate, but in no event shall the rebate not
3 exceed 10 percent of paid premiums.
4 (2) The premium rebate authorized by this section
5 shall be effective for an insured on an annual basis, unless
6 the individual fails to maintain or improve his or her health
7 status while participating in an approved wellness program, or
8 credible evidence demonstrates that the individual is not
9 participating in the approved wellness program.
10 Section 6. Section 627.65626, Florida Statutes, is
11 amended to read:
12 627.65626 Insurance rebates for healthy lifestyles.--
13 (1) Any rate, rating schedule, or rating manual for a
14 health insurance policy that provides creditable coverage as
15 defined in s. 627.6561(5) filed with the office shall provide
16 for an appropriate rebate of premiums paid in the last policy
17 year, contract year, or calendar year when the majority of
18 members of a health plan have enrolled and maintained
19 participation in any health wellness, maintenance, or
20 improvement program offered by the group policyholder and
21 health plan employer. The rebate may be based upon premiums
22 paid in the last calendar year or policy year. The group
23 employer must provide evidence of demonstrative maintenance or
24 improvement of the enrollees' health status as determined by
25 assessments of agreed-upon health status indicators between
26 the policyholder employer and the health insurer, including,
27 but not limited to, reduction in weight, body mass index, and
28 smoking cessation. The group or health insurer may contract
29 with a third-party administrator to assemble and report the
30 health status required in this subsection between the
31 policyholder and the health insurer. Any rebate provided by
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1 the health insurer is presumed to be appropriate unless
2 credible data demonstrates otherwise, or unless the rebate
3 program requires the insured to incur costs to qualify for the
4 rebate which equal or exceeds the value of the rebate, but the
5 rebate may shall not exceed 10 percent of paid premiums.
6 (2) The premium rebate authorized by this section
7 shall be effective for an insured on an annual basis unless
8 the number of participating members on the policy renewal
9 anniversary employees becomes less than the majority of the
10 members employees eligible for participation in the wellness
11 program.
12 Section 7. Paragraphs (d) and (j) of subsection (5) of
13 section 627.6692, Florida Statutes, are amended to read:
14 627.6692 Florida Health Insurance Coverage
15 Continuation Act.--
16 (5) CONTINUATION OF COVERAGE UNDER GROUP HEALTH
17 PLANS.--
18 (d)1. A qualified beneficiary must give written notice
19 to the insurance carrier within 63 30 days after the
20 occurrence of a qualifying event. Unless otherwise specified
21 in the notice, a notice by any qualified beneficiary
22 constitutes notice on behalf of all qualified beneficiaries.
23 The written notice must inform the insurance carrier of the
24 occurrence and type of the qualifying event giving rise to the
25 potential election by a qualified beneficiary of continuation
26 of coverage under the group health plan issued by that
27 insurance carrier, except that in cases where the covered
28 employee has been involuntarily discharged, the nature of such
29 discharge need not be disclosed. The written notice must, at a
30 minimum, identify the employer, the group health plan number,
31 the name and address of all qualified beneficiaries, and such
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Bill No. HB 811, 2nd Eng.
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1 other information required by the insurance carrier under the
2 terms of the group health plan or the commission by rule, to
3 the extent that such information is known by the qualified
4 beneficiary.
5 2. Within 14 days after the receipt of written notice
6 under subparagraph 1., the insurance carrier shall send each
7 qualified beneficiary by certified mail an election and
8 premium notice form, approved by the office, which form must
9 provide for the qualified beneficiary's election or
10 nonelection of continuation of coverage under the group health
11 plan and the applicable premium amount due after the election
12 to continue coverage. This subparagraph does not require
13 separate mailing of notices to qualified beneficiaries
14 residing in the same household, but requires a separate
15 mailing for each separate household.
16 (j) Notwithstanding paragraph (b), if a qualified
17 beneficiary in the military reserve or National Guard has
18 elected to continue coverage and is thereafter called to
19 active duty and the coverage under the group plan is
20 terminated by the beneficiary or the carrier due to the
21 qualified beneficiary becoming eligible for TRICARE (the
22 health care program provided by the United States Defense
23 Department), the 18-month period or such other applicable
24 maximum time period for which the qualified beneficiary would
25 otherwise be entitled to continue coverage is tolled during
26 the time that he or she is covered under the TRICARE program.
27 Within 63 30 days after the federal TRICARE coverage
28 terminates, the qualified beneficiary may elect to continue
29 coverage under the group health plan, retroactively to the
30 date coverage terminated under TRICARE, for the remainder of
31 the 18-month period or such other applicable time period,
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1 subject to termination of coverage at the earliest of the
2 conditions specified in paragraph (b).
