Florida Senate - 2013                                    SB 1278
       By Senator Sachs
       34-00743A-13                                          20131278__
    1                        A bill to be entitled                      
    2         An act relating to health flex plans; amending s.
    3         408.909, F.S.; revising the expiration date to extend
    4         the availability of health flex plans to low-income
    5         uninsured state residents; providing an effective
    6         date.
    8  Be It Enacted by the Legislature of the State of Florida:
   10         Section 1. Section 408.909, Florida Statutes, is amended to
   11  read:
   12         408.909 Health flex plans.—
   13         (1) INTENT.—The Legislature finds that a significant
   14  proportion of the residents of this state are unable to obtain
   15  affordable health insurance coverage. Therefore, it is the
   16  intent of the Legislature to expand the availability of health
   17  care options for low-income uninsured state residents by
   18  encouraging health insurers, health maintenance organizations,
   19  health-care-provider-sponsored organizations, local governments,
   20  health care districts, or other public or private community
   21  based organizations to develop alternative approaches to
   22  traditional health insurance which emphasize coverage for basic
   23  and preventive health care services. To the maximum extent
   24  possible, these options should be coordinated with existing
   25  governmental or community-based health services programs in a
   26  manner that is consistent with the objectives and requirements
   27  of such programs.
   28         (2) DEFINITIONS.—As used in this section, the term:
   29         (a) “Agency” means the Agency for Health Care
   30  Administration.
   31         (b) “Office” means the Office of Insurance Regulation of
   32  the Financial Services Commission.
   33         (c) “Enrollee” means an individual who has been determined
   34  to be eligible for and is receiving health care coverage under a
   35  health flex plan approved under this section.
   36         (d) “Health care coverage” or “health flex plan coverage”
   37  means health care services that are covered as benefits under an
   38  approved health flex plan or that are otherwise provided, either
   39  directly or through arrangements with other persons, via a
   40  health flex plan on a prepaid per capita basis or on a prepaid
   41  aggregate fixed-sum basis.
   42         (e) “Health flex plan” means a health plan approved under
   43  subsection (3) which guarantees payment for specified health
   44  care coverage provided to the enrollee who purchases coverage
   45  directly from the plan or through a small business purchasing
   46  arrangement sponsored by a local government.
   47         (f) “Health flex plan entity” means a health insurer,
   48  health maintenance organization, health-care-provider-sponsored
   49  organization, local government, health care district, other
   50  public or private community-based organization, or public
   51  private partnership that develops and implements an approved
   52  health flex plan and is responsible for administering the health
   53  flex plan and paying all claims for health flex plan coverage by
   54  enrollees of the health flex plan.
   55         (3) PROGRAM.—The agency and the office shall each approve
   56  or disapprove health flex plans that provide health care
   57  coverage for eligible participants. A health flex plan may limit
   58  or exclude benefits otherwise required by law for insurers
   59  offering coverage in this state, may cap the total amount of
   60  claims paid per year per enrollee, may limit the number of
   61  enrollees, or may take any combination of those actions. A
   62  health flex plan offering may include the option of a
   63  catastrophic plan supplementing the health flex plan.
   64         (a) The agency shall develop guidelines for the review of
   65  applications for health flex plans and shall disapprove or
   66  withdraw approval of plans that do not meet or no longer meet
   67  minimum standards for quality of care and access to care. The
   68  agency shall ensure that the health flex plans follow
   69  standardized grievance procedures similar to those required of
   70  health maintenance organizations.
   71         (b) The office shall develop guidelines for the review of
   72  health flex plan applications and provide regulatory oversight
   73  of health flex plan advertisement and marketing procedures. The
   74  office shall disapprove or shall withdraw approval of plans
   75  that:
   76         1. Contain any ambiguous, inconsistent, or misleading
   77  provisions or any exceptions or conditions that deceptively
   78  affect or limit the benefits purported to be assumed in the
   79  general coverage provided by the health flex plan;
   80         2. Provide benefits that are unreasonable in relation to
   81  the premium charged or contain provisions that are unfair or
   82  inequitable or contrary to the public policy of this state, that
   83  encourage misrepresentation, or that result in unfair
   84  discrimination in sales practices;
   85         3. Cannot demonstrate that the health flex plan is
   86  financially sound and that the applicant is able to underwrite
   87  or finance the health care coverage provided; or
   88         4. Cannot demonstrate that the applicant and its management
   89  are in compliance with the standards required under s.
   90  624.404(3).
