Senate Bill sb1274c2
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Florida Senate - 2006 CS for CS for SB 1274
By the Committees on Health Care; Banking and Insurance; and
Senator Atwater
587-2312-06
1 A bill to be entitled
2 An act relating to plans, policies, contracts,
3 and programs for the provision of health care
4 services; amending s. 408.909, F.S.; revising
5 eligibility requirements for participation in
6 health flex plans; amending s. 627.642, F.S.;
7 requiring an identification card containing
8 specified information to be given to insureds
9 who have health and accident insurance;
10 amending s. 627.657, F.S.; requiring an
11 identification card containing specified
12 information to be given to insureds under group
13 health insurance policies; amending s. 636.204,
14 F.S.; deleting a requirement that an
15 application for licensure as a discount medical
16 plan organization must be accompanied by a copy
17 of the applicant's most recent financial
18 statements; amending s. 636.206, F.S.;
19 authorizing the Office of Insurance Regulation
20 to examine or investigate the business of a
21 discount medical plan organization under
22 certain circumstances; amending s. 636.210,
23 F.S.; providing an exception to the prohibited
24 restrictions on free access to plan providers
25 for hospital services; amending s. 636.216,
26 F.S.; revising the charges and filing
27 requirements for access to certain health care
28 services; amending s. 636.218, F.S.; deleting a
29 requirement that audited financial statements
30 be included in the annual report filed by a
31 discount medical plan organization; amending s.
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1 636.220, F.S.; requiring a discount medical
2 plan organization to certify in writing and
3 under oath that certain requirements are
4 satisfied; amending s. 641.31, F.S.; requiring
5 an identification card to be given to persons
6 having health care services through a health
7 maintenance contract; amending ss. 383.145,
8 641.185, 641.2018, 641.3107, 641.3922, and
9 641.513, F.S.; conforming cross-references to
10 changes made by the act; providing application;
11 providing effective dates.
12
13 Be It Enacted by the Legislature of the State of Florida:
14
15 Section 1. Effective July 1, 2006, subsection (5) of
16 section 408.909, Florida Statutes, is amended to read:
17 408.909 Health flex plans.--
18 (5) ELIGIBILITY.--Eligibility to enroll in an approved
19 health flex plan is limited to residents of this state who:
20 (a)1. Are 64 years of age or younger;
21 2.(b) Have a family income equal to or less than 250
22 200 percent of the federal poverty level;
23 3.(c) Are eligible under a federally approved Medicaid
24 demonstration waiver and reside in Palm Beach County or
25 Miami-Dade County;
26 4.(d) Are not covered by a private insurance policy
27 and are not eligible for coverage through a public health
28 insurance program, such as Medicare or Medicaid, unless
29 specifically authorized under paragraph (c), or another public
30 health care program, such as KidCare, and have not been
31 covered at any time during the past 6 months; and
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1 5.(e) Have applied for health care coverage through an
2 approved health flex plan and have agreed to make any payments
3 required for participation, including periodic payments or
4 payments due at the time health care services are provided;
5 or.
6 (b) Are part of an employer group in which at least 75
7 percent of the employees have a family income equal to or less
8 than 250 percent of the federal poverty level and the employer
9 has not offered health insurance during the past 6 months.
10 Section 2. Subsection (3) is added to section 627.642,
11 Florida Statutes, to read:
12 627.642 Outline of coverage.--
13 (3) In addition to the outline of coverage, a policy
14 as specified in s. 627.6699(3)(k) must be accompanied by an
15 identification card that contains, at a minimum:
16 (a) The name of the organization issuing the policy or
17 the name of the organization administering the policy,
18 whichever applies.
19 (b) The name of the contract holder.
20 (c) The type of plan only if the plan is filed in the
21 state, an indication that the plan is self-funded, or the name
22 of the network.
23 (d) The member identification number, contract number,
24 and policy or group number, if applicable.
25 (e) A contact phone number or electronic address for
26 authorizations.
27 (f) A phone number or electronic address whereby the
28 covered person or hospital, physician, or other person
29 rendering services covered by the policy may determine if the
30 plan is insured and may obtain a benefits verification in
31 order to estimate patient financial responsibility, in
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1 compliance with privacy rules under the Health Insurance
2 Portability and Accountability Act.
3 (g) The national plan identifier, in accordance with
4 the compliance date set forth by the federal Department of
5 Health and Human Services.
6
7 The identification card must present the information in a
8 readily identifiable manner or, alternatively, the information
9 may be embedded on the card and available through magnetic
10 stripe or smart card. The information may also be provided
11 through other electronic technology.