3 Section 8. Paragraph (a) of subsection (4), paragraph
4 (c) of subsection (5), and paragraphs (b) and (j) of
5 subsection (11) of section 627.6699, Florida Statutes, are
6 amended, and paragraph (o) is added to subsection (11) of that
7 section, to read:
8 627.6699 Employee Health Care Access Act.--
9 (4) APPLICABILITY AND SCOPE.--
10 (a)1. This section applies to a health benefit plan
11 that provides coverage to employees of a small employer in
12 this state, unless the coverage policy is marketed directly to
13 the individual employee, and the employer does not contribute
14 directly or indirectly to participate in the collection or
15 distribution of premiums or facilitate the administration of
16 the coverage policy in any manner. For the purposes of this
17 subparagraph, an employer is not deemed to be contributing to
18 the premiums or facilitating the administration of coverage if
19 the employer does not contribute to the premium and merely
20 collects the premiums for coverage from an employee's wages or
21 salary through payroll deduction and submits payment for the
22 premiums of one or more employees in a lump sum to a carrier.
23 2. A carrier authorized to issue group or individual
24 health benefit plans under this chapter or chapter 641 may
25 offer coverage as described in this subparagraph to individual
26 employees without being subject to this section if the
27 employer has not had a group health benefit plan in place in
28 the prior 6 months. A carrier authorized to issue group or
29 individual health benefit plans under this chapter or chapter
30 641 may offer coverage as described in this subparagraph to
31 employees that are not eligible employees as defined in this
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1 section, whether or not the small employer has a group health
2 benefit plan in place. A carrier that offers coverage as
3 described in this subparagraph must provide a cancellation
4 notice to the primary insured at least 10 days prior to
5 canceling the coverage for nonpayment of premium.
6 (5) AVAILABILITY OF COVERAGE.--
7 (c) Every small employer carrier must, as a condition
8 of transacting business in this state:
9 1. Offer and issue all small employer health benefit
10 plans on a guaranteed-issue basis to every eligible small
11 employer, with 2 to 50 eligible employees, that elects to be
12 covered under such plan, agrees to make the required premium
13 payments, and satisfies the other provisions of the plan. A
14 rider for additional or increased benefits may be medically
15 underwritten and may only be added to the standard health
16 benefit plan. The increased rate charged for the additional or
17 increased benefit must be rated in accordance with this
18 section.
19 2. In the absence of enrollment availability in the
20 Florida Health Insurance Plan, offer and issue basic and
21 standard small employer health benefit plans and a
22 high-deductible plan that meets the requirements of a health
23 savings account plan or health reimbursement account as
24 defined by federal law, on a guaranteed-issue basis, during a
25 31-day open enrollment period of August 1 through August 31 of
26 each year, to every eligible small employer, with fewer than
27 two eligible employees, which small employer is not formed
28 primarily for the purpose of buying health insurance and which
29 elects to be covered under such plan, agrees to make the
30 required premium payments, and satisfies the other provisions
31 of the plan. Coverage provided under this subparagraph shall
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1 begin on October 1 of the same year as the date of enrollment,
2 unless the small employer carrier and the small employer agree
3 to a different date. A rider for additional or increased
4 benefits may be medically underwritten and may only be added
5 to the standard health benefit plan. The increased rate
6 charged for the additional or increased benefit must be rated
7 in accordance with this section. For purposes of this
8 subparagraph, a person, his or her spouse, and his or her
9 dependent children constitute a single eligible employee if
10 that person and spouse are employed by the same small employer
11 and either that person or his or her spouse has a normal work
12 week of less than 25 hours. Any right to an open enrollment of
13 health benefit coverage for groups of fewer than two
14 employees, pursuant to this section, shall remain in full
15 force and effect in the absence of the availability of new
16 enrollment into the Florida Health Insurance Plan.
17 3. This paragraph does not limit a carrier's ability
18 to offer other health benefit plans to small employers if the
19 standard and basic health benefit plans are offered and
20 rejected.
21 (11) SMALL EMPLOYER HEALTH REINSURANCE PROGRAM.--
22 (b)1. The program shall operate subject to the
23 supervision and control of the board.
24 2. Effective upon this act becoming a law, the board
25 shall consist of the director of the office or his or her
26 designee, who shall serve as the chairperson, and 13
27 additional members who are representatives of carriers and
28 insurance agents and are appointed by the director of the
29 office and serve as follows:
30 a. Five members shall be representatives of health
31 insurers licensed under chapter 624 or chapter 641. Two
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1 members shall be agents who are actively engaged in the sale
2 of health insurance. Four members shall be employers or
3 representatives of employers. One member shall be a person
4 covered under an individual health insurance policy issued by
5 a licensed insurer in this state. One member shall represent
6 the Agency for Health Care Administration and shall be
7 recommended by the Secretary of Health Care Administration.
