(LATE FILED)	Amendment
Bill No. 0811

Amendment No. 751107

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

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