Florida Senate - 2016 PROPOSED COMMITTEE SUBSTITUTE
Bill No. CS for SB 1170
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576-03408-16
Proposed Committee Substitute by the Committee on Appropriations
(Appropriations Subcommittee on Health and Human Services)
1 A bill to be entitled
2 An act relating to health plan regulatory
3 administration; amending s. 408.909, F.S.; redefining
4 the term “health care coverage” or “health flex plan
5 coverage”; amending s. 409.817, F.S.; deleting a
6 provision authorizing group insurance plans to impose
7 a certain preexisting condition exclusion; amending s.
8 624.123, F.S.; conforming a cross-reference; amending
9 s. 627.402, F.S.; redefining the term
10 “nongrandfathered health plan”; amending s. 627.411,
11 F.S.; deleting a provision relating to a minimum loss
12 ratio standard for specified health insurance
13 coverage; deleting provisions specifying certain
14 incurred claims; amending s. 627.6011, F.S.,
15 conforming a cross-reference; amending s. 627.602,
16 F.S.; conforming a cross-reference; amending s.
17 627.642, F.S.; revising the policies to which certain
18 outline of coverage requirements apply; amending s.
19 627.6425, F.S.; redefining the term “individual health
20 insurance”; revising applicability; amending s.
21 627.6487, F.S.; redefining terms; repealing s.
22 627.64871, F.S., relating to certification of
23 coverage; amending s. 627.6512, F.S.; revising a
24 provision specifying that certain sections of the
25 Florida Insurance Code do not apply to a group health
26 insurance policy as that policy relates to specified
27 benefits, under certain circumstances; amending s.
28 627.6513, F.S.; excluding applicability as to certain
29 types of benefits or coverages; amending s. 627.6561,
30 F.S.; conforming a cross-reference; revising
31 conditions under which an insurer may impose a
32 preexisting condition exclusion; deleting the
33 definition of the term “creditable coverage”; removing
34 certain requirements relating to creditable coverage
35 to conform to changes made by the act; amending s.
36 627.6562, F.S.; redefining the term “creditable
37 coverage”; providing exceptions and applicability;
38 amending s. 627.65626, F.S.; conforming a cross
39 reference; amending s. 627.6699, F.S.; redefining
40 terms; deleting a provision that requires a certain
41 health benefit plan to comply with specified
42 preexisting condition provisions; amending s.
43 627.6741, F.S.; conforming cross-references;
44 conforming a provision to changes made by the act;
45 amending s. 641.31, F.S.; deleting a provision
46 specifying that a law restricting or limiting
47 deductibles, coinsurance, copayments, or annual or
48 lifetime maximum payments may not apply to a certain
49 health maintenance organization contract; conforming a
50 cross-reference; amending s. 641.31071, F.S.;
51 conforming a cross-reference; deleting the definition
52 of the term “creditable coverage”; removing certain
53 requirements relating to creditable coverage to
54 conform to changes made by the act; amending s.
55 641.31074; requiring a health maintenance organization
56 that issues a health insurance contract, rather than a
57 group health insurance contract, to renew or continue
58 in force such coverage at the contract holder’s
59 option; revising conditions under which a health
60 maintenance organization may discontinue offering a
61 particular contract form; adding to the conditions
62 under which a health maintenance organization may, at
63 the time of coverage renewal, modify coverage for a
64 product offered; amending s. 641.312, F.S.; conforming
65 a cross-reference; providing an effective date.
66
67 Be It Enacted by the Legislature of the State of Florida:
68
69 Section 1. Paragraph (d) of subsection (2) of section
70 408.909, Florida Statutes, is amended to read:
71 408.909 Health flex plans.—
72 (2) DEFINITIONS.—As used in this section, the term:
73 (d) “Health care coverage” or “health flex plan coverage”
74 means health care services that are covered as benefits under an
75 approved health flex plan or that are otherwise provided, either
76 directly or through arrangements with other persons, via a
77 health flex plan on a prepaid per capita basis or on a prepaid
78 aggregate fixed-sum basis. The terms may also include one or
79 more of the excepted benefits under s. 627.6513(1)-(13) s.
80 627.6561(5)(b), the benefits under s. 627.6561(5)(c), if offered
81 separately, or the benefits under s. 627.6561(5)(d), if offered
82 as independent, noncoordinated benefits.
83 Section 2. Section 409.817, Florida Statutes, is amended to
84 read:
85 409.817 Approval of health benefits coverage; financial
86 assistance.—In order for health insurance coverage to qualify
87 for premium assistance payments for an eligible child under ss.
88 409.810-409.821, the health benefits coverage must:
89 (1) Be certified by the Office of Insurance Regulation of
90 the Financial Services Commission under s. 409.818 as meeting,
91 exceeding, or being actuarially equivalent to the benchmark
92 benefit plan;
93 (2) Be guarantee issued;
94 (3) Be community rated;
95 (4) Not impose any preexisting condition exclusion for
96 covered benefits; however, group health insurance plans may
97 permit the imposition of a preexisting condition exclusion, but
98 only insofar as it is permitted under s. 627.6561;
99 (5) Comply with the applicable limitations on premiums and
100 cost sharing in s. 409.816;
101 (6) Comply with the quality assurance and access standards
102 developed under s. 409.820; and
103 (7) Establish periodic open enrollment periods, which may
104 not occur more frequently than quarterly.
