Florida Senate - 2016 COMMITTEE AMENDMENT
Bill No. SB 1170
Ì747432$Î747432
LEGISLATIVE ACTION
Senate . House
Comm: RCS .
01/26/2016 .
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The Committee on Banking and Insurance (Detert) recommended the
following:
1 Senate Amendment (with title amendment)
2
3 Delete everything after the enacting clause
4 and insert:
5 Section 1. Paragraph (d) of subsection (2) of section
6 408.909, Florida Statutes, is amended to read:
7 408.909 Health flex plans.—
8 (2) DEFINITIONS.—As used in this section, the term:
9 (d) “Health care coverage” or “health flex plan coverage”
10 means health care services that are covered as benefits under an
11 approved health flex plan or that are otherwise provided, either
12 directly or through arrangements with other persons, via a
13 health flex plan on a prepaid per capita basis or on a prepaid
14 aggregate fixed-sum basis. The terms may also include one or
15 more of the excepted benefits under s. 627.6513(1)-(13) s.
16 627.6561(5)(b), the benefits under s. 627.6561(5)(c), if offered
17 separately, or the benefits under s. 627.6561(5)(d), if offered
18 as independent, noncoordinated benefits.
19 Section 2. Section 409.817, Florida Statutes, is amended to
20 read:
21 409.817 Approval of health benefits coverage; financial
22 assistance.—In order for health insurance coverage to qualify
23 for premium assistance payments for an eligible child under ss.
24 409.810-409.821, the health benefits coverage must:
25 (1) Be certified by the Office of Insurance Regulation of
26 the Financial Services Commission under s. 409.818 as meeting,
27 exceeding, or being actuarially equivalent to the benchmark
28 benefit plan;
29 (2) Be guarantee issued;
30 (3) Be community rated;
31 (4) Not impose any preexisting condition exclusion for
32 covered benefits; however, group health insurance plans may
33 permit the imposition of a preexisting condition exclusion, but
34 only insofar as it is permitted under s. 627.6561;
35 (5) Comply with the applicable limitations on premiums and
36 cost sharing in s. 409.816;
37 (6) Comply with the quality assurance and access standards
38 developed under s. 409.820; and
39 (7) Establish periodic open enrollment periods, which may
40 not occur more frequently than quarterly.
41 Section 3. Paragraph (b) of subsection (1) of section
42 624.123, Florida Statutes, is amended to read:
43 624.123 Certain international health insurance policies;
44 exemption from code.—
45 (1) International health insurance policies and
46 applications may be solicited and sold in this state at any
47 international airport to a resident of a foreign country. Such
48 international health insurance policies shall be solicited and
49 sold only by a licensed health insurance agent and underwritten
50 only by an admitted insurer. For purposes of this subsection:
51 (b) “International health insurance policy” means health
52 insurance, as provided defined in s. 627.6562(3)(a)2. s.
53 627.6561(5)(a)2., which is offered to an individual, covering
54 only a resident of a foreign country on an annual basis.
55 Section 4. Subsection (2) of section 627.402, Florida
56 Statutes, is amended to read:
57 627.402 Definitions.—As used in this part, the term:
58 (2) “Nongrandfathered health plan” is a health insurance
59 policy or health maintenance organization contract that is not a
60 grandfathered health plan and does not provide the benefits or
61 coverages specified under s. 627.6513(1)-(14) s. 627.6561(5)(b)
62 (e).
63 Section 5. Subsection (3) of section 627.411, Florida
64 Statutes, is amended to read:
65 627.411 Grounds for disapproval.—
66 (3)(a) For health insurance coverage as described in s.
67 627.6561(5)(a)2., the minimum loss ratio standard of incurred
68 claims to earned premium for the form shall be 65 percent.
69 (b) Incurred claims are claims occurring within a fixed
70 period, whether or not paid during the same period, under the
71 terms of the policy period.
72 1. Claims include scheduled benefit payments or services
73 provided by a provider or through a provider network for dental,
74 vision, disability, and similar health benefits.
75 2. Claims do not include state assessments, taxes, company
76 expenses, or any expense incurred by the company for the cost of
77 adjusting and settling a claim, including the review,
78 qualification, oversight, management, or monitoring of a claim
79 or incentives or compensation to providers for other than the
80 provisions of health care services.
81 3. A company may at its discretion include costs that are
82 demonstrated to reduce claims, such as fraud intervention
83 programs or case management costs, which are identified in each
84 filing, are demonstrated to reduce claims costs, and do not
85 result in increasing the experience period loss ratio by more
86 than 5 percent.
87 4. For scheduled claim payments, such as disability income
88 or long-term care, the incurred claims shall be the present
89 value of the benefit payments discounted for continuance and
90 interest.
91 Section 6. Section 627.6011, Florida Statutes, is amended
92 to read:
93 627.6011 Mandated coverages.—Mandatory health benefits
94 regulated under this chapter are not intended to apply to the
95 types of health benefit plans listed in s. 627.6513(1)-(14) s.
