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A bill to be entitled

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An act relating to health insurance; amending s. 408.814,

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F.S.; revising the eligibility requirements for

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participation in the Medikids program or the Florida

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Healthy Kids program; removing certain limitations;

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amending s. 408.909, F.S.; revising eligibility for

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enrollment in a health flex plan; revising the expiration

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date of the health flex plan program; creating s.

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408.9091, F.S.; creating the Cover Florida Health Care

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Access Program; providing a short title; providing

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legislative intent; providing definitions; requiring the

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Agency for Health Care Administration and the Office of

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Insurance Regulation of the Financial Services Commission

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within the Department of Financial Services to jointly  

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administer the program; providing program requirements;

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requiring the development of guidelines to meet minimum

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standards for quality care and access to care; requiring

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the agency to ensure that the Cover Florida plans follow

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standardized grievance procedures; requiring the Executive

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Office of the Governor, the agency, and the office to

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develop a public awareness program; authorizing public and

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private entities to design or extend incentives for

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participation in the Cover Florida Access Program;

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requiring the agency and the office to announce an

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invitation to negotiate for Cover Florida plan entities to

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design a coverage proposal; requiring the agency and the

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office to approve one plan entity; authorizing the agency

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and the office to approve one regional network plan in

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each existing Medicaid area; requiring the invitation to

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negotiate to include certain guidelines; providing certain

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conditions in which plans are disapproved or withdrawn;

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authorizing the agency and the office to announce an

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invitation to negotiate for companies that offer

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supplemental insurance or discount medical plans;

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providing that certain licensing requirements or ch. 641,

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F.S., are not applicable to a Cover Florida plan;

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providing that Cover Florida plans are considered

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insurance under certain conditions; excluding Cover

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Florida plans from the Florida Life and Health Insurance

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Guaranty Association and the Health Maintenance

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Organization Consumer Assistance Plan; providing

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requirements for eligibility in a Cover Florida plan;

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requiring each Cover Florida plan to maintain and provide

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certain records; providing that coverage under a Cover

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Florida plan is not an entitlement and does not give rise

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to a cause of action; requiring the agency and the office

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to evaluate the Cover Florida program and submit an annual

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report to the Governor and the Legislature; requiring the

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agency and the Financial Services Commission to adopt

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rules; amending s. 627.6562, F.S.; requiring insurance

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policies that provide dependent coverage to provide the

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policyholder with the option of insuring a child until the

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age of 30 under certain circumstances; providing an

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effective date.

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Be It Enacted by the Legislature of the State of Florida:

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     Section 1.  Subsection (5) of section 409.814, Florida

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Statutes, is amended to read:

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     409.814  Eligibility.--A child who has not reached 19 years

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of age whose family income is equal to or below 200 percent of

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the federal poverty level is eligible for the Florida Kidcare

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program as provided in this section. For enrollment in the

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Children's Medical Services Network, a complete application

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includes the medical or behavioral health screening. If,

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subsequently, an individual is determined to be ineligible for

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coverage, he or she must immediately be disenrolled from the

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respective Florida Kidcare program component.

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     (5)  A child whose family income is above 200 percent of the

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federal poverty level or a child who is excluded under the

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provisions of subsection (4) may participate in the Medikids

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program as provided in s. 409.8132 or, if the child is ineligible

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for Medikids by reason of age, in the Florida Healthy Kids

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program, subject to the following provisions:

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     (a)  The family is not eligible for premium assistance

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payments and must pay the full cost of the premium, including any

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administrative costs.

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     (b) The agency is authorized to place limits on enrollment

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in Medikids by these children in order to avoid adverse

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selection. The number of children participating in Medikids whose

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family income exceeds 200 percent of the federal poverty level

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must not exceed 10 percent of total enrollees in the Medikids

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program.

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     (b)(c) The board of directors of the Florida Healthy Kids

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Corporation may is authorized to place limits on enrollment of

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these children in order to avoid adverse selection. In addition,

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the board is authorized to offer a reduced benefit package to

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these children in order to limit program costs for such families.