12 Section 3. Present subsection (2) of section 627.657,
13 Florida Statutes, is renumbered as subsection (3), and a new
14 subsection (2) is added to that section, to read:
15 627.657 Provisions of group health insurance
16 policies.--
17 (2) The medical policy as specified in s.
18 627.6699(3)(k) must be accompanied by an identification card
19 that contains, at a minimum:
20 (a) The name of the organization issuing the policy or
21 name of the organization administering the policy, whichever
22 applies.
23 (b) The name of the certificateholder.
24 (c) The type of plan only if the plan is filed in the
25 state, an indication that the plan is self-funded, or the name
26 of the network.
27 (d) The member identification number, contract number,
28 and policy or group number, if applicable.
29 (e) A contact phone number or electronic address for
30 authorizations.
31
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1 (f) A phone number or electronic address whereby the
2 covered person or hospital, physician, or other person
3 rendering services covered by the policy may determine if the
4 plan is insured and may obtain a benefits verification in
5 order to estimate patient financial responsibility, in
6 compliance with privacy rules under the Health Insurance
7 Portability and Accountability Act.
8 (g) The national plan identifier, in accordance with
9 the compliance date set forth by the federal Department of
10 Health and Human Services.
11
12 The identification card must present the information in a
13 readily identifiable manner or, alternatively, the information
14 may be embedded on the card and available through magnetic
15 stripe or smart card. The information may also be provided
16 through other electronic technology.
17 Section 4. Subsection (2) of section 636.204, Florida
18 Statutes, is amended to read:
19 636.204 License required.--
20 (2) An application for a license to operate as a
21 discount medical plan organization must be filed with the
22 office on a form prescribed by the commission. Such
23 application must be sworn to by an officer or authorized
24 representative of the applicant and be accompanied by the
25 following, if applicable:
26 (a) A copy of the applicant's articles of
27 incorporation or other organizing documents, including all
28 amendments.
29 (b) A copy of the applicant's bylaws.
30 (c) A list of the names, addresses, official
31 positions, and biographical information of the individuals who
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1 are responsible for conducting the applicant's affairs,
2 including, but not limited to, all members of the board of
3 directors, board of trustees, executive committee, or other
4 governing board or committee, the officers, contracted
5 management company personnel, and any person or entity owning
6 or having the right to acquire 10 percent or more of the
7 voting securities of the applicant. Such listing must fully
8 disclose the extent and nature of any contracts or
9 arrangements between any individual who is responsible for
10 conducting the applicant's affairs and the discount medical
11 plan organization, including any possible conflicts of
12 interest.
13 (d) A complete biographical statement, on forms
14 prescribed by the commission, an independent investigation
15 report, and a set of fingerprints, as provided in chapter 624,
16 with respect to each individual identified under paragraph
17 (c).
18 (e) A statement generally describing the applicant,
19 its facilities and personnel, and the medical services to be
20 offered.
21 (f) A copy of the form of all contracts made or to be
22 made between the applicant and any providers or provider
23 networks regarding the provision of medical services to
24 members.
25 (g) A copy of the form of any contract made or
26 arrangement to be made between the applicant and any person
27 listed in paragraph (c).
28 (h) A copy of the form of any contract made or to be
29 made between the applicant and any person, corporation,
30 partnership, or other entity for the performance on the
31 applicant's behalf of any function, including, but not limited
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1 to, marketing, administration, enrollment, investment
2 management, and subcontracting for the provision of health
3 services to members.
4 (i) A copy of the applicant's most recent financial
5 statements audited by an independent certified public
6 accountant. An applicant that is a subsidiary of a parent
7 entity that is publicly traded and that prepares audited
8 financial statements reflecting the consolidated operations of
9 the parent entity and the subsidiary may petition the office
10 to accept, in lieu of the audited financial statement of the
11 applicant, the audited financial statement of the parent
12 entity and a written guaranty by the parent entity that the
13 minimum capital requirements of the applicant required by this
14 part will be met by the parent entity.
15 (i)(j) A description of the proposed method of
16 marketing.
17 (j)(k) A description of the subscriber complaint
18 procedures to be established and maintained.
19 (k)(l) The fee for issuance of a license.
20 (l)(m) Such other information as the commission or
21 office may reasonably require to make the determinations
22 required by this part.