96 627.6561(5)(b)-(e), issued in any market, unless specifically
97 designated otherwise. For purposes of this section, the term
98 “mandatory health benefits” means those benefits set forth in
99 ss. 627.6401-627.64193, and any other mandatory treatment or
100 health coverages or benefits enacted on or after July 1, 2012.
101 Section 7. Paragraph (h) of subsection (1) of section
102 627.602, Florida Statutes, is amended to read:
103 627.602 Scope, format of policy.—
104 (1) Each health insurance policy delivered or issued for
105 delivery to any person in this state must comply with all
106 applicable provisions of this code and all of the following
107 requirements:
108 (h) Section 641.312 and the provisions of the Employee
109 Retirement Income Security Act of 1974, as implemented by 29
110 C.F.R. s. 2560.503-1, relating to internal grievances. This
111 paragraph does not apply to a health insurance policy that is
112 subject to the Subscriber Assistance Program under s. 408.7056
113 or to the types of benefits or coverages provided under s.
114 627.6513(1)-(14) s. 627.6561(5)(b)-(e) issued in any market.
115 Section 8. Subsection (1) of section 627.642, Florida
116 Statutes, is amended to read:
117 627.642 Outline of coverage.—
118 (1) A policy offering benefits defined in s. 627.6513(1)
119 (14) or a large group no individual or family accident and
120 health insurance policy may not shall be delivered, or issued
121 for delivery, in this state unless:
122 (a) It is accompanied by an appropriate outline of
123 coverage; or
124 (b) An appropriate outline of coverage is completed and
125 delivered to the applicant at the time application is made, and
126 an acknowledgment of receipt or certificate of delivery of such
127 outline is provided to the insurer with the application.
128
129 In the case of a direct response, such as a written application
130 to the insurance company from an applicant, the outline of
131 coverage shall accompany the policy when issued.
132 Section 9. Subsections (1), (6), and (7) of section
133 627.6425, Florida Statutes, are amended, to read:
134 627.6425 Renewability of individual coverage.—
135 (1) Except as otherwise provided in this section, an
136 insurer that provides individual health insurance coverage to an
137 individual shall renew or continue in force such coverage at the
138 option of the individual. For the purpose of this section, the
139 term “individual health insurance” means health insurance
140 coverage, as described in s. 624.603 s. 627.6561(5)(a)2.,
141 offered to an individual in this state, including certificates
142 of coverage offered to individuals in this state as part of a
143 group policy issued to an association outside this state, but
144 the term does not include short-term limited duration insurance
145 or excepted benefits specified in s. 627.6513(1)-(14) subsection
146 (6) or subsection (7).
147 (6) The requirements of this section do not apply to any
148 health insurance coverage in relation to its provision of
149 excepted benefits described in s. 627.6561(5)(b).
150 (7) The requirements of this section do not apply to any
151 health insurance coverage in relation to its provision of
152 excepted benefits described in s. 627.6561(5)(c), (d), or (e),
153 if the benefits are provided under a separate policy,
154 certificate, or contract of insurance.
155 Section 10. Paragraph (b) of subsection (2) and subsection
156 (3) of section 627.6487, Florida Statutes, are amended to read:
157 627.6487 Guaranteed availability of individual health
158 insurance coverage to eligible individuals.—
159 (2) For the purposes of this section:
160 (b) “Individual health insurance” means health insurance,
161 as defined in s. 624.603 s. 627.6561(5)(a)2., which is offered
162 to an individual, including certificates of coverage offered to
163 individuals in this state as part of a group policy issued to an
164 association outside this state, but the term does not include
165 short-term limited duration insurance or excepted benefits
166 specified in s. 627.6513(1)-(14) s. 627.6561(5)(b) or, if the
167 benefits are provided under a separate policy, certificate, or
168 contract, the term does not include excepted benefits specified
169 in s. 627.6561(5)(c), (d), or (e).
170 (3) For the purposes of this section, the term “eligible
171 individual” means an individual:
172 (a)1. For whom, as of the date on which the individual
173 seeks coverage under this section, the aggregate of the periods
174 of creditable coverage, as defined in s. 627.6562(3) s.
175 627.6561(5) and (6), is 18 or more months; and
176 2.a. Whose most recent prior creditable coverage was under
177 a group health plan, governmental plan, or church plan, or
178 health insurance coverage offered in connection with any such
179 plan; or
180 b. Whose most recent prior creditable coverage was under an
181 individual plan issued in this state by a health insurer or
182 health maintenance organization, which coverage is terminated
183 due to the insurer or health maintenance organization becoming
184 insolvent or discontinuing the offering of all individual
185 coverage in the State of Florida, or due to the insured no
186 longer living in the service area in the State of Florida of the
187 insurer or health maintenance organization that provides
188 coverage through a network plan in the State of Florida;
189 (b) Who is not eligible for coverage under:
190 1. A group health plan, as defined in s. 2791 of the Public
191 Health Service Act;
192 2. A conversion policy or contract issued by an authorized
193 insurer or health maintenance organization under s. 627.6675 or
194 s. 641.3921, respectively, offered to an individual who is no
195 longer eligible for coverage under either an insured or self
196 insured employer plan;
197 3. Part A or part B of Title XVIII of the Social Security
198 Act; or
199 4. A state plan under Title XIX of such act, or any
200 successor program, and does not have other health insurance
201 coverage;
202 (c) With respect to whom the most recent coverage within
203 the coverage period described in paragraph (a) was not
204 terminated based on a factor described in s. 627.6571(2)(a) or
205 (b), relating to nonpayment of premiums or fraud, unless such
206 nonpayment of premiums or fraud was due to acts of an employer
207 or person other than the individual;
208 (d) Who, having been offered the option of continuation
209 coverage under a COBRA continuation provision or under s.
