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The Committee on Health Policy (Dean) recommended the following

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amendment:

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     Senate Amendment (with title amendment)

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     Between lines 96 and 97

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and insert:

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     Section 4.  Section 408.909, Florida Statutes, is amended to

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read:

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     408.909  Health flex plans.--

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     (1)  INTENT.--The Legislature finds that a significant

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proportion of the residents of this state are unable to obtain

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affordable health insurance coverage. Therefore, it is the intent

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of the Legislature to expand the availability of health care

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options for low-income uninsured state residents by encouraging

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health insurers, health maintenance organizations, health-care-

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provider-sponsored organizations, local governments, health care

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districts, or other public or private community-based

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organizations to develop alternative approaches to traditional

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health insurance which emphasize coverage for basic and

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preventive health care services. To the maximum extent possible,

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these options should be coordinated with existing governmental or

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community-based health services programs in a manner that is

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consistent with the objectives and requirements of such programs.

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     (2)  DEFINITIONS.--As used in this section, the term:

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     (a)  "Agency" means the Agency for Health Care

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Administration.

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     (b)  "Office" means the Office of Insurance Regulation of

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the Financial Services Commission.

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     (c)  "Enrollee" means an individual who has been determined

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to be eligible for and is receiving health care coverage under a

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health flex plan approved under this section.

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     (d)  "Health care coverage" or "health flex plan coverage"

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means health care services that are covered as benefits under an

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approved health flex plan or that are otherwise provided, either

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directly or through arrangements with other persons, via a health

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flex plan on a prepaid per capita basis or on a prepaid aggregate

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fixed-sum basis.

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     (e)  "Health flex plan" means a health plan approved under

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subsection (3) which guarantees payment for specified health care

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coverage provided to the enrollee who purchases coverage directly

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from the plan as an individual or as a small business, or through

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a small business purchasing arrangement sponsored by a local

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government.

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     (f)  "Health flex plan entity" means a health insurer,

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health maintenance organization, health-care-provider-sponsored

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organization, local government, health care district, other

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public or private community-based organization, or public-private

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partnership that develops and implements an approved health flex

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plan and is responsible for administering the health flex plan

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and paying all claims for health flex plan coverage by enrollees

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of the health flex plan.

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     (3)  PROGRAM.--The agency and the office shall each approve

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or disapprove health flex plans that provide health care coverage

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for eligible participants. A health flex plan may limit or

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exclude benefits or provider network requirements otherwise

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required by law for insurers offering coverage in this state, may

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cap the total amount of claims paid per year per enrollee, may

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limit the number of enrollees, or may take any combination of

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those actions. A health flex plan offering may include the option

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of a catastrophic plan or a catastrophic plan supplementing the

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health flex plan.

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     (a)  The agency shall develop guidelines for the review of

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applications for health flex plans and shall disapprove or

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withdraw approval of plans that do not meet or no longer meet

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minimum standards for quality of care and access to care. The

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agency shall ensure that the health flex plans follow

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standardized grievance procedures similar to those required of

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health maintenance organizations.

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     (b)  The office shall develop guidelines for the review of

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health flex plan applications and provide regulatory oversight of

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health flex plan advertisement and marketing procedures. The

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office shall disapprove or shall withdraw approval of plans that:

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     1.  Contain any ambiguous, inconsistent, or misleading

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provisions or any exceptions or conditions that deceptively

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affect or limit the benefits purported to be assumed in the

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general coverage provided by the health flex plan;

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     2.  Provide benefits that are unreasonable in relation to

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the premium charged or contain provisions that are unfair or

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inequitable or contrary to the public policy of this state, that

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encourage misrepresentation, or that result in unfair

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discrimination in sales practices;

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     3.  Cannot demonstrate that the health flex plan is

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financially sound and that the applicant is able to underwrite or

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finance the health care coverage provided; or

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     4.  Cannot demonstrate that the applicant and its management

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are in compliance with the standards required under s.

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624.404(3).

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     (c)  The agency and the Financial Services Commission may

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adopt rules as needed to administer this section.

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     (4)  LICENSE NOT REQUIRED.--Neither the licensing

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requirements of the Florida Insurance Code nor chapter 641,

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relating to health maintenance organizations, is applicable to a

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health flex plan approved under this section, unless expressly

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made applicable. However, for the purpose of prohibiting unfair

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trade practices, health flex plans are considered to be insurance

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subject to the applicable provisions of part IX of chapter 626,

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except as otherwise provided in this section.