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The number of children participating in the Florida Healthy Kids

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program whose family income exceeds 200 percent of the federal

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poverty level must not exceed 10 percent of total enrollees in

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the Florida Healthy Kids program.

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     Section 2.  Subsections (5) and (10) of section 408.909,

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Florida Statutes, are amended to read:

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     408.909  Health flex plans.--

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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)  Are 64 years of age or younger;

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     (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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     (c)(d) Are not covered by a private insurance policy and

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are 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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     (d)(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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     (10) EXPIRATION.--This section expires July 1, 2013 2008.

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     Section 3.  Section 408.9091, Florida Statutes, is created

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to read:

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     408.9091 Cover Florida Health Care Access Act.--

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     (1) SHORT TITLE.--This section may be cited as the "Cover

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Florida Health Access Program Act."

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

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proportion of state residents are unable to obtain affordable

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health insurance coverage. The Legislature also finds that

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existing "health flex" plan coverage has had limited

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participation due in part to narrow eligibility restrictions as

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well as minimal benefit options for catastrophic and emergency

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care coverage. Therefore, it is the Legislature's intent to

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expand the availability of health care options for uninsured

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residents by developing an affordable health care product that

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emphasizes coverage for basic and preventive health care

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services; provides inpatient hospital, urgent, and emergency care

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services; and is offered statewide by approved health insurers,

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health maintenance organizations, health-care-provider-sponsored

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organizations, or health care districts.

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     (3) 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 insurance coverage

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under a Cover Florida plan.

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     (d) "Cover Florida plan" means a consumer choice benefit

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plan approved under this section which guarantees payment or

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coverage for specified benefits provided to an enrollee.

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     (e) "Cover Florida plan coverage" means health care

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services that are covered as benefits under a Cover Florida plan.

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     (f) "Cover Florida plan entity" means a health insurer,

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health maintenance organization, health-care-provider-sponsored

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organization, or health care district that develops and

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implements a Cover Florida plan and is responsible for

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administering the plan and paying all claims for Cover Florida

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plan coverage by enrollees.

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     (g) "Cover Florida Plus" plan means a supplemental

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insurance product, such as for additional catastrophic coverage

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or dental, vision, or cancer coverage, approved under this

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section and offered to all enrollees.

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     (4) PROGRAM.--The agency and the office shall jointly

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establish and administer the Cover Florida Health Care Access

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Program.

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     (a) General Cover Florida plan components must require

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that:

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     1. Plans are offered as guaranteed issue to enrollees,

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subject to exclusions for preexisting conditions approved by the

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office and the agency.

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     2. Plans are portable, such that the enrollee remains

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covered regardless of employment status or the cost-sharing of

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premiums.

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     3. Plans may provide for cost containment through limits on

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the number of services, caps on benefit payments, and copayments

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for services.

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     4. A Cover Florida health plan entity makes all benefit

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plan and marketing materials available in English and Spanish.

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     5. In order to provide for consumer choice, Cover Florida

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health plan entities develop two alternative benefit option plans

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having different cost and benefit levels, including at least one

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plan that provides catastrophic coverage.

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     6. Plans without catastrophic coverage provide coverage

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options for the following services, including, but not limited

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to:

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     a. Preventive health services, including preventive

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screenings, annual health assessments, and well-care and well-

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woman services, including mammograms, screenings for cervical

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cancer, noninvasive colorectal or prostate screenings, and

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immunizations.

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     b. Incentives for routine, preventive care.

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     c. Office visits for the diagnosis and treatment of illness

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or injury.

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     d. Office surgery, including anesthesia.

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     e. Services related to behavioral health services.

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     f. Durable medical equipment and prosthetics.

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     g. Diabetic supplies.