210 627.6692, elected such coverage; and
211 (e) Who, if the individual elected such continuation
212 provision, has exhausted such continuation coverage under such
213 provision or program.
214 Section 11. Section 627.64871, Florida Statutes, is
215 repealed.
216 Section 12. Section 627.6512, Florida Statutes, is amended
217 to read:
218 627.6512 Exemption of certain group health insurance
219 policies.—Sections 627.6561, 627.65615, 627.65625, and 627.6571
220 do not apply to:
221 (1) any group insurance policy in relation to its provision
222 of excepted benefits described in s. 627.6513(1)-(14) s.
223 627.6561(5)(b).
224 (2) Any group health insurance policy in relation to its
225 provision of excepted benefits described in s. 627.6561(5)(c),
226 if the benefits:
227 (a) Are provided under a separate policy, certificate, or
228 contract of insurance; or
229 (b) Are otherwise not an integral part of the policy.
230 (3) Any group health insurance policy in relation to its
231 provision of excepted benefits described in s. 627.6561(5)(d),
232 if all of the following conditions are met:
233 (a) The benefits are provided under a separate policy,
234 certificate, or contract of insurance;
235 (b) There is no coordination between the provision of such
236 benefits and any exclusion of benefits under any group policy
237 maintained by the same policyholder; and
238 (c) Such benefits are paid with respect to an event without
239 regard to whether benefits are provided with respect to such an
240 event under any group health policy maintained by the same
241 policyholder.
242 (4) Any group health policy in relation to its provision of
243 excepted benefits described in s. 627.6561(5)(e), if the
244 benefits are provided under a separate policy, certificate, or
245 contract of insurance.
246 Section 13. Section 627.6513, Florida Statutes, is amended
247 to read:
248 627.6513 Scope.—Section 641.312 and the provisions of the
249 Employee Retirement Income Security Act of 1974, as implemented
250 by 29 C.F.R. s. 2560.503-1, relating to internal grievances,
251 apply to all group health insurance policies issued under this
252 part. This section does not apply to a group health insurance
253 policy that is subject to the Subscriber Assistance Program in
254 s. 408.7056 or to: the types of benefits or coverages provided
255 under s. 627.6561(5)(b)-(e) issued in any market.
256 (1) Coverage only for accident insurance or disability
257 income insurance, or any combination thereof.
258 (2) Coverage issued as a supplement to liability insurance.
259 (3) Liability insurance, including general liability
260 insurance and automobile liability insurance.
261 (4) Workers’ compensation or similar insurance.
262 (5) Automobile medical payment insurance.
263 (6) Credit-only insurance.
264 (7) Coverage for onsite medical clinics, including prepaid
265 health clinics under part II of chapter 641.
266 (8) Other similar insurance coverage, specified in rules
267 adopted by the commission, under which benefits for medical care
268 are secondary or incidental to other insurance benefits. To the
269 extent possible, such rules must be consistent with regulations
270 adopted by the United States Department of Health and Human
271 Services.
272 (9) Limited scope dental or vision benefits, if offered
273 separately.
274 (10) Benefits for long-term care, nursing home care, home
275 health care, or community-based care, or any combination
276 thereof, if offered separately.
277 (11) Other similar limited benefits, if offered separately,
278 as specified in rules adopted by the commission.
279 (12) Coverage only for a specified disease or illness, if
280 offered as independent, noncoordinated benefits.
281 (13) Hospital indemnity or other fixed indemnity insurance,
282 if offered as independent, noncoordinated benefits.
283 (14) Benefits provided through a Medicare supplemental
284 health insurance policy, as defined under s. 1882(g)(1) of the
285 Social Security Act, coverage supplemental to the coverage
286 provided under 10 U.S.C. chapter 55, and similar supplemental
287 coverage provided to coverage under a group health plan, which
288 are offered as a separate insurance policy and as independent,
289 noncoordinated benefits.
290 Section 14. Section 627.6561, Florida Statutes, is
291 repealed.
292 Section 15. Subsection (3) of section 627.6562, Florida
293 Statutes, is amended to read:
294 627.6562 Dependent coverage.—
295 (3) If, pursuant to subsection (2), a child is provided
296 coverage under the parent’s policy after the end of the calendar
297 year in which the child reaches age 25 and coverage for the
298 child is subsequently terminated, the child is not eligible to
299 be covered under the parent’s policy unless the child was
300 continuously covered by other creditable coverage without a gap
301 in coverage of more than 63 days.