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     (5)  ELIGIBILITY.--Eligibility to enroll in an approved

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health flex plan is limited to residents of this state who:

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     (a)1. Are 64 years of age or younger;

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     2.(b) Have a family income equal to or less than 300 200

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percent of the federal poverty level;

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     (c) Are eligible under a federally approved Medicaid

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demonstration waiver and reside in Palm Beach County or Miami-

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Dade County;

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     3.(d) Are not covered by a private insurance policy and are

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not eligible for coverage through a public health insurance

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program, such as Medicare or Medicaid, unless specifically

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authorized under paragraph (c), or another public health care

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program, such as Kidcare, and have not been covered at any time

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during the past 6 months; and

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     4.(e) Have applied for health care coverage through an

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approved health flex plan and have agreed to make any payments

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required for participation, including periodic payments or

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payments due at the time health care services are provided.

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     (b) Are part of an employer group in which at least 75

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percent of the employees have a family income equal to or less

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than 300 percent of the federal poverty level, and the employee

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group is not covered by a private health insurance policy and has

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not been covered at any time during the immediately preceding 6

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months. If the health flex plan entity is a health insurer,

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health plan, or health maintenance organization properly licensed

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under Florida law, only 50 percent of the employees must meet the

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income requirements of this paragraph.

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     (6)  RECORDS.--Each health flex plan shall maintain

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enrollment data and reasonable records of its losses, expenses,

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and claims experience and shall make those records reasonably

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available to enable the office to monitor and determine the

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financial viability of the health flex plan, as necessary.

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Provider networks and total enrollment by area shall be reported

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to the agency biannually to enable the agency to monitor access

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to care.

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     (7)  NOTICE.--The denial of coverage by a health flex plan,

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or the nonrenewal or cancellation of coverage, must be

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accompanied by the specific reasons for denial, nonrenewal, or

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cancellation. Notice of nonrenewal or cancellation must be

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provided at least 45 days in advance of the nonrenewal or

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cancellation, except that 10 days' written notice must be given

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for cancellation due to nonpayment of premiums. If the health

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flex plan fails to give the required notice, the health flex plan

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coverage must remain in effect until notice is appropriately

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given.

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     (8)  NONENTITLEMENT.--Coverage under an approved health flex

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plan is not an entitlement, and a cause of action does not arise

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against the state, a local government entity, or any other

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political subdivision of this state, or against the agency, for

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failure to make coverage available to eligible persons under this

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section.

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     (9)  PROGRAM EVALUATION.--The agency and the office shall

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evaluate the pilot program and its effect on the entities that

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seek approval as health flex plans, on the number of enrollees,

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and on the scope of the health care coverage offered under a

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health flex plan; shall provide an assessment of the health flex

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plans and their potential applicability in other settings; shall

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use health flex plans to gather more information to evaluate low-

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income consumer driven benefit packages; and shall, by January 1,

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2005, and annually thereafter, jointly submit a report to the

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Governor, the President of the Senate, and the Speaker of the

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House of Representatives.

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     (10) EXPIRATION.--This section expires July 1, 2008.

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     Section 5.  Subsection (41) is added to section 641.31,

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Florida Statutes, to read:

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     641.31  Health maintenance contracts.--

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     (41) Unless the employer chooses otherwise, for all

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policies issued or renewed after October 1, 2008, all eligible

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employees and their dependents shall be enrolled for coverage at

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the time of issuance or during the next open or special

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enrollment period, unless the employee provides written notice to

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the employer declining coverage. Such notice must include

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evidence of coverage under an existing group insurance policy or

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group health benefit plan, or reasons for declining coverage.

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Such notice shall be retained by the employer as part of the

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employee's employment or insurance file. An employer may require

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its employees to participate in its group health plan as a

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condition of employment.

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     Section 6.  Present subsection (4) of section 627.653,

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Florida Statutes, is renumbered as subsection (5), and a new

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subsection (4) is added to that section, to read:

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     627.653  Employee groups.--

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     (4) Unless the employer chooses otherwise, for all policies

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issued or renewed after October 1, 2008, all eligible employees

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and their dependents shall be enrolled for coverage at the time

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of issuance or during the next open or special enrollment period,

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unless the employee provides written notice to the employer

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declining coverage. Such notice must include evidence of coverage

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under an existing group insurance policy or group health benefit

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plan, or reasons for declining coverage. Such notice shall be

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retained by the employer as part of the employee's employment or

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insurance file. An employer may require its employees to

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participate in its group health plan as a condition of

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employment.