8 The director of the office shall include representatives of
9 small employer carriers subject to assessment under this
10 subsection. If two or more carriers elect to be risk-assuming
11 carriers, the membership must include at least two
12 representatives of risk-assuming carriers; if one carrier is
13 risk-assuming, one member must be a representative of such
14 carrier. At least one member must be a carrier who is subject
15 to the assessments, but is not a small employer carrier.
16 Subject to such restrictions, at least five members shall be
17 selected from individuals recommended by small employer
18 carriers pursuant to procedures provided by rule of the
19 commission. Three members shall be selected from a list of
20 health insurance carriers that issue individual health
21 insurance policies. At least two of the three members selected
22 must be reinsuring carriers. Two members shall be selected
23 from a list of insurance agents who are actively engaged in
24 the sale of health insurance.
25 b. A member appointed under this subparagraph shall
26 serve a term of 4 years and shall continue in office until the
27 member's successor takes office, except that, in order to
28 provide for staggered terms, the director of the office shall
29 designate two of the initial appointees under this
30 subparagraph to serve terms of 2 years and shall designate
31 three of the initial appointees under this subparagraph to
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1 serve terms of 3 years.
2 3. The director of the office may remove a member for
3 cause.
4 4. Vacancies on the board shall be filled in the same
5 manner as the original appointment for the unexpired portion
6 of the term.
7 5. The director of the office may require an entity
8 that recommends persons for appointment to submit additional
9 lists of recommended appointees.
10 (j)1. Before July March 1 of each calendar year, the
11 board shall determine and report to the office the program net
12 loss for the previous year, including administrative expenses
13 for that year, and the incurred losses for the year, taking
14 into account investment income and other appropriate gains and
15 losses.
16 2. Any net loss for the year shall be recouped by
17 assessment of the carriers, as follows:
18 a. The operating losses of the program shall be
19 assessed in the following order subject to the specified
20 limitations. The first tier of assessments shall be made
21 against reinsuring carriers in an amount which shall not
22 exceed 5 percent of each reinsuring carrier's premiums from
23 health benefit plans covering small employers. If such
24 assessments have been collected and additional moneys are
25 needed, the board shall make a second tier of assessments in
26 an amount which shall not exceed 0.5 percent of each carrier's
27 health benefit plan premiums. Except as provided in paragraph
28 (n), risk-assuming carriers are exempt from all assessments
29 authorized pursuant to this section. The amount paid by a
30 reinsuring carrier for the first tier of assessments shall be
31 credited against any additional assessments made.
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1 b. The board shall equitably assess carriers for
2 operating losses of the plan based on market share. The board
3 shall annually assess each carrier a portion of the operating
4 losses of the plan. The first tier of assessments shall be
5 determined by multiplying the operating losses by a fraction,
6 the numerator of which equals the reinsuring carrier's earned
7 premium pertaining to direct writings of small employer health
8 benefit plans in the state during the calendar year for which
9 the assessment is levied, and the denominator of which equals
10 the total of all such premiums earned by reinsuring carriers
11 in the state during that calendar year. The second tier of
12 assessments shall be based on the premiums that all carriers,
13 except risk-assuming carriers, earned on all health benefit
14 plans written in this state. The board may levy interim
15 assessments against carriers to ensure the financial ability
16 of the plan to cover claims expenses and administrative
17 expenses paid or estimated to be paid in the operation of the
18 plan for the calendar year prior to the association's
19 anticipated receipt of annual assessments for that calendar
20 year. Any interim assessment is due and payable within 30 days
21 after receipt by a carrier of the interim assessment notice.
22 Interim assessment payments shall be credited against the
23 carrier's annual assessment. Health benefit plan premiums and
24 benefits paid by a carrier that are less than an amount
25 determined by the board to justify the cost of collection may
26 not be considered for purposes of determining assessments.
27 c. Subject to the approval of the office, the board
28 shall make an adjustment to the assessment formula for
29 reinsuring carriers that are approved as federally qualified
30 health maintenance organizations by the Secretary of Health
31 and Human Services pursuant to 42 U.S.C. s. 300e(c)(2)(A) to
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1 the extent, if any, that restrictions are placed on them that
2 are not imposed on other small employer carriers.