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     7. Plans providing catastrophic coverage, at a minimum,

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provide coverage options for all of the services listed under

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subparagraph 6., and in addition include, but are not limited to,

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coverage options for:

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     a. Inpatient hospital stays.

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     b. Hospital emergency care services.

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     c. Urgent care services.

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     d. Outpatient facility services, outpatient surgery, and

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outpatient diagnostic services.

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     8. Plans offer prescription drug benefit coverage on all

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plans, or use a prescription drug manager, such as the Florida

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Discount Drug Card Program.

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     9. Plans provide, in enrollment materials, plain-language

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information on policy benefit coverage, benefit limits, cost-

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sharing requirements, and exclusions and a clear representation

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of what is not covered in the plan.

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     10. Plans offered through a qualified employer meet the

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requirements of s. 125 of the Internal Revenue Code.

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     (b) Guidelines shall be developed to ensure that Cover

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Florida plans meet minimum standards for quality of care and

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access to care. The agency shall ensure that the Cover Florida

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plans follow standardized grievance procedures.

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     (c) Changes in Cover Florida plan benefits, premiums, and

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policy forms are subject to regulatory oversight by the office

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and agency as provided by rules adopted by the Financial Services

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Commission and the agency.

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     (d) The agency, the office, and the Executive Office of the

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Governor shall develop a public awareness program to be

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implemented throughout the state for the promotion of the Cover

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Florida Health Access Program.

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     (e) Public or private entities may design programs to

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encourage Floridians to participate in the Cover Florida Health

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Access Program, or to encourage employers to cosponsor some share

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of Cover Florida plan premiums for employees.

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     (5) PLAN PROPOSALS.--The agency and the office shall

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announce, no later than July 1, 2008, an invitation to negotiate

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for Cover Florida plan entities to design a Cover Florida plan

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proposal in which benefits and premiums are specified.

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     (a) The invitation to negotiate shall include guidelines

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for the review of Cover Florida plan applications, policy forms,

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and all associated forms, and provide regulatory oversight of

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Cover Florida plan advertisement and marketing procedures. A plan

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shall be disapproved or withdrawn if the plan:

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     1. Contains 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 plan;

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     2. Provides benefits that are unreasonable in relation to

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the premium charged or contains provisions that are unfair or

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inequitable, that are contrary to the public policy of this

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state, that encourage misrepresentation, or that result in unfair

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discrimination in sales practices;

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     3. Cannot demonstrate that the plan is financially sound

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and that the applicant is able to underwrite or finance the

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health care coverage provided;

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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); or

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     5. Does not guarantee that enrollees may participate in the

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Cover Florida plan entity's comprehensive network of providers,

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as determined by the office, the agency, and the contract.

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     (b) The agency and the office may announce an invitation to

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negotiate for companies that offer supplemental insurance or

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discount medical plans that are licensed under part II of chapter

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636 to design Cover Florida Plus products.

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     (c) The agency and office shall approve at least one Cover

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Florida plan entity having an existing statewide network of

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providers, and may approve at least one regional network plan in

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each existing Medicaid area.

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     (6) LICENSE NOT REQUIRED.--

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     (a) The licensing requirements of the Florida Insurance

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Code and chapter 641, relating to health maintenance

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organizations, do not apply to a Cover Florida plan approved

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under this section unless expressly made applicable. However, for

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the purpose of prohibiting unfair trade practices, Cover Florida

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plans are considered to be insurance subject to the applicable

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provisions of part IX of chapter 626, except as otherwise

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provided in this section.

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     (b) Cover Florida plans are not covered by the Florida Life

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and Health Insurance Guaranty Association under part III of

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chapter 631 or by the Health Maintenance Organization Consumer

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Assistance Plan under part IV of chapter 631.

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     (7) ELIGIBILITY.--Eligibility to enroll in a Cover Florida

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plan is limited to residents of this state who meet all of the

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following:

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     (a) Are 19 to 64 years of age.

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     (b) 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, Medicaid, or Kidcare.