302 (a) For the purposes of this subsection, the term
303 “creditable coverage” means, with respect to an individual,
304 coverage of the individual under any of the following: has the
305 same meaning as provided in s. 627.6561(5).
306 1. A group health plan, as defined in s. 2791 of the Public
307 Health Service Act.
308 2. Health insurance coverage consisting of medical care
309 provided directly through insurance or reimbursement or
310 otherwise, and including terms and services paid for as medical
311 care, under any hospital or medical service policy or
312 certificate, hospital or medical service plan contract, or
313 health maintenance contract offered by a health insurance
314 issuer.
315 3. Part A or part B of Title XVIII of the Social Security
316 Act.
317 4. Title XIX of the Social Security Act, other than
318 coverage consisting solely of benefits under s. 1928.
319 5. 10 U.S.C. chapter 55.
320 6. A medical care program of the Indian Health Service or
321 of a tribal organization.
322 7. The Florida Comprehensive Health Association or another
323 state health benefit risk pool.
324 8. A health plan offered under 5 U.S.C. chapter 89.
325 9. A public health plan as defined by rules adopted by the
326 commission. To the greatest extent possible, such rules must be
327 consistent with regulations adopted by the United States
328 Department of Health and Human Services.
329 10. A health benefit plan under s. 5(e) of the Peace Corps
330 Act, 22 U.S.C. s. 2504(e).
331 (b) Creditable coverage does not include coverage that
332 consists of one or more, or any combination thereof, of the
333 following excepted benefits:
334 1. Coverage only for accident insurance or disability
335 income insurance, or any combination thereof.
336 2. Coverage issued as a supplement to liability insurance.
337 3. Liability insurance, including general liability
338 insurance and automobile liability insurance.
339 4. Workers’ compensation or similar insurance.
340 5. Automobile medical payment insurance.
341 6. Credit-only insurance.
342 7. Coverage for onsite medical clinics, including prepaid
343 health clinics under part II of chapter 641.
344 8. Other similar insurance coverage specified in rules
345 adopted by the commission under which benefits for medical care
346 are secondary or incidental to other insurance benefits. To the
347 extent possible, such rules must be consistent with regulations
348 adopted by the United States Department of Health and Human
349 Services.
350 (c) The following benefits are not subject to the
351 creditable coverage requirements, if offered separately:
352 1. Limited scope dental or vision benefits.
353 2. Benefits for long-term care, nursing home care, home
354 health care, or community-based care, or any combination
355 thereof.
356 3. Other similar, limited benefits specified in rules
357 adopted by the commission.
358 (d) The following benefits are not subject to creditable
359 coverage requirements if offered as independent, noncoordinated
360 benefits:
361 1. Coverage only for a specified disease or illness.
362 2. Hospital indemnity or other fixed indemnity insurance.
363 (e) Benefits provided through a Medicare supplemental
364 health insurance policy, as defined under s. 1882(g)(1) of the
365 Social Security Act, coverage supplemental to the coverage
366 provided under 10 U.S.C. chapter 55, and similar supplemental
367 coverage provided to coverage under a group health plan are not
368 considered creditable coverage if offered as a separate
369 insurance policy.
370 Section 16. Subsection (1) of section 627.65626, Florida
371 Statutes, is amended to read:
372 627.65626 Insurance rebates for healthy lifestyles.—
373 (1) Any rate, rating schedule, or rating manual for a
374 health insurance policy that provides creditable coverage as
375 defined in s. 627.6562(3) s. 627.6561(5) filed with the office
376 shall provide for an appropriate rebate of premiums paid in the
377 last policy year, contract year, or calendar year when the
378 majority of members of a health plan have enrolled and
379 maintained participation in any health wellness, maintenance, or
380 improvement program offered by the group policyholder and health
381 plan. The rebate may be based upon premiums paid in the last
382 calendar year or policy year. The group must provide evidence of
383 demonstrative maintenance or improvement of the enrollees’
384 health status as determined by assessments of agreed-upon health
385 status indicators between the policyholder and the health
386 insurer, including, but not limited to, reduction in weight,
387 body mass index, and smoking cessation. The group or health
388 insurer may contract with a third-party administrator to
389 assemble and report the health status required in this
390 subsection between the policyholder and the health insurer. Any
391 rebate provided by the health insurer is presumed to be
392 appropriate unless credible data demonstrates otherwise, or
393 unless the rebate program requires the insured to incur costs to
394 qualify for the rebate which equal or exceed the value of the
395 rebate, but the rebate may not exceed 10 percent of paid
396 premiums.
397 Section 17. Paragraphs (e), (l), and (n) of subsection (3),
398 paragraphs (c) and (d) of subsection (5), and paragraph (b) of
399 subsection (6) of section 627.6699, Florida Statutes, are
400 amended to read:
401 627.6699 Employee Health Care Access Act.—
402 (3) DEFINITIONS.—As used in this section, the term:
403 (e) “Creditable coverage” has the same meaning ascribed in
404 s. 627.6562(3) s. 627.6561.