105 Section 3. Paragraph (b) of subsection (1) of section
106 624.123, Florida Statutes, is amended to read:
107 624.123 Certain international health insurance policies;
108 exemption from code.—
109 (1) International health insurance policies and
110 applications may be solicited and sold in this state at any
111 international airport to a resident of a foreign country. Such
112 international health insurance policies shall be solicited and
113 sold only by a licensed health insurance agent and underwritten
114 only by an admitted insurer. For purposes of this subsection:
115 (b) “International health insurance policy” means health
116 insurance, as provided defined in s. 627.6562(3)(a)2. s.
117 627.6561(5)(a)2., which is offered to an individual, covering
118 only a resident of a foreign country on an annual basis.
119 Section 4. Subsection (2) of section 627.402, Florida
120 Statutes, is amended to read:
121 627.402 Definitions.—As used in this part, the term:
122 (2) “Nongrandfathered health plan” is a health insurance
123 policy or health maintenance organization contract that is not a
124 grandfathered health plan and does not provide the benefits or
125 coverages specified under s. 627.6513(1)-(14) s. 627.6561(5)(b)
126 (e).
127 Section 5. Subsection (3) of section 627.411, Florida
128 Statutes, is amended to read:
129 627.411 Grounds for disapproval.—
130 (3)(a) For health insurance coverage as described in s.
131 627.6561(5)(a)2., the minimum loss ratio standard of incurred
132 claims to earned premium for the form shall be 65 percent.
133 (b) Incurred claims are claims occurring within a fixed
134 period, whether or not paid during the same period, under the
135 terms of the policy period.
136 1. Claims include scheduled benefit payments or services
137 provided by a provider or through a provider network for dental,
138 vision, disability, and similar health benefits.
139 2. Claims do not include state assessments, taxes, company
140 expenses, or any expense incurred by the company for the cost of
141 adjusting and settling a claim, including the review,
142 qualification, oversight, management, or monitoring of a claim
143 or incentives or compensation to providers for other than the
144 provisions of health care services.
145 3. A company may at its discretion include costs that are
146 demonstrated to reduce claims, such as fraud intervention
147 programs or case management costs, which are identified in each
148 filing, are demonstrated to reduce claims costs, and do not
149 result in increasing the experience period loss ratio by more
150 than 5 percent.
151 4. For scheduled claim payments, such as disability income
152 or long-term care, the incurred claims shall be the present
153 value of the benefit payments discounted for continuance and
154 interest.
155 Section 6. Section 627.6011, Florida Statutes, is amended
156 to read:
157 627.6011 Mandated coverages.—Mandatory health benefits
158 regulated under this chapter are not intended to apply to the
159 types of health benefit plans listed in s. 627.6513(1)-(14) s.
160 627.6561(5)(b)-(e), issued in any market, unless specifically
161 designated otherwise. For purposes of this section, the term
162 “mandatory health benefits” means those benefits set forth in
163 ss. 627.6401-627.64193, and any other mandatory treatment or
164 health coverages or benefits enacted on or after July 1, 2012.
165 Section 7. Paragraph (h) of subsection (1) of section
166 627.602, Florida Statutes, is amended to read:
167 627.602 Scope, format of policy.—
168 (1) Each health insurance policy delivered or issued for
169 delivery to any person in this state must comply with all
170 applicable provisions of this code and all of the following
171 requirements:
172 (h) Section 641.312 and the provisions of the Employee
173 Retirement Income Security Act of 1974, as implemented by 29
174 C.F.R. s. 2560.503-1, relating to internal grievances. This
175 paragraph does not apply to a health insurance policy that is
176 subject to the Subscriber Assistance Program under s. 408.7056
177 or to the types of benefits or coverages provided under s.
178 627.6513(1)-(14) s. 627.6561(5)(b)-(e) issued in any market.
179 Section 8. Subsection (1) of section 627.642, Florida
180 Statutes, is amended to read:
181 627.642 Outline of coverage.—
182 (1) A policy offering benefits defined in s. 627.6513(1)
183 (14) or a large group No individual or family accident and
184 health insurance policy may not shall be delivered, or issued
185 for delivery, in this state unless:
186 (a) It is accompanied by an appropriate outline of
187 coverage; or
188 (b) An appropriate outline of coverage is completed and
189 delivered to the applicant at the time application is made, and
190 an acknowledgment of receipt or certificate of delivery of such
191 outline is provided to the insurer with the application.
192
193 In the case of a direct response, such as a written application
194 to the insurance company from an applicant, the outline of
195 coverage shall accompany the policy when issued.