23 Section 5. Subsection (1) of section 636.206, Florida
24 Statutes, is amended to read:
25 636.206 Examinations and investigations.--
26 (1) The office may examine or investigate the business
27 and affairs of any discount medical plan organization if the
28 commissioner has reason to believe that the discount medical
29 plan organization is not complying with the requirements of
30 this part. The office may order any discount medical plan
31 organization or applicant to produce any records, books,
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1 files, advertising and solicitation materials, or other
2 information and may take statements under oath to determine
3 whether the discount medical plan organization or applicant is
4 in violation of the law or is acting contrary to the public
5 interest. The expenses incurred in conducting any examination
6 or investigation must be paid by the discount medical plan
7 organization or applicant. Examinations and investigations
8 must be conducted as provided in chapter 624.
9 Section 6. Subsection (1) of section 636.210, Florida
10 Statutes, is amended to read:
11 636.210 Prohibited activities of a discount medical
12 plan organization.--
13 (1) A discount medical plan organization may not:
14 (a) Use in its advertisements, marketing material,
15 brochures, and discount cards the term "insurance" except as
16 otherwise provided in this part or as a disclaimer of any
17 relationship between discount medical plan organization
18 benefits and insurance;
19 (b) Use in its advertisements, marketing material,
20 brochures, and discount cards the terms "health plan,"
21 "coverage," "copay," "copayments," "preexisting conditions,"
22 "guaranteed issue," "premium," "PPO," "preferred provider
23 organization," or other terms in a manner that could
24 reasonably mislead a person into believing the discount
25 medical plan was health insurance;
26 (c) Have restrictions on free access to plan
27 providers, except for hospital services, including, but not
28 limited to, waiting periods and notification periods; or
29 (d) Pay providers any fees for medical services.
30 Section 7. Section 636.216, Florida Statutes, is
31 amended to read:
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1 636.216 Charge or form filings.--
2 (1) All charges to members must be filed with the
3 office. and Any charge to members greater than $30 per month
4 or $360 per year for access to health care services other than
5 those provided by physicians licensed under chapter 458 or
6 chapter 459, or by hospitals licensed under chapter 395, must
7 be approved by the office before the charges can be used. Any
8 charge to members greater than $60 per month or $720 per year
9 for health care services that include services provided by
10 physicians licensed under chapter 458 or chapter 459, or by
11 hospitals licensed under chapter 395, must be approved by the
12 office before the charges may be used. The discount medical
13 plan organization has the burden of proof that the charges
14 bear a reasonable relation to the benefits received by the
15 member.
16 (2) There must be a written agreement between the
17 discount medical plan organization and the member specifying
18 the benefits under the discount medical plan and complying
19 with the disclosure requirements of this part.
20 (3) All forms used, including the written agreement
21 pursuant to subsection (2), must first be filed with and
22 approved by the office. Every form filed shall be identified
23 by a unique form number placed in the lower left corner of
24 each form.
25 (4) A charge or form is considered approved on the
26 60th day after its date of filing unless it has been
27 previously disapproved by the office. The office shall
28 disapprove any form that does not meet the requirements of
29 this part or that is unreasonable, discriminatory, misleading,
30 or unfair. If such filing is filings are disapproved, the
31
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1 office shall notify the discount medical plan organization and
2 shall specify in the notice the reasons for disapproval.
3 Section 8. Section 636.218, Florida Statutes, is
4 amended to read:
5 636.218 Annual reports.--
6 (1) Each discount medical plan organization must file
7 with the office, within 3 months after the end of each fiscal
8 year, an annual report.
9 (2) Such reports must be on forms prescribed by the
10 commission and must include:
11 (a) Audited financial statements prepared in
12 accordance with generally accepted accounting principles
13 certified by an independent certified public accountant,
14 including the organization's balance sheet, income statement,
15 and statement of changes in cash flow for the preceding year.
16 An organization that is a subsidiary of a parent entity that
17 is publicly traded and that prepares audited financial
18 statements reflecting the consolidated operations of the
19 parent entity and the organization may petition the office to
20 accept, in lieu of the audited financial statement of the
21 organization, the audited financial statement of the parent
22 entity and a written guaranty by the parent entity that the
23 minimum capital requirements of the organization required by
24 this part will be met by the parent entity.
25 (a)(b) If different from the initial application or
26 the last annual report, a list of the names and residence
27 addresses of all persons responsible for the conduct of the
28 organization's affairs, together with a disclosure of the
29 extent and nature of any contracts or arrangements between
30 such persons and the discount medical plan organization,
31 including any possible conflicts of interest.
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1 (b)(c) The number of discount medical plan members in
2 the state.