405 (l) “Late enrollee” means an eligible employee or dependent
406 who, with respect to coverage under a group health policy, is a
407 participant or beneficiary who enrolls under the policy other
408 than during:
409 1. The first period in which the individual is eligible to
410 enroll under the policy.
411 2. A special enrollment period, as provided under s.
412 627.65615 as defined under s. 627.6561(1)(b).
413 (n) “Modified community rating” means a method used to
414 develop carrier premiums which spreads financial risk across a
415 large population; allows the use of separate rating factors for
416 age, gender, family composition, tobacco usage, and geographic
417 area as determined under paragraph (5)(e) (5)(f); and allows
418 adjustments for: claims experience, health status, or duration
419 of coverage as permitted under subparagraph (6)(b)5.; and
420 administrative and acquisition expenses as permitted under
421 subparagraph (6)(b)5.
422 (5) AVAILABILITY OF COVERAGE.—
423 (c) Except as provided in paragraph (d), a health benefit
424 plan covering small employers must comply with preexisting
425 condition provisions specified in s. 627.6561 or, for health
426 maintenance contracts, in s. 641.31071.
427 (c)(d) A health benefit plan covering small employers,
428 issued or renewed on or after January 1, 1994, must comply with
429 the following conditions:
430 1. All health benefit plans must be offered and issued on a
431 guaranteed-issue basis. Additional or increased benefits may
432 only be offered by riders.
433 2. Paragraph (c) applies to health benefit plans issued to
434 a small employer who has two or more eligible employees and to
435 health benefit plans that are issued to a small employer who has
436 fewer than two eligible employees and that cover an employee who
437 has had creditable coverage continually to a date not more than
438 63 days before the effective date of the new coverage.
439 2.3. For health benefit plans that are issued to a small
440 employer who has fewer than two employees and that cover an
441 employee who has not been continually covered by creditable
442 coverage within 63 days before the effective date of the new
443 coverage, preexisting condition provisions must not exclude
444 coverage for a period beyond 24 months following the employee’s
445 effective date of coverage and may relate only to:
446 a. Conditions that, during the 24-month period immediately
447 preceding the effective date of coverage, had manifested
448 themselves in such a manner as would cause an ordinarily prudent
449 person to seek medical advice, diagnosis, care, or treatment or
450 for which medical advice, diagnosis, care, or treatment was
451 recommended or received; or
452 b. A pregnancy existing on the effective date of coverage.
453 (6) RESTRICTIONS RELATING TO PREMIUM RATES.—
454 (b) For all small employer health benefit plans that are
455 subject to this section and issued by small employer carriers on
456 or after January 1, 1994, premium rates for health benefit plans
457 are subject to the following:
458 1. Small employer carriers must use a modified community
459 rating methodology in which the premium for each small employer
460 is determined solely on the basis of the eligible employee’s and
461 eligible dependent’s gender, age, family composition, tobacco
462 use, or geographic area as determined under paragraph (5)(e)
463 (5)(f) and in which the premium may be adjusted as permitted by
464 this paragraph. A small employer carrier is not required to use
465 gender as a rating factor for a nongrandfathered health plan.
466 2. Rating factors related to age, gender, family
467 composition, tobacco use, or geographic location may be
468 developed by each carrier to reflect the carrier’s experience.
469 The factors used by carriers are subject to office review and
470 approval.
471 3. Small employer carriers may not modify the rate for a
472 small employer for 12 months from the initial issue date or
473 renewal date, unless the composition of the group changes or
474 benefits are changed. However, a small employer carrier may
475 modify the rate one time within the 12 months after the initial
476 issue date for a small employer who enrolls under a previously
477 issued group policy that has a common anniversary date for all
478 employers covered under the policy if:
479 a. The carrier discloses to the employer in a clear and
480 conspicuous manner the date of the first renewal and the fact
481 that the premium may increase on or after that date.
482 b. The insurer demonstrates to the office that efficiencies
483 in administration are achieved and reflected in the rates
484 charged to small employers covered under the policy.
485 4. A carrier may issue a group health insurance policy to a
486 small employer health alliance or other group association with
487 rates that reflect a premium credit for expense savings
488 attributable to administrative activities being performed by the
489 alliance or group association if such expense savings are
490 specifically documented in the insurer’s rate filing and are
491 approved by the office. Any such credit may not be based on
492 different morbidity assumptions or on any other factor related
493 to the health status or claims experience of any person covered
494 under the policy. This subparagraph does not exempt an alliance
495 or group association from licensure for activities that require
496 licensure under the insurance code. A carrier issuing a group
497 health insurance policy to a small employer health alliance or
498 other group association shall allow any properly licensed and
499 appointed agent of that carrier to market and sell the small
500 employer health alliance or other group association policy. Such
501 agent shall be paid the usual and customary commission paid to
502 any agent selling the policy.