196 Section 9. Subsections (1), (6), and (7) of section
197 627.6425, Florida Statutes, are amended, to read:
198 627.6425 Renewability of individual coverage.—
199 (1) Except as otherwise provided in this section, an
200 insurer that provides individual health insurance coverage to an
201 individual shall renew or continue in force such coverage at the
202 option of the individual. For the purpose of this section, the
203 term “individual health insurance” means health insurance
204 coverage, as described in s. 624.603 s. 627.6561(5)(a)2.,
205 offered to an individual in this state, including certificates
206 of coverage offered to individuals in this state as part of a
207 group policy issued to an association outside this state, but
208 the term does not include short-term limited duration insurance
209 or excepted benefits specified in s. 627.6513(1)-(14) subsection
210 (6) or subsection (7).
211 (6) The requirements of this section do not apply to any
212 health insurance coverage in relation to its provision of
213 excepted benefits described in s. 627.6561(5)(b).
214 (7) The requirements of this section do not apply to any
215 health insurance coverage in relation to its provision of
216 excepted benefits described in s. 627.6561(5)(c), (d), or (e),
217 if the benefits are provided under a separate policy,
218 certificate, or contract of insurance.
219 Section 10. Paragraph (b) of subsection (2) and subsection
220 (3) of section 627.6487, Florida Statutes, are amended to read:
221 627.6487 Guaranteed availability of individual health
222 insurance coverage to eligible individuals.—
223 (2) For the purposes of this section:
224 (b) “Individual health insurance” means health insurance,
225 as defined in s. 624.603 s. 627.6561(5)(a)2., which is offered
226 to an individual, including certificates of coverage offered to
227 individuals in this state as part of a group policy issued to an
228 association outside this state, but the term does not include
229 short-term limited duration insurance or excepted benefits
230 specified in s. 627.6513(1)-(14) s. 627.6561(5)(b) or, if the
231 benefits are provided under a separate policy, certificate, or
232 contract, the term does not include excepted benefits specified
233 in s. 627.6561(5)(c), (d), or (e).
234 (3) For the purposes of this section, the term “eligible
235 individual” means an individual:
236 (a)1. For whom, as of the date on which the individual
237 seeks coverage under this section, the aggregate of the periods
238 of creditable coverage, as defined in s. 627.6562(3) s.
239 627.6561(5) and (6), is 18 or more months; and
240 2.a. Whose most recent prior creditable coverage was under
241 a group health plan, governmental plan, or church plan, or
242 health insurance coverage offered in connection with any such
243 plan; or
244 b. Whose most recent prior creditable coverage was under an
245 individual plan issued in this state by a health insurer or
246 health maintenance organization, which coverage is terminated
247 due to the insurer or health maintenance organization becoming
248 insolvent or discontinuing the offering of all individual
249 coverage in the State of Florida, or due to the insured no
250 longer living in the service area in the State of Florida of the
251 insurer or health maintenance organization that provides
252 coverage through a network plan in the State of Florida;
253 (b) Who is not eligible for coverage under:
254 1. A group health plan, as defined in s. 2791 of the Public
255 Health Service Act;
256 2. A conversion policy or contract issued by an authorized
257 insurer or health maintenance organization under s. 627.6675 or
258 s. 641.3921, respectively, offered to an individual who is no
259 longer eligible for coverage under either an insured or self
260 insured employer plan;
261 3. Part A or part B of Title XVIII of the Social Security
262 Act; or
263 4. A state plan under Title XIX of such act, or any
264 successor program, and does not have other health insurance
265 coverage;
266 (c) With respect to whom the most recent coverage within
267 the coverage period described in paragraph (a) was not
268 terminated based on a factor described in s. 627.6571(2)(a) or
269 (b), relating to nonpayment of premiums or fraud, unless such
270 nonpayment of premiums or fraud was due to acts of an employer
271 or person other than the individual;
272 (d) Who, having been offered the option of continuation
273 coverage under a COBRA continuation provision or under s.
274 627.6692, elected such coverage; and
275 (e) Who, if the individual elected such continuation
276 provision, has exhausted such continuation coverage under such
277 provision or program.
278 Section 11. Section 627.64871, Florida Statutes, is
279 repealed.
280 Section 12. Section 627.6512, Florida Statutes, is amended
281 to read:
282 627.6512 Exemption of certain group health insurance
283 policies.—Sections 627.6561, 627.65615, 627.65625, and 627.6571
284 do not apply to:
285 (1) any group insurance policy in relation to its provision
286 of excepted benefits described in s. 627.6513(1)-(14)
287 627.6561(5)(b).
288 (2) Any group health insurance policy in relation to its
289 provision of excepted benefits described in s. 627.6561(5)(c),
290 if the benefits:
291 (a) Are provided under a separate policy, certificate, or
292 contract of insurance; or
293 (b) Are otherwise not an integral part of the policy.
294 (3) Any group health insurance policy in relation to its
295 provision of excepted benefits described in s. 627.6561(5)(d),
296 if all of the following conditions are met:
297 (a) The benefits are provided under a separate policy,
298 certificate, or contract of insurance;
299 (b) There is no coordination between the provision of such
300 benefits and any exclusion of benefits under any group policy
301 maintained by the same policyholder; and
302 (c) Such benefits are paid with respect to an event without
303 regard to whether benefits are provided with respect to such an
304 event under any group health policy maintained by the same
305 policyholder.