3 (c)(d) Such other information relating to the
4 performance of the discount medical plan organization as is
5 reasonably required by the commission or office.
6 (3) Every discount medical plan organization which
7 fails to file an annual report in the form and within the time
8 required by this section shall forfeit up to $500 for each day
9 for the first 10 days during which the neglect continues and
10 shall forfeit up to $1,000 for each day after the first 10
11 days during which the neglect continues; and, upon notice by
12 the office to that effect, the organization's authority to
13 enroll new members or to do business in this state ceases
14 while such default continues. The office shall deposit all
15 sums collected by the office under this section to the credit
16 of the Insurance Regulatory Trust Fund. The office may not
17 collect more than $50,000 for each report.
18 Section 9. Section 636.220, Florida Statutes, is
19 amended to read:
20 636.220 Minimum capital requirements.--
21 (1) Each discount medical plan organization must at
22 all times maintain a net worth of at least $150,000 and shall
23 certify in writing and under oath at the time of licensure and
24 annually thereafter that the minimum capitalization
25 requirements of this part are satisfied.
26 (2) The office may not issue a license unless the
27 discount medical plan organization has a net worth of at least
28 $150,000.
29 Section 10. Present subsections (5) through (40) of
30 section 641.31, Florida Statutes, are renumbered as
31
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1 subsections (6) through (41), respectively, and a new
2 subsection (5) is added to that section, to read:
3 641.31 Health maintenance contracts.--
4 (5) The contract, certificate, or member handbook must
5 be accompanied by an identification card that contains, at a
6 minimum:
7 (a) The name of the organization offering the contract
8 or name of the organization administering the contract,
9 whichever applies.
10 (b) The name of the subscriber.
11 (c) A statement that the health plan is a health
12 maintenance organization. Only a health plan with a
13 certificate of authority issued under this chapter may be
14 identified as a health maintenance organization.
15 (d) The member identification number, contract number,
16 and group number, if applicable.
17 (e) A contact phone number or electronic address for
18 authorizations.
19 (f) A phone number or electronic address whereby the
20 covered person or hospital, physician, or other person
21 rendering services covered by the contract may determine if
22 the plan is insured and may obtain a benefits verification in
23 order to estimate patient financial responsibility, in
24 compliance with privacy rules under the Health Insurance
25 Portability and Accountability Act.
26 (g) The national plan identifier, in accordance with
27 the compliance date set forth by the federal Department of
28 Health and Human Services.
29
30 The identification card must present the information in a
31 readily identifiable manner or, alternatively, the information
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1 may be embedded on the card and available through magnetic
2 stripe or smart card. The information may also be provided
3 through other electronic technology.
4 Section 11. Paragraph (j) of subsection (3) of section
5 383.145, Florida Statutes, is amended to read:
6 383.145 Newborn and infant hearing screening.--
7 (3) REQUIREMENTS FOR SCREENING OF NEWBORNS; INSURANCE
8 COVERAGE; REFERRAL FOR ONGOING SERVICES.--
9 (j) The initial procedure for screening the hearing of
10 the newborn or infant and any medically necessary followup
11 reevaluations leading to diagnosis shall be a covered benefit,
12 reimbursable under Medicaid as an expense compensated
13 supplemental to the per diem rate for Medicaid patients
14 enrolled in MediPass or Medicaid patients covered by a fee for
15 service program. For Medicaid patients enrolled in HMOs,
16 providers shall be reimbursed directly by the Medicaid Program
17 Office at the Medicaid rate. This service may not be
18 considered a covered service for the purposes of establishing
19 the payment rate for Medicaid HMOs. All health insurance
20 policies and health maintenance organizations as provided
21 under ss. 627.6416, 627.6579, and 641.31(31)(30), except for
22 supplemental policies that only provide coverage for specific
23 diseases, hospital indemnity, or Medicare supplement, or to
24 the supplemental polices, shall compensate providers for the
25 covered benefit at the contracted rate. Nonhospital-based
26 providers shall be eligible to bill Medicaid for the
27 professional and technical component of each procedure code.
28 Section 12. Paragraphs (b) and (i) of subsection (1)
29 of section 641.185, Florida Statutes, are amended to read:
30 641.185 Health maintenance organization subscriber
31 protections.--
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1 (1) With respect to the provisions of this part and
2 part III, the principles expressed in the following statements
3 shall serve as standards to be followed by the commission, the
4 office, the department, and the Agency for Health Care
5 Administration in exercising their powers and duties, in
6 exercising administrative discretion, in administrative
7 interpretations of the law, in enforcing its provisions, and
8 in adopting rules:
9 (b) A health maintenance organization subscriber
10 should receive quality health care from a broad panel of
11 providers, including referrals, preventive care pursuant to s.