3 3. Before July March 1 of each year, the board shall
4 determine and file with the office an estimate of the
5 assessments needed to fund the losses incurred by the program
6 in the previous calendar year.
7 4. If the board determines that the assessments needed
8 to fund the losses incurred by the program in the previous
9 calendar year will exceed the amount specified in subparagraph
10 2., the board shall evaluate the operation of the program and
11 report its findings, including any recommendations for changes
12 to the plan of operation, to the office within 180 90 days
13 following the end of the calendar year in which the losses
14 were incurred. The evaluation shall include an estimate of
15 future assessments, the administrative costs of the program,
16 the appropriateness of the premiums charged and the level of
17 carrier retention under the program, and the costs of coverage
18 for small employers. If the board fails to file a report with
19 the office within 180 90 days following the end of the
20 applicable calendar year, the office may evaluate the
21 operations of the program and implement such amendments to the
22 plan of operation the office deems necessary to reduce future
23 losses and assessments.
24 5. If assessments exceed the amount of the actual
25 losses and administrative expenses of the program, the excess
26 shall be held as interest and used by the board to offset
27 future losses or to reduce program premiums. As used in this
28 paragraph, the term "future losses" includes reserves for
29 incurred but not reported claims.
30 6. Each carrier's proportion of the assessment shall
31 be determined annually by the board, based on annual
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1 statements and other reports considered necessary by the board
2 and filed by the carriers with the board.
3 7. Provision shall be made in the plan of operation
4 for the imposition of an interest penalty for late payment of
5 an assessment.
6 8. A carrier may seek, from the office, a deferment,
7 in whole or in part, from any assessment made by the board.
8 The office may defer, in whole or in part, the assessment of a
9 carrier if, in the opinion of the office, the payment of the
10 assessment would place the carrier in a financially impaired
11 condition. If an assessment against a carrier is deferred, in
12 whole or in part, the amount by which the assessment is
13 deferred may be assessed against the other carriers in a
14 manner consistent with the basis for assessment set forth in
15 this section. The carrier receiving such deferment remains
16 liable to the program for the amount deferred and is
17 prohibited from reinsuring any individuals or groups in the
18 program if it fails to pay assessments.
19 (o) The board shall advise the office, the Agency for
20 Health Care Administration, the department, other executive
21 departments, and the Legislature on health insurance issues.
22 Specifically, the board shall:
23 1. Provide a forum for stakeholders, consisting of
24 insurers, employers, agents, consumers, and regulators, in the
25 private health insurance market in this state.
26 2. Review and recommend strategies to improve the
27 functioning of the health insurance markets in this state with
28 a specific focus on market stability, access, and pricing.
29 3. Make recommendations to the office for legislation
30 addressing health insurance market issues and provide comments
31 on health insurance legislation proposed by the office.
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1 4. Meet at least three times each year. One meeting
2 shall be held to hear reports and to secure public comment on
3 the health insurance market, to develop any legislation needed
4 to address health insurance market issues, and to provide
5 comments on health insurance legislation proposed by the
6 office.
7 5. Issue a report to the office on the state of the
8 health insurance market by September 1 each year. The report
9 shall include recommendations for changes in the health
10 insurance market, results from implementation of previous
11 recommendations, and information on health insurance markets.
12 Section 9. Subsection (1) of section 641.27, Florida
13 Statutes, is amended to read:
14 641.27 Examination by the department.--
15 (1) The office shall examine the affairs,
16 transactions, accounts, business records, and assets of any
17 health maintenance organization as often as it deems it
18 expedient for the protection of the people of this state, but
19 not less frequently than once every 5 3 years. In lieu of
20 making its own financial examination, the office may accept an
21 independent certified public accountant's audit report
22 prepared on a statutory accounting basis consistent with this
23 part. However, except when the medical records are requested
24 and copies furnished pursuant to s. 456.057, medical records
25 of individuals and records of physicians providing service
26 under contract to the health maintenance organization shall
27 not be subject to audit, although they may be subject to
28 subpoena by court order upon a showing of good cause. For the
29 purpose of examinations, the office may administer oaths to
30 and examine the officers and agents of a health maintenance
31 organization concerning its business and affairs. The
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1 examination of each health maintenance organization by the
2 office shall be subject to the same terms and conditions as
3 apply to insurers under chapter 624. In no event shall
4 expenses of all examinations exceed a maximum of $50,000
5 $20,000 for any 1-year period. Any rehabilitation,
6 liquidation, conservation, or dissolution of a health
7 maintenance organization shall be conducted under the
8 supervision of the department, which shall have all power with
9 respect thereto granted to it under the laws governing the
10 rehabilitation, liquidation, reorganization, conservation, or
11 dissolution of life insurance companies.