306 (4) Any group health policy in relation to its provision of
307 excepted benefits described in s. 627.6561(5)(e), if the
308 benefits are provided under a separate policy, certificate, or
309 contract of insurance.
310 Section 13. Section 627.6513, Florida Statutes, is amended
311 to read:
312 627.6513 Scope.—Section 641.312 and the provisions of the
313 Employee Retirement Income Security Act of 1974, as implemented
314 by 29 C.F.R. s. 2560.503-1, relating to internal grievances,
315 apply to all group health insurance policies issued under this
316 part. This section does not apply to a group health insurance
317 policy that is subject to the Subscriber Assistance Program in
318 s. 408.7056 or to: the types of benefits or coverages provided
319 under s. 627.6561(5)(b)-(e) issued in any market.
320 (1) Coverage only for accident insurance, or disability
321 income insurance, or any combination thereof.
322 (2) Coverage issued as a supplement to liability insurance.
323 (3) Liability insurance, including general liability
324 insurance and automobile liability insurance.
325 (4) Workers’ compensation or similar insurance.
326 (5) Automobile medical payment insurance.
327 (6) Credit-only insurance.
328 (7) Coverage for onsite medical clinics, including prepaid
329 health clinics under part II of chapter 641.
330 (8) Other similar insurance coverage, specified in rules
331 adopted by the commission, under which benefits for medical care
332 are secondary or incidental to other insurance benefits. To the
333 extent possible, such rules must be consistent with regulations
334 adopted by the United States Department of Health and Human
335 Services.
336 (9) Limited scope dental or vision benefits, if offered
337 separately.
338 (10) Benefits for long-term care, nursing home care, home
339 health care, or community-based care, or any combination
340 thereof, if offered separately.
341 (11) Other similar, limited benefits, if offered
342 separately, as specified in rules adopted by the commission.
343 (12) Coverage only for a specified disease or illness, if
344 offered as independent, noncoordinated benefits.
345 (13) Hospital indemnity or other fixed indemnity insurance,
346 if offered as independent, noncoordinated benefits.
347 (14) Benefits provided through a Medicare supplemental
348 health insurance policy, as defined under s. 1882(g)(1) of the
349 Social Security Act, coverage supplemental to the coverage
350 provided under 10 U.S.C. chapter 55, and similar supplemental
351 coverage provided to coverage under a group health plan, which
352 are offered as a separate insurance policy and as independent,
353 noncoordinated benefits.
354 Section 14. Section 627.6561, Florida Statutes, is amended
355 to read:
356 627.6561 Preexisting conditions.—
357 (1) As used in this section, the term:
358 (a) “Enrollment date” means, with respect to an individual
359 covered under a group health policy, the date of enrollment of
360 the individual in the plan or coverage or, if earlier, the first
361 day of the waiting period of such enrollment.
362 (b) “Late enrollee” means, with respect to coverage under a
363 group health policy, a participant or beneficiary who enrolls
364 under the policy other than during:
365 1. The first period in which the individual is eligible to
366 enroll under the policy.
367 2. A special enrollment period, as provided under s.
368 627.65615.
369 (c) “Waiting period” means, with respect to a group health
370 policy and an individual who is a potential participant or
371 beneficiary of the policy, the period that must pass with
372 respect to the individual before the individual is eligible to
373 be covered for benefits under the terms of the policy.
374 (2) Subject to the exceptions specified in subsection (4),
375 an insurer that offers group health insurance coverage may, with
376 respect to a participant or beneficiary, impose a preexisting
377 condition exclusion only if:
378 (a) Such exclusion relates to a physical or mental
379 condition, regardless of the cause of the condition, for which
380 medical advice, diagnosis, care, or treatment was recommended or
381 received within the 6-month period ending on the enrollment
382 date;
383 (b) Such exclusion extends for a period of not more than 12
384 months, or 18 months in the case of a late enrollee, after the
385 enrollment date; and
386 (c) The period of any such preexisting condition exclusion
387 is reduced by the aggregate of the periods of creditable
388 coverage, as defined in s. 627.6562(3) subsection (5),
389 applicable to the participant or beneficiary as of the
390 enrollment date.
391 (3) Genetic information may not be treated as a condition
392 described in paragraph (2)(a) in the absence of a diagnosis of
393 the condition related to such information.
394 (4)(a) Subject to paragraph (b), an insurer that offers
395 group health insurance coverage may not impose any preexisting
396 condition exclusion in the case of:
397 1. An individual who, as of the last day of the 30-day
398 period beginning with the date of birth, is covered under
399 creditable coverage.
400 2. A child who is adopted or placed for adoption before
401 attaining 18 years of age and who, as of the last day of the 30
402 day period beginning on the date of the adoption or placement
403 for adoption, is covered under creditable coverage. This
404 provision does not apply to coverage before the date of such
405 adoption or placement for adoption.
406 3. Pregnancy.
407 (b) Subparagraphs 1. and 2. do not apply to an individual
408 after the end of the first 63-day period during all of which the
409 individual was not covered under any creditable coverage.