503 5. Any adjustments in rates for claims experience, health
504 status, or duration of coverage may not be charged to individual
505 employees or dependents. For a small employer’s policy, such
506 adjustments may not result in a rate for the small employer
507 which deviates more than 15 percent from the carrier’s approved
508 rate. Any such adjustment must be applied uniformly to the rates
509 charged for all employees and dependents of the small employer.
510 A small employer carrier may make an adjustment to a small
511 employer’s renewal premium, up to 10 percent annually, due to
512 the claims experience, health status, or duration of coverage of
513 the employees or dependents of the small employer. If the
514 aggregate resulting from the application of such adjustment
515 exceeds the premium that would have been charged by application
516 of the approved modified community rate by 4 percent for the
517 current policy term, the carrier shall limit the application of
518 such adjustments only to minus adjustments. For any subsequent
519 policy term, if the total aggregate adjusted premium actually
520 charged does not exceed the premium that would have been charged
521 by application of the approved modified community rate by 4
522 percent, the carrier may apply both plus and minus adjustments.
523 A small employer carrier may provide a credit to a small
524 employer’s premium based on administrative and acquisition
525 expense differences resulting from the size of the group. Group
526 size administrative and acquisition expense factors may be
527 developed by each carrier to reflect the carrier’s experience
528 and are subject to office review and approval.
529 6. A small employer carrier rating methodology may include
530 separate rating categories for one dependent child, for two
531 dependent children, and for three or more dependent children for
532 family coverage of employees having a spouse and dependent
533 children or employees having dependent children only. A small
534 employer carrier may have fewer, but not greater, numbers of
535 categories for dependent children than those specified in this
536 subparagraph.
537 7. Small employer carriers may not use a composite rating
538 methodology to rate a small employer with fewer than 10
539 employees. For the purposes of this subparagraph, the term
540 “composite rating methodology” means a rating methodology that
541 averages the impact of the rating factors for age and gender in
542 the premiums charged to all of the employees of a small
543 employer.
544 8. A carrier may separate the experience of small employer
545 groups with fewer than 2 eligible employees from the experience
546 of small employer groups with 2-50 eligible employees for
547 purposes of determining an alternative modified community
548 rating.
549 a. If a carrier separates the experience of small employer
550 groups, the rate to be charged to small employer groups of fewer
551 than 2 eligible employees may not exceed 150 percent of the rate
552 determined for small employer groups of 2-50 eligible employees.
553 However, the carrier may charge excess losses of the experience
554 pool consisting of small employer groups with less than 2
555 eligible employees to the experience pool consisting of small
556 employer groups with 2-50 eligible employees so that all losses
557 are allocated and the 150-percent rate limit on the experience
558 pool consisting of small employer groups with less than 2
559 eligible employees is maintained.
560 b. Notwithstanding s. 627.411(1), the rate to be charged to
561 a small employer group of fewer than 2 eligible employees,
562 insured as of July 1, 2002, may be up to 125 percent of the rate
563 determined for small employer groups of 2-50 eligible employees
564 for the first annual renewal and 150 percent for subsequent
565 annual renewals.
566 9. A carrier shall separate the experience of grandfathered
567 health plans from nongrandfathered health plans for determining
568 rates.
569 Section 18. Subsection (1) and paragraph (c) of subsection
570 (2) of section 627.6741, Florida Statutes, are amended to read:
571 627.6741 Issuance, cancellation, nonrenewal, and
572 replacement.—
573 (1)(a) An insurer issuing Medicare supplement policies in
574 this state shall offer the opportunity of enrolling in a
575 Medicare supplement policy, without conditioning the issuance or
576 effectiveness of the policy on, and without discriminating in
577 the price of the policy based on, the medical or health status
578 or receipt of health care by the individual:
579 1. To any individual who is 65 years of age or older, or
580 under 65 years of age and eligible for Medicare by reason of
581 disability or end-stage renal disease, and who resides in this
582 state, upon the request of the individual during the 6-month
583 period beginning with the first month in which the individual
584 has attained 65 years of age and is enrolled in Medicare Part B,
585 or is eligible for Medicare by reason of a disability or end
586 stage renal disease, and is enrolled in Medicare Part B; or
587 2. To any individual who is 65 years of age or older, or
588 under 65 years of age and eligible for Medicare by reason of a
589 disability or end-stage renal disease, who is enrolled in
590 Medicare Part B, and who resides in this state, upon the request
591 of the individual during the 2-month period following
592 termination of coverage under a group health insurance policy.
593 (b) The 6-month period to enroll in a Medicare supplement
594 policy for an individual who is under 65 years of age and is
595 eligible for Medicare by reason of disability or end-stage renal
596 disease and otherwise eligible under subparagraph (a)1. or
597 subparagraph (a)2. and first enrolled in Medicare Part B before
598 October 1, 2009, begins on October 1, 2009.
599 (c) A company that has offered Medicare supplement policies
600 to individuals under 65 years of age who are eligible for
601 Medicare by reason of disability or end-stage renal disease
602 before October 1, 2009, may, for one time only, effect a rate
603 schedule change that redefines the age bands of the premium
604 classes without activating the period of discontinuance required
605 by s. 627.410(6)(e)2.