   91         (c) The agency and the Financial Services Commission may
   92  adopt rules as needed to administer this section.
   93         (4) LICENSE NOT REQUIRED.—Neither the licensing
   94  requirements of the Florida Insurance Code nor chapter 641,
   95  relating to health maintenance organizations, is applicable to a
   96  health flex plan approved under this section, unless expressly
   97  made applicable. However, for the purpose of prohibiting unfair
   98  trade practices, health flex plans are considered to be
   99  insurance subject to the applicable provisions of part IX of
  100  chapter 626, except as otherwise provided in this section.
  101         (5) ELIGIBILITY.—Eligibility to enroll in an approved
  102  health flex plan is limited to residents of this state who:
  103         (a)1. Have a family income equal to or less than 300
  104  percent of the federal poverty level;
  105         2. Are not covered by a private insurance policy and are
  106  not eligible for coverage through a public health insurance
  107  program, such as Medicare or Medicaid, or another public health
  108  care program, such as Kidcare, and have not been covered at any
  109  time during the past 6 months, except that:
  110         a. A person who was covered under an individual health
  111  maintenance contract issued by a health maintenance organization
  112  licensed under part I of chapter 641 which was also an approved
  113  health flex plan on October 1, 2008, may apply for coverage in
  114  the same health maintenance organization’s health flex plan
  115  without a lapse in coverage if all other eligibility
  116  requirements are met; or
  117         b. A person who was covered under Medicaid or Kidcare and
  118  lost eligibility for the Medicaid or Kidcare subsidy due to
  119  income restrictions within 90 days prior to applying for health
  120  care coverage through an approved health flex plan may apply for
  121  coverage in a health flex plan without a lapse in coverage if
  122  all other eligibility requirements are met; and
  123         3. Have applied for health care coverage as an individual
  124  through an approved health flex plan and have agreed to make any
  125  payments required for participation, including periodic payments
  126  or payments due at the time health care services are provided;
  127  or
  128         (b) Are part of an employer group of which at least 75
  129  percent of the employees have a family income equal to or less
  130  than 300 percent of the federal poverty level and the employer
  131  group is not covered by a private health insurance policy and
  132  has not been covered at any time during the past 6 months. If
  133  the health flex plan entity is a health insurer, health plan, or
  134  health maintenance organization licensed under Florida law, only
  135  50 percent of the employees must meet the income requirements
  136  for the purpose of this paragraph.
  137         (6) RECORDS.—Each health flex plan shall maintain
  138  enrollment data and reasonable records of its losses, expenses,
  139  and claims experience and shall make those records reasonably
  140  available to enable the office to monitor and determine the
  141  financial viability of the health flex plan, as necessary.
  142  Provider networks and total enrollment by area shall be reported
  143  to the agency biannually to enable the agency to monitor access
  144  to care.
  145         (7) NOTICE.—The denial of coverage by a health flex plan,
  146  or the nonrenewal or cancellation of coverage, must be
  147  accompanied by the specific reasons for denial, nonrenewal, or
  148  cancellation. Notice of nonrenewal or cancellation must be
  149  provided at least 45 days in advance of the nonrenewal or
  150  cancellation, except that 10 days’ written notice must be given
  151  for cancellation due to nonpayment of premiums. If the health
  152  flex plan fails to give the required notice, the health flex
  153  plan coverage must remain in effect until notice is
  154  appropriately given.
  155         (8) NONENTITLEMENT.—Coverage under an approved health flex
  156  plan is not an entitlement, and a cause of action does not arise
  157  against the state, a local government entity, or any other
  158  political subdivision of this state, or against the agency, for
  159  failure to make coverage available to eligible persons under
  160  this section.
  161         (9) PROGRAM EVALUATION.—The agency and the office shall
  162  evaluate the pilot program and its effect on the entities that
  163  seek approval as health flex plans, on the number of enrollees,
  164  and on the scope of the health care coverage offered under a
  165  health flex plan; shall provide an assessment of the health flex
  166  plans and their potential applicability in other settings; shall
  167  use health flex plans to gather more information to evaluate
  168  low-income consumer driven benefit packages; and shall, by
  169  January 1, 2005, and annually thereafter, jointly submit a
  170  report to the Governor, the President of the Senate, and the
  171  Speaker of the House of Representatives.
  172         (10) EXPIRATION.—This section expires July 1, 2018 July 1,
  173  2013.
  174         Section 2. This act shall take effect June 30, 2013.