410 (5)(a) The term, “creditable coverage,” means, with respect
411 to an individual, coverage of the individual under any of the
412 following:
413 1. A group health plan, as defined in s. 2791 of the Public
414 Health Service Act.
415 2. Health insurance coverage consisting of medical care,
416 provided directly, through insurance or reimbursement, or
417 otherwise and including terms and services paid for as medical
418 care, under any hospital or medical service policy or
419 certificate, hospital or medical service plan contract, or
420 health maintenance contract offered by a health insurance
421 issuer.
422 3. Part A or part B of Title XVIII of the Social Security
423 Act.
424 4. Title XIX of the Social Security Act, other than
425 coverage consisting solely of benefits under s. 1928.
426 5. Chapter 55 of Title 10, United States Code.
427 6. A medical care program of the Indian Health Service or
428 of a tribal organization.
429 7. The Florida Comprehensive Health Association or another
430 state health benefit risk pool.
431 8. A health plan offered under chapter 89 of Title 5,
432 United States Code.
433 9. A public health plan as defined by rules adopted by the
434 commission. To the greatest extent possible, such rules must be
435 consistent with regulations adopted by the United States
436 Department of Health and Human Services.
437 10. A health benefit plan under s. 5(e) of the Peace Corps
438 Act (22 U.S.C. s. 2504(e)).
439 (b) Creditable coverage does not include coverage that
440 consists solely of one or more or any combination thereof of the
441 following excepted benefits:
442 1. Coverage only for accident, or disability income
443 insurance, or any combination thereof.
444 2. Coverage issued as a supplement to liability insurance.
445 3. Liability insurance, including general liability
446 insurance and automobile liability insurance.
447 4. Workers’ compensation or similar insurance.
448 5. Automobile medical payment insurance.
449 6. Credit-only insurance.
450 7. Coverage for onsite medical clinics, including prepaid
451 health clinics under part II of chapter 641.
452 8. Other similar insurance coverage, specified in rules
453 adopted by the commission, under which benefits for medical care
454 are secondary or incidental to other insurance benefits. To the
455 extent possible, such rules must be consistent with regulations
456 adopted by the United States Department of Health and Human
457 Services.
458 (c) The following benefits are not subject to the
459 creditable coverage requirements, if offered separately:
460 1. Limited scope dental or vision benefits.
461 2. Benefits for long-term care, nursing home care, home
462 health care, community-based care, or any combination thereof.
463 3. Such other similar, limited benefits as are specified in
464 rules adopted by the commission.
465 (d) The following benefits are not subject to creditable
466 coverage requirements if offered as independent, noncoordinated
467 benefits:
468 1. Coverage only for a specified disease or illness.
469 2. Hospital indemnity or other fixed indemnity insurance.
470 (e) Benefits provided through a Medicare supplemental
471 health insurance, as defined under s. 1882(g)(1) of the Social
472 Security Act, coverage supplemental to the coverage provided
473 under chapter 55 of Title 10, United States Code, and similar
474 supplemental coverage provided to coverage under a group health
475 plan are not considered creditable coverage if offered as a
476 separate insurance policy.
477 (6)(a) A period of creditable coverage may not be counted,
478 with respect to enrollment of an individual under a group health
479 plan, if, after such period and before the enrollment date,
480 there was a 63-day period during all of which the individual was
481 not covered under any creditable coverage.
482 (b) Any period during which an individual is in a waiting
483 period for any coverage under a group health plan or for group
484 health insurance coverage may not be taken into account in
485 determining the 63-day period under paragraph (a) or paragraph
486 (4)(b).
487 (7)(a) Except as otherwise provided under paragraph (b), an
488 insurer shall count a period of creditable coverage without
489 regard to the specific benefits covered under the period.
490 (b) An insurer may elect to count, as creditable coverage,
491 coverage of benefits within each of several classes or
492 categories of benefits specified in rules adopted by the
493 commission rather than as provided under paragraph (a). To the
494 extent possible, such rules must be consistent with regulations
495 adopted by the United States Department of Health and Human
496 Services. Such election shall be made on a uniform basis for all
497 participants and beneficiaries. Under such election, an insurer
498 shall count a period of creditable coverage with respect to any
499 class or category of benefits if any level of benefits is
500 covered within such class or category.
501 (c) In the case of an election with respect to an insurer
502 under paragraph (b), the insurer shall:
503 1. Prominently state in 10-point type or larger in any
504 disclosure statements concerning the policy, and state to each
505 certificateholder at the time of enrollment under the policy,
506 that the insurer has made such election; and
507 2. Include in such statements a description of the effect
508 of this election.
509 (8)(a) Periods of creditable coverage with respect to an
510 individual shall be established through presentation of
511 certifications described in this subsection or in such other
512 manner as is specified in rules adopted by the commission. To
513 the extent possible, such rules must be consistent with
514 regulations adopted by the United States Department of Health
515 and Human Services.
516 (b) An insurer that offers group health insurance coverage
517 shall provide the certification described in paragraph (a):
518 1. At the time an individual ceases to be covered under the
519 plan or otherwise becomes covered under a COBRA continuation
520 provision or continuation pursuant to s. 627.6692.