606 (d) As a part of an insurer’s rate filings, before and
607 including the insurer’s first rate filing for a block of policy
608 forms in 2015, notwithstanding the provisions of s.
609 627.410(6)(e)3., an insurer shall consider the experience of the
610 policies or certificates for the premium classes including
611 individuals under 65 years of age and eligible for Medicare by
612 reason of disability or end-stage renal disease separately from
613 the balance of the block so as not to affect the other premium
614 classes. For filings in such time period only, credibility of
615 that experience shall be as follows: if a block of policy forms
616 has 1,250 or more policies or certificates in force in the age
617 band including ages under 65 years of age, full or 100-percent
618 credibility shall be given to the experience; and if fewer than
619 250 policies or certificates are in force, no or zero-percent
620 credibility shall be given. Linear interpolation shall be used
621 for in-force amounts between the low and high values. Florida
622 only experience shall be used if it is 100-percent credible. If
623 Florida-only experience is not 100-percent credible, a
624 combination of Florida-only and nationwide experience shall be
625 used. If Florida-only experience is zero-percent credible,
626 nationwide experience shall be used. The insurer may file its
627 initial rates and any rate adjustment based upon the experience
628 of these policies or certificates or based upon expected claim
629 experience using experience data of the same company, other
630 companies in the same or other states, or using data publicly
631 available from the Centers for Medicaid and Medicare Services if
632 the insurer’s combined Florida and nationwide experience is not
633 100-percent credible, separate from the balance of all other
634 Medicare supplement policies.
635
636 A Medicare supplement policy issued to an individual under
637 subparagraph (a)1. or subparagraph (a)2. may not exclude
638 benefits based on a preexisting condition if the individual has
639 a continuous period of creditable coverage, as defined in s.
640 627.6562(3) s. 627.6561(5), of at least 6 months as of the date
641 of application for coverage.
642 (2) For both individual and group Medicare supplement
643 policies:
644 (c) If a Medicare supplement policy or certificate replaces
645 another Medicare supplement policy or certificate or creditable
646 coverage as defined in s. 627.6562(3) s. 627.6561(5), the
647 replacing insurer shall waive any time periods applicable to
648 preexisting conditions, waiting periods, elimination periods,
649 and probationary periods in the new Medicare supplement policy
650 for similar benefits to the extent such time was spent under the
651 original policy, subject to the requirements of s. 627.6561(6)
652 (11).
653 Section 19. Paragraphs (f) and (h) of subsection (1) of
654 section 641.185, Florida Statutes, are amended to read:
655 641.185 Health maintenance organization subscriber
656 protections.—
657 (1) With respect to the provisions of this part and part
658 III, the principles expressed in the following statements shall
659 serve as standards to be followed by the commission, the office,
660 the department, and the Agency for Health Care Administration in
661 exercising their powers and duties, in exercising administrative
662 discretion, in administrative interpretations of the law, in
663 enforcing its provisions, and in adopting rules:
664 (f) A health maintenance organization subscriber should
665 receive the flexibility to transfer to another Florida health
666 maintenance organization, regardless of health status, pursuant
667 to ss. 641.228, 641.3104, 641.3107, 641.3111, 641.3921, and
668 641.3922.
669 (h) A health maintenance organization that issues a group
670 health contract must: provide coverage for preexisting
671 conditions pursuant to s. 641.31071; guarantee renewability of
672 coverage pursuant to s. 641.31074,; provide notice of
673 cancellation pursuant to s. 641.3108,; provide extension of
674 benefits pursuant to s. 641.3111,; provide for conversion on
675 termination of eligibility pursuant to s. 641.3921,; and provide
676 for conversion contracts and conditions pursuant to s. 641.3922.
677 Section 20. Subsection (2) and paragraph (a) of subsection
678 (40) of section 641.31, Florida Statutes, are amended to read:
679 641.31 Health maintenance contracts.—
680 (2) The rates charged by any health maintenance
681 organization to its subscribers shall not be excessive,
682 inadequate, or unfairly discriminatory or follow a rating
683 methodology that is inconsistent, indeterminate, or ambiguous or
684 encourages misrepresentation or misunderstanding. A law
685 restricting or limiting deductibles, coinsurance, copayments, or
686 annual or lifetime maximum payments shall not apply to any
687 health maintenance organization contract that provides coverage
688 as described in s. 641.31071(5)(a)2., offered or delivered to an
689 individual or a group of 51 or more persons. The commission, in
690 accordance with generally accepted actuarial practice as applied
691 to health maintenance organizations, may define by rule what
692 constitutes excessive, inadequate, or unfairly discriminatory
693 rates and may require whatever information it deems necessary to
694 determine that a rate or proposed rate meets the requirements of
695 this subsection.