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     (c) Have not been covered by any health insurance program

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at any time during the past 6 months, unless coverage under a

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health insurance program was terminated within the previous 6

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months due to:

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     1. Loss of a job that provided an employer-sponsored health

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benefit plan;

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     2. Exhaustion of coverage that was continued under COBRA or

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continuation-of-coverage requirements under s. 627.6692;

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     3. Reaching the limiting age under the policy; or

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     4. Death of, or divorce from, a spouse who was provided

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employer-sponsored health benefit plan.

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     (d) Have applied for health care coverage through a Cover

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Florida plan and have agreed to make any payments required for

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participation, including periodic payments or payments due at the

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time health care services are provided.

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     (8) RECORDS.--Each Cover Florida plan must maintain

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enrollment data and provide network data and reasonable records

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to enable the office and agency to monitor plans and to determine

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the financial viability of the Cover Florida plan, as necessary.

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     (9) NONENTITLEMENT.--Coverage under a Cover Florida plan is

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not an entitlement, and a cause of action does not arise against

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the state, a local government entity, any other political

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subdivision of this state, or the agency or office for failure to

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make coverage available to eligible persons under this section.

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

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     (a) Evaluate the Cover Florida program and its effect on

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the entities that seek approval as Cover Florida plans, on the

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number of enrollees, and on the scope of the health care coverage

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offered under a Cover Florida plan;

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     (b) Provide an assessment of the Cover Florida plans and

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their potential applicability in other settings;

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     (c) Use Cover Florida plans to gather more information to

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evaluate low-income, consumer-driven benefit packages; and

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     (d) Jointly submit by March 1, 2009, and annually

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thereafter, a report to the Governor, the President of the

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Senate, and the Speaker of the House of Representatives providing

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the information specified in paragraphs (a)-(c) and

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recommendations relating to the successful implementation and

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administration of the program.

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     (11) RULEMAKING AUTHORITY.--The agency and the Financial

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Services Commission may adopt rules as needed to administer this

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section.

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     Section 4.  Effective upon this act becoming law and

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applicable to policies issued or renewed on or after October 1,

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2008, section 627.6562, Florida Statutes, is amended to read:

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     627.6562  Dependent coverage.--

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     (1)  If an insurer offers coverage that insures dependent

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children of the policyholder or certificateholder, the policy

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must insure a dependent child of the policyholder or

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certificateholder at least until the end of the calendar year in

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which the child reaches the age of 25, if the child meets all of

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the following:

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     (a)  The child is dependent upon the policyholder or

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certificateholder for support.

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     (b)  The child is living in the household of the

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policyholder or certificateholder, or the child is a full-time or

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part-time student.

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     (2) A policy that is subject to the requirements of

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subsection (1) must also offer the policyholder or

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certificateholder the option to insure a child of the

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policyholder or certificateholder at least until the end of the

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calendar year in which the child reaches the age of 30, if the

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child:

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     (a) Is unmarried and does not have a dependent of his or

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her own;

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     (b) Is a resident of this state or a full-time or part-time

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student; and

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     (c) Is not provided coverage as a named subscriber,

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insured, enrollee, or covered person under any other group,

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blanket, or franchise health insurance policy or individual

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health benefits plan, or entitled to benefits under Title XVIII

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of the Social Security Act.

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     (3) If, pursuant to subsection (2), a child is provided

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coverage under the parent's policy after the end of the calendar

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year in which the child reaches age 25, and coverage for the

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child is subsequently terminated, the child is not eligible to be

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covered under the parent's policy unless the child was

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continuously covered by other creditable coverage without a gap

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in coverage of more than 63 days. For the purposes of this

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subsection, the term "creditable coverage" has the same meaning

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as defined in s. 627.6561(5).

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     (4)(2) Nothing in This section does not affect or preempt

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affects or preempts an insurer's right to medically underwrite or

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charge the appropriate premium.

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     Section 5.  This act shall take effect upon becoming a law.