521 2. In the case of an individual becoming covered under a
522 COBRA continuation provision or pursuant to s. 627.6692, at the
523 time the individual ceases to be covered under such a provision.
524 3. Upon the request on behalf of an individual made not
525 later than 24 months after the date of cessation of the coverage
526 described in this paragraph.
527
528 The certification under subparagraph 1. may be provided, to the
529 extent practicable, at a time consistent with notices required
530 under any applicable COBRA continuation provision or
531 continuation pursuant to s. 627.6692.
532 (c) The certification described in this section is a
533 written certification that must include:
534 1. The period of creditable coverage of the individual
535 under the policy and the coverage, if any, under such COBRA
536 continuation provision or continuation pursuant to s. 627.6692;
537 and
538 2. The waiting period, if any, imposed with respect to the
539 individual for any coverage under such policy.
540 (d) In the case of an election described in subsection (7)
541 by an insurer, if the insurer enrolls an individual for coverage
542 under the plan and the individual provides a certification of
543 coverage of the individual, as provided in this subsection:
544 1. Upon request of such insurer, the insurer that issued
545 the certification provided by the individual shall promptly
546 disclose to such requesting plan or insurer information on
547 coverage of classes and categories of health benefits available
548 under such insurer’s plan or coverage.
549 2. Such insurer may charge the requesting insurer for the
550 reasonable cost of disclosing such information.
551 (e) The commission shall adopt rules to prevent an
552 insurer’s failure to provide information under this subsection
553 with respect to previous coverage of an individual from
554 adversely affecting any subsequent coverage of the individual
555 under another group health plan or health insurance coverage. To
556 the greatest extent possible, such rules must be consistent with
557 regulations adopted by the United States Department of Health
558 and Human Services.
559 (9)(a) Except as provided in paragraph (b), no period
560 before July 1, 1996, shall be taken into account in determining
561 creditable coverage.
562 (b) The commission shall adopt rules that provide a process
563 whereby individuals who need to establish creditable coverage
564 for periods before July 1, 1996, and who would have such
565 coverage credited but for paragraph (a), may be given credit for
566 creditable coverage for such periods through the presentation of
567 documents or other means. To the greatest extent possible, such
568 rules must be consistent with regulations adopted by the United
569 States Department of Health and Human Services.
570 (10) Except as otherwise provided in this subsection,
571 paragraph (8)(b) applies to events that occur on or after July
572 1, 1996.
573 (a) In no case is a certification required to be provided
574 under paragraph (8)(b) prior to June 1, 1997.
575 (b) In the case of an event that occurred on or after July
576 1, 1996, and before October 1, 1996, a certification is not
577 required to be provided under paragraph (8)(b), unless an
578 individual, with respect to whom the certification is required
579 to be made, requests such certification in writing.
580 (11) In the case of an individual who seeks to establish
581 creditable coverage for any period for which certification is
582 not required because it relates to an event that occurred before
583 July 1, 1996:
584 (a) The individual may present other creditable coverage in
585 order to establish the period of creditable coverage.
586 (b) An insurer is not subject to any penalty or enforcement
587 action with respect to the insurer’s crediting, or not
588 crediting, such coverage if the insurer has sought to comply in
589 good faith with applicable provisions of this section.
590 (12) For purposes of subsection (9), any plan amendment
591 made pursuant to a collective bargaining agreement relating to
592 the plan which amends the plan solely to conform to any
593 requirement of this section may not be treated as a termination
594 of such collective bargaining agreement.
595 (13) This section does not apply to any health insurance
596 coverage in relation to its provision of excepted benefits
597 described in paragraph (5)(b).
598 (14) This section does not apply to any health insurance
599 coverage in relation to its provision of excepted benefits
600 described in paragraphs (5)(c), (d), or (e), if the benefits are
601 provided under a separate policy, certificate, or contract of
602 insurance.
603 (15) This section applies to health insurance coverage
604 offered, sold, issued, renewed, or in effect on or after July 1,
605 1997.
606 Section 15. Subsection (3) of section 627.6562, Florida
607 Statutes, is amended to read:
608 627.6562 Dependent coverage.—
609 (3) If, pursuant to subsection (2), a child is provided
610 coverage under the parent’s policy after the end of the calendar
611 year in which the child reaches age 25 and coverage for the
612 child is subsequently terminated, the child is not eligible to
613 be covered under the parent’s policy unless the child was
614 continuously covered by other creditable coverage without a gap
615 in coverage of more than 63 days.
616 (a) For the purposes of this subsection, the term
617 “creditable coverage” means, with respect to an individual,
618 coverage of the individual under any of the following: has the
619 same meaning as provided in s. 627.6561(5).
620 1. A group health plan, as defined in s. 2791 of the Public
621 Health Service Act.
622 2. Health insurance coverage consisting of medical care
623 provided directly through insurance or reimbursement or
624 otherwise, and including terms and services paid for as medical
625 care, under any hospital or medical service policy or
626 certificate, hospital or medical service plan contract, or
627 health maintenance contract offered by a health insurance
628 issuer.
629 3. Part A or part B of Title XVIII of the Social Security
630 Act.
631 4. Title XIX of the Social Security Act, other than
632 coverage consisting solely of benefits under s. 1928.