696 (40)(a) Any group rate, rating schedule, or rating manual
697 for a health maintenance organization policy, which provides
698 creditable coverage as defined in s. 627.6562(3) s. 627.6561(5),
699 filed with the office shall provide for an appropriate rebate of
700 premiums paid in the last policy year, contract year, or
701 calendar year when the majority of members of a health plan are
702 enrolled in and have maintained participation in any health
703 wellness, maintenance, or improvement program offered by the
704 group contract holder. The group must provide evidence of
705 demonstrative maintenance or improvement of his or her health
706 status as determined by assessments of agreed-upon health status
707 indicators between the group and the health insurer, including,
708 but not limited to, reduction in weight, body mass index, and
709 smoking cessation. Any rebate provided by the health maintenance
710 organization is presumed to be appropriate unless credible data
711 demonstrates otherwise, or unless the rebate program requires
712 the insured to incur costs to qualify for the rebate which
713 equals or exceeds the value of the rebate but the rebate may not
714 exceed 10 percent of paid premiums.
715 Section 21. Section 641.31071, Florida Statutes, is
716 repealed.
717 Section 22. Subsection (4) of section 641.3111, Florida
718 Statutes, is amended to read:
719 641.3111 Extension of benefits.—
720 (4) Except as provided in subsection (1), no subscriber is
721 entitled to an extension of benefits if the termination of the
722 contract by the health maintenance organization is based upon
723 any event referred to in s. 641.3922(7)(a), (b), or (e).
724 Section 23. Section 641.312, Florida Statutes, is amended
725 to read:
726 641.312 Scope.—The Office of Insurance Regulation may adopt
727 rules to administer the provisions of the National Association
728 of Insurance Commissioners’ Uniform Health Carrier External
729 Review Model Act, issued by the National Association of
730 Insurance Commissioners and dated April 2010. This section does
731 not apply to a health maintenance contract that is subject to
732 the Subscriber Assistance Program under s. 408.7056 or to the
733 types of benefits or coverages provided under s. 627.6513(1)
734 (14) s. 627.6561(5)(b)-(e) issued in any market.
735 Section 24. This act shall take effect July 1, 2016.
736
737 ================= T I T L E A M E N D M E N T ================
738 And the title is amended as follows:
739 Delete everything before the enacting clause
740 and insert:
741 A bill to be entitled
742 An act relating to health plan regulatory
743 administration; amending s. 408.909, F.S.; redefining
744 the term “health care coverage” or “health flex plan
745 coverage”; amending s. 409.817, F.S.; deleting a
746 provision authorizing group insurance plans to impose
747 a certain preexisting condition exclusion; amending s.
748 624.123, F.S.; conforming a cross-reference; amending
749 s. 627.402, F.S.; redefining the term
750 “nongrandfathered health plan”; amending s. 627.411,
751 F.S.; deleting a provision relating to a minimum loss
752 ratio standard for specified health insurance
753 coverage; deleting provisions specifying certain
754 incurred claims; amending s. 627.6011, F.S.,
755 conforming a cross-reference; amending s. 627.602,
756 F.S.; conforming a cross-reference; amending s.
757 627.642, F.S.; revising the policies to which certain
758 outline of coverage requirements apply; amending s.
759 627.6425, F.S.; redefining the term “individual health
760 insurance”; revising applicability; amending s.
761 627.6487, F.S.; redefining terms; repealing s.
762 627.64871, F.S., relating to certification of
763 coverage; amending s. 627.6512, F.S.; revising a
764 provision specifying that certain sections of the
765 Florida Insurance Code do not apply to a group health
766 insurance policy as that policy relates to specified
767 benefits, under certain circumstances; amending s.
768 627.6513, F.S.; excluding applicability as to certain
769 types of benefits or coverages; repealing s. 627.6561,
770 F.S., relating to preexisting conditions; amending s.
771 627.6562, F.S.; redefining the term “creditable
772 coverage”; providing exceptions and applicability;
773 amending s. 627.65626, F.S.; conforming a cross
774 reference; amending s. 627.6699, F.S.; redefining
775 terms; deleting a provision that requires a certain
776 health benefit plan to comply with specified
777 preexisting condition provisions; conforming
778 provisions to changes made by the act; amending s.
779 627.6741, F.S.; conforming cross-references;
780 conforming a provision to changes made by the act;
781 amending s. 641.185, F.S.; revising certain standards
782 to remove requirements for a health maintenance
783 organization to provide specified coverage for
784 preexisting conditions; conforming provisions to
785 changes made by the act; amending s. 641.31, F.S.;
786 deleting a provision specifying that a law restricting
787 or limiting deductibles, coinsurance, copayments, or
788 annual or lifetime maximum payments may not apply to a
789 certain health maintenance organization contract;
790 conforming a cross-reference; repealing s. 641.31071,
791 F.S., relating to preexisting conditions; amending s.
792 641.3111, F.S.; deleting a provision specifying that a
793 subscriber is not entitled to an extension of benefits
794 under certain circumstances after termination of a
795 group health maintenance contract; amending s.
796 641.312, F.S.; conforming a cross-reference; providing
797 an effective date.