12 Section 10. Subsection (40) of section 641.31, Florida
13 Statutes, is amended to read:
14 641.31 Health maintenance contracts.--
15 (40)(a) Any group rate, rating schedule, or rating
16 manual for a health maintenance organization policy, which
17 provides creditable coverage as defined in s. 627.6561(5),
18 filed with the office shall provide for an appropriate rebate
19 of premiums paid in the last policy year, contract year, or
20 calendar year when the majority of members of a health
21 individual covered by such plan are is enrolled in and
22 maintained maintains participation in any health wellness,
23 maintenance, or improvement program offered by the group
24 contract holder approved by the health plan. The group
25 individual must provide evidence of demonstrative maintenance
26 or improvement of his or her health status as determined by
27 assessments of agreed-upon health status indicators between
28 the group individual and the health insurer, including, but
29 not limited to, reduction in weight, body mass index, and
30 smoking cessation. Any rebate provided by the health
31 maintenance organization insurer is presumed to be appropriate
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1 unless credible data demonstrates otherwise, or unless the
2 rebate program requires the insured to incur costs to qualify
3 for the rebate which equals or exceeds the value of the rebate
4 but the rebate may shall not exceed 10 percent of paid
5 premiums.
6 (b) The premium rebate authorized by this section
7 shall be effective for a subscriber an insured on an annual
8 basis, unless the number of participating members on the
9 contract renewal anniversary becomes fewer than the majority
10 of the members eligible for participation in the wellness
11 program individual fails to maintain or improve his or her
12 health status while participating in an approved wellness
13 program, or credible evidence demonstrates that the individual
14 is not participating in the approved wellness program.
15 (c) A health maintenance organization that issues
16 individual contracts may offer a premium rebate, as provided
17 under this section, for a healthy lifestyle program.
18 Section 11. Except as otherwise expressly provided in
19 this act and except for this section, which shall take effect
20 upon becoming a law, this act shall take effect July 1, 2005,
21 and shall apply to all policies or contracts issued or renewed
22 on or after July 1, 2005.
23
24
25 ================ T I T L E A M E N D M E N T ===============
26 And the title is amended as follows:
27 Delete everything before the enacting clause
28
29 and insert:
30 A bill to be entitled
31 An act relating to health insurance; amending
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1 s. 408.05, F.S.; changing the due date for a
2 report from the Agency for Health Care
3 Administration regarding the State Center for
4 Health Statistics; amending s. 408.909, F.S.;
5 providing an additional criterion for the
6 Office of Insurance Regulation to disapprove or
7 withdraw approval of health flex plans;
8 amending s. 627.413, F.S.; authorizing insurers
9 and health maintenance organizations to offer
10 policies or contracts providing for a
11 high-deductible plan meeting federal
12 requirements and in conjunction with a health
13 savings account; amending s. 627.638, F.S.;
14 revising direct payment provisions for
15 insurers; amending s. 627.6402, F.S.; revising
16 the requirements for the healthy lifestyle
17 premium rebate; amending s. 627.65626, F.S.;
18 providing insurance rebates for healthy
19 lifestyles; amending s. 627.6692, F.S.;
20 extending a time period within which eligible
21 employees may apply for continuation of
22 coverage; amending s. 627.6699, F.S.; revising
23 standards for determining applicability of the
24 Employee Health Care Access Act; prescribing
25 acts that may be performed by an employer
26 without being considered contributing to
27 premiums or facilitating administration of a
28 policy; authorizing certain carriers to offer
29 coverage to certain employees without being
30 subject to the act under certain circumstances;
31 requiring a carrier who offers such coverage to
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1 provide notice to the primary insured prior to
2 cancellation for nonpayment of premium;
3 revising an availability of coverage provision
4 of the Employee Health Care Access Act;
5 including high-deductible plans meeting federal
6 health savings account plan requirements;
7 revising membership of the board of the small
8 employer health reinsurance program; revising
9 certain reporting dates relating to program
10 losses and assessments; requiring the board to
11 advise executive and legislative entities on
12 health insurance issues; providing
13 requirements; amending s. 641.27, F.S.;
14 increasing the interval at which the office
15 examines health maintenance organizations;
16 deleting authorization for the office to accept
17 an audit report from a certified public
18 accountant in lieu of conducting its own
19 examination; increasing an expense limitation;
20 amending s. 641.31, F.S.; providing for an
21 insurance rebate for members in a health
22 wellness program; providing for the rebate to
23 cease under certain conditions; providing
24 effective dates.
25
26
27
28
29
30
31
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