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     Section 7.  Paragraph (h) of subsection (5) of section

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627.6699, Florida Statutes, is amended to read:

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     627.6699  Employee Health Care Access Act.--

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     (5)  AVAILABILITY OF COVERAGE.--

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     (h)  All health benefit plans issued under this section must

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comply with the following conditions:

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     1.  For employers who have fewer than two employees, a late

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enrollee may be excluded from coverage for no longer than 24

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months if he or she was not covered by creditable coverage

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continually to a date not more than 63 days before the effective

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date of his or her new coverage.

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     2.  Any requirement used by a small employer carrier in

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determining whether to provide coverage to a small employer

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group, including requirements for minimum participation of

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eligible employees and minimum employer contributions, must be

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applied uniformly among all small employer groups having the same

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number of eligible employees applying for coverage or receiving

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coverage from the small employer carrier, except that a small

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employer carrier that participates in, administers, or issues

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health benefits pursuant to s. 381.0406 which do not include a

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preexisting condition exclusion may require as a condition of

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offering such benefits that the employer has had no health

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insurance coverage for its employees for a period of at least 6

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months. A small employer carrier may vary application of minimum

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participation requirements and minimum employer contribution

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requirements only by the size of the small employer group.

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     3. Unless the employer chooses otherwise, for all policies

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issued or renewed after October 1, 2008, all eligible employees

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and their dependents shall be enrolled for coverage at the time

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of issuance or during the next open or special enrollment period,

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unless the employee provides written notice to the employer

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declining coverage. Such notice must include evidence of coverage

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under an existing group insurance policy or group health benefit

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plan, or reasons for declining coverage. Such notice shall be

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retained by the employer as part of the employee's employment or

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insurance file. An employer may require its employees to

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participate in its group health plan as a condition of

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employment.

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     4.3. In applying minimum participation requirements with

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respect to a small employer, a small employer carrier shall not

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consider as an eligible employee employees or dependents who have

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qualifying existing coverage in an employer-based group insurance

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plan or an ERISA qualified self-insurance plan in determining

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whether the applicable percentage of participation is met.

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However, a small employer carrier may count eligible employees

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and dependents who have coverage under another health plan that

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is sponsored by that employer.

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     5.4. A small employer carrier shall not increase any

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requirement for minimum employee participation or any requirement

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for minimum employer contribution applicable to a small employer

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at any time after the small employer has been accepted for

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coverage, unless the employer size has changed, in which case the

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small employer carrier may apply the requirements that are

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applicable to the new group size.

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     6.5. If a small employer carrier offers coverage to a small

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employer, it must offer coverage to all the small employer's

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eligible employees and their dependents. A small employer carrier

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may not offer coverage limited to certain persons in a group or

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to part of a group, except with respect to late enrollees.

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     7.6. A small employer carrier may not modify any health

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benefit plan issued to a small employer with respect to a small

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employer or any eligible employee or dependent through riders,

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endorsements, or otherwise to restrict or exclude coverage for

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certain diseases or medical conditions otherwise covered by the

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health benefit plan.

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     8.7. An initial enrollment period of at least 30 days must

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be provided. An annual 30-day open enrollment period must be

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offered to each small employer's eligible employees and their

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dependents. A small employer carrier must provide special

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enrollment periods as required by s. 627.65615.

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================ T I T L E  A M E N D M E N T ================

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And the title is amended as follows:

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     On line 13, after the semicolon,

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insert:

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amending s. 408.909, F.S.; expanding the definition of

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"health flex plan" to include those who purchase

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coverage as an individual; authorizing a health flex

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plan to limit or exclude certain provider network

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requirements; providing that a health flex plan

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offering may include the option of a catastrophic plan

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supplementing the health flex plan; revising

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requirements for eligibility to enroll in a health flex

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plan; extending the date of expiration of certain

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provisions of state law regarding health flex plans;

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amending ss. 641.31, 627.653, and 627.6699, F.S.;

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requiring that all health maintenance contracts

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providing coverage for a member of the subscriber's

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family comply with certain provisions of state law;

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requiring that, for all policies issued or renewed

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after a specified date, all eligible employees and

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their dependents be enrolled for coverage at the time

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of issuance of a policy or during the next open or

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special enrollment period, unless the employer chooses

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otherwise or the employee provides written notice to

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the employer declining coverage; requiring that such

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notice contain certain information; requiring that such

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notice be retained by the employer as part of the

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employee's employment or insurance file; authorizing an

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employer to require its employees to participate in its

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group health plan as a condition of employment;

4/8/2008  9:16:00 AM     3-06839-08