633 5. Title 10 U.S.C. chapter 55.
634 6. A medical care program of the Indian Health Service or
635 of a tribal organization.
636 7. The Florida Comprehensive Health Association or another
637 state health benefit risk pool.
638 8. A health plan offered under 5 U.S.C. chapter 89.
639 9. A public health plan as defined by rules adopted by the
640 commission. To the greatest extent possible, such rules must be
641 consistent with regulations adopted by the United States
642 Department of Health and Human Services.
643 10. A health benefit plan under s. 5(e) of the Peace Corps
644 Act, 22 U.S.C. s. 2504(e).
645 (b) Creditable coverage does not include coverage that
646 consists of one or more, or any combination thereof, of the
647 following excepted benefits:
648 1. Coverage only for accident insurance, or disability
649 income insurance, or any combination thereof.
650 2. Coverage issued as a supplement to liability insurance.
651 3. Liability insurance, including general liability
652 insurance and automobile liability insurance.
653 4. Workers’ compensation or similar insurance.
654 5. Automobile medical payment insurance.
655 6. Credit-only insurance.
656 7. Coverage for onsite medical clinics, including prepaid
657 health clinics under part II of chapter 641.
658 8. Other similar insurance coverage specified in rules
659 adopted by the commission under which benefits for medical care
660 are secondary or incidental to other insurance benefits. To the
661 extent possible, such rules must be consistent with regulations
662 adopted by the United States Department of Health and Human
663 Services.
664 (c) The following benefits are not subject to the
665 creditable coverage requirements, if offered separately:
666 1. Limited scope dental or vision benefits.
667 2. Benefits for long-term care, nursing home care, home
668 health care, community-based care, or any combination thereof.
669 3. Other similar, limited benefits specified in rules
670 adopted by the commission.
671 (d) The following benefits are not subject to creditable
672 coverage requirements if offered as independent, noncoordinated
673 benefits:
674 1. Coverage only for a specified disease or illness.
675 2. Hospital indemnity or other fixed indemnity insurance.
676 (e) Benefits provided through a Medicare supplemental
677 health insurance policy, as defined under s. 1882(g)(1) of the
678 Social Security Act, coverage supplemental to the coverage
679 provided under 10 U.S.C. chapter 55, and similar supplemental
680 coverage provided to coverage under a group health plan are not
681 considered creditable coverage if offered as a separate
682 insurance policy.
683 Section 16. Subsection (1) of section 627.65626, Florida
684 Statutes, is amended to read:
685 627.65626 Insurance rebates for healthy lifestyles.—
686 (1) Any rate, rating schedule, or rating manual for a
687 health insurance policy that provides creditable coverage as
688 defined in s. 627.6562(3) 627.6561(5) filed with the office
689 shall provide for an appropriate rebate of premiums paid in the
690 last policy year, contract year, or calendar year when the
691 majority of members of a health plan have enrolled and
692 maintained participation in any health wellness, maintenance, or
693 improvement program offered by the group policyholder and health
694 plan. The rebate may be based upon premiums paid in the last
695 calendar year or policy year. The group must provide evidence of
696 demonstrative maintenance or improvement of the enrollees’
697 health status as determined by assessments of agreed-upon health
698 status indicators between the policyholder and the health
699 insurer, including, but not limited to, reduction in weight,
700 body mass index, and smoking cessation. The group or health
701 insurer may contract with a third-party administrator to
702 assemble and report the health status required in this
703 subsection between the policyholder and the health insurer. Any
704 rebate provided by the health insurer is presumed to be
705 appropriate unless credible data demonstrates otherwise, or
706 unless the rebate program requires the insured to incur costs to
707 qualify for the rebate which equal or exceed the value of the
708 rebate, but the rebate may not exceed 10 percent of paid
709 premiums.
710 Section 17. Paragraphs (e) and (l) of subsection (3) and
711 paragraph (d) of subsection (5) of section 627.6699, Florida
712 Statutes, are amended to read:
713 627.6699 Employee Health Care Access Act.—
714 (3) DEFINITIONS.—As used in this section, the term:
715 (e) “Creditable coverage” has the same meaning as provided
716 ascribed in s. 627.6562(3) 627.6561.
717 (l) “Late enrollee” means an eligible employee or dependent
718 who, with respect to coverage under a group health policy, is a
719 participant or beneficiary who enrolls under the policy other
720 than during:
721 1. The first period in which the individual is eligible to
722 enroll under the policy.
723 2. A special enrollment period, as provided under s.
724 627.65615 as defined under s. 627.6561(1)(b).
725 (5) AVAILABILITY OF COVERAGE.—
726 (d) A health benefit plan covering small employers, issued
727 or renewed on or after January 1, 1994, must comply with the
728 following conditions:
729 1. All health benefit plans must be offered and issued on a
730 guaranteed-issue basis. Additional or increased benefits may
731 only be offered by riders.
732 2. Paragraph (c) applies to health benefit plans issued to
733 a small employer who has two or more eligible employees and to
734 health benefit plans that are issued to a small employer who has
735 fewer than two eligible employees and that cover an employee who
736 has had creditable coverage continually to a date not more than
737 63 days before the effective date of the new coverage.