12 641.402(1), emergency screening and services pursuant to ss.
13 641.31(13)(12) and 641.513, and second opinions pursuant to s.
14 641.51.
15 (i) A health maintenance organization subscriber
16 should receive timely and, if necessary, urgent grievances and
17 appeals within the health maintenance organization pursuant to
18 ss. 641.228, 641.31(6)(5), 641.47, and 641.511.
19 Section 13. Subsection (1) of section 641.2018,
20 Florida Statutes, is amended to read:
21 641.2018 Limited coverage for home health care
22 authorized.--
23 (1) Notwithstanding other provisions of this chapter,
24 a health maintenance organization may issue a contract that
25 limits coverage to home health care services only. The
26 organization and the contract shall be subject to all of the
27 requirements of this part that do not require or otherwise
28 apply to specific benefits other than home care services. To
29 this extent, all of the requirements of this part apply to any
30 organization or contract that limits coverage to home care
31 services, except the requirements for providing comprehensive
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1 health care services as provided in ss. 641.19(4), (11), and
2 (12), and 641.31(1), except ss. 641.31(10)(9), (13)(12), (17),
3 (18), (19), (20), (21), (22), and (25)(24) and 641.31095.
4 Section 14. Section 641.3107, Florida Statutes, is
5 amended to read:
6 641.3107 Delivery of contract.--Unless delivered upon
7 execution or issuance, a health maintenance contract,
8 certificate of coverage, or member handbook shall be mailed or
9 delivered to the subscriber or, in the case of a group health
10 maintenance contract, to the employer or other person who will
11 hold the contract on behalf of the subscriber group within 10
12 working days from approval of the enrollment form by the
13 health maintenance organization or by the effective date of
14 coverage, whichever occurs first. However, if the employer or
15 other person who will hold the contract on behalf of the
16 subscriber group requires retroactive enrollment of a
17 subscriber, the organization shall deliver the contract,
18 certificate, or member handbook to the subscriber within 10
19 days after receiving notice from the employer of the
20 retroactive enrollment. This section does not apply to the
21 delivery of those contracts specified in s. 641.31(14)(13).
22 Section 15. Paragraph (a) of subsection (7) of section
23 641.3922, Florida Statutes, is amended to read:
24 641.3922 Conversion contracts; conditions.--Issuance
25 of a converted contract shall be subject to the following
26 conditions:
27 (7) REASONS FOR CANCELLATION; TERMINATION.--The
28 converted health maintenance contract must contain a
29 cancellation or nonrenewability clause providing that the
30 health maintenance organization may refuse to renew the
31 contract of any person covered thereunder, but cancellation or
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1 nonrenewal must be limited to one or more of the following
2 reasons:
3 (a) Fraud or intentional misrepresentation, subject to
4 the limitations of s. 641.31(24)(23), in applying for any
5 benefits under the converted health maintenance contract.;
6 Section 16. Subsection (4) of section 641.513, Florida
7 Statutes, is amended to read:
8 641.513 Requirements for providing emergency services
9 and care.--
10 (4) A subscriber may be charged a reasonable
11 copayment, as provided in s. 641.31(13)(12), for the use of an
12 emergency room.
13 Section 17. Except as otherwise expressly provided in
14 this act, this act shall take effect January 1, 2007, and
15 shall apply to identification cards issued for policies or
16 certificates issued or renewed on or after that date.
17
18 STATEMENT OF SUBSTANTIAL CHANGES CONTAINED IN
COMMITTEE SUBSTITUTE FOR
19 CS for Senate Bill 1274
20
21 The committee substitute extends eligibility for a health flex
plan to persons who are part of an employer group in which at
22 least 75 percent of the employees have a family income equal
to or less than 250 percent of the federal poverty level and
23 the employer has not offered health insurance during the past
six months.
24
The committee substitute also removes the requirement that
25 discount medical plan organizations file audited financial
statements; requires the organizations to certify that minimum
26 capitalization requirements are satisfied; allows for a market
investigation by OIR of an organization only "for cause";
27 allows organizations to require a waiting period for accessing
hospital services; allows organizations to charge up to $60
28 per month without prior approval from OIR for plans that cover
physicians or hospital services; and requires an organization
29 to file forms for informational purposes with OIR before they
can market the form.
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