738 2.3. For health benefit plans that are issued to a small
739 employer who has fewer than two employees and that cover an
740 employee who has not been continually covered by creditable
741 coverage within 63 days before the effective date of the new
742 coverage, preexisting condition provisions must not exclude
743 coverage for a period beyond 24 months following the employee’s
744 effective date of coverage and may relate only to:
745 a. Conditions that, during the 24-month period immediately
746 preceding the effective date of coverage, had manifested
747 themselves in such a manner as would cause an ordinarily prudent
748 person to seek medical advice, diagnosis, care, or treatment or
749 for which medical advice, diagnosis, care, or treatment was
750 recommended or received; or
751 b. A pregnancy existing on the effective date of coverage.
752 Section 18. Subsection (1) and paragraph (c) of subsection
753 (2) of section 627.6741, Florida Statutes, are amended to read:
754 627.6741 Issuance, cancellation, nonrenewal, and
755 replacement.—
756 (1)(a) An insurer issuing Medicare supplement policies in
757 this state shall offer the opportunity of enrolling in a
758 Medicare supplement policy, without conditioning the issuance or
759 effectiveness of the policy on, and without discriminating in
760 the price of the policy based on, the medical or health status
761 or receipt of health care by the individual:
762 1. To any individual who is 65 years of age or older, or
763 under 65 years of age and eligible for Medicare by reason of
764 disability or end-stage renal disease, and who resides in this
765 state, upon the request of the individual during the 6-month
766 period beginning with the first month in which the individual
767 has attained 65 years of age and is enrolled in Medicare Part B,
768 or is eligible for Medicare by reason of a disability or end
769 stage renal disease, and is enrolled in Medicare Part B; or
770 2. To any individual who is 65 years of age or older, or
771 under 65 years of age and eligible for Medicare by reason of a
772 disability or end-stage renal disease, who is enrolled in
773 Medicare Part B, and who resides in this state, upon the request
774 of the individual during the 2-month period following
775 termination of coverage under a group health insurance policy.
776 (b) The 6-month period to enroll in a Medicare supplement
777 policy for an individual who is under 65 years of age and is
778 eligible for Medicare by reason of disability or end-stage renal
779 disease and otherwise eligible under subparagraph (a)1. or
780 subparagraph (a)2. and first enrolled in Medicare Part B before
781 October 1, 2009, begins on October 1, 2009.
782 (c) A company that has offered Medicare supplement policies
783 to individuals under 65 years of age who are eligible for
784 Medicare by reason of disability or end-stage renal disease
785 before October 1, 2009, may, for one time only, effect a rate
786 schedule change that redefines the age bands of the premium
787 classes without activating the period of discontinuance required
788 by s. 627.410(6)(e)2.
789 (d) As a part of an insurer’s rate filings, before and
790 including the insurer’s first rate filing for a block of policy
791 forms in 2015, notwithstanding the provisions of s.
792 627.410(6)(e)3., an insurer shall consider the experience of the
793 policies or certificates for the premium classes including
794 individuals under 65 years of age and eligible for Medicare by
795 reason of disability or end-stage renal disease separately from
796 the balance of the block so as not to affect the other premium
797 classes. For filings in such time period only, credibility of
798 that experience shall be as follows: if a block of policy forms
799 has 1,250 or more policies or certificates in force in the age
800 band including ages under 65 years of age, full or 100-percent
801 credibility shall be given to the experience; and if fewer than
802 250 policies or certificates are in force, no or zero-percent
803 credibility shall be given. Linear interpolation shall be used
804 for in-force amounts between the low and high values. Florida
805 only experience shall be used if it is 100-percent credible. If
806 Florida-only experience is not 100-percent credible, a
807 combination of Florida-only and nationwide experience shall be
808 used. If Florida-only experience is zero-percent credible,
809 nationwide experience shall be used. The insurer may file its
810 initial rates and any rate adjustment based upon the experience
811 of these policies or certificates or based upon expected claim
812 experience using experience data of the same company, other
813 companies in the same or other states, or using data publicly
814 available from the Centers for Medicaid and Medicare Services if
815 the insurer’s combined Florida and nationwide experience is not
816 100-percent credible, separate from the balance of all other
817 Medicare supplement policies.
818
819 A Medicare supplement policy issued to an individual under
820 subparagraph (a)1. or subparagraph (a)2. may not exclude
821 benefits based on a preexisting condition if the individual has
822 a continuous period of creditable coverage, as defined in s.
823 627.6562(3) 627.6561(5), of at least 6 months as of the date of
824 application for coverage.
825 (2) For both individual and group Medicare supplement
826 policies:
827 (c) If a Medicare supplement policy or certificate replaces
828 another Medicare supplement policy or certificate or creditable
829 coverage as defined in s. 627.6562(3) 627.6561(5), the replacing
830 insurer shall waive any time periods applicable to preexisting
831 conditions, waiting periods, elimination periods, and
832 probationary periods in the new Medicare supplement policy for
833 similar benefits to the extent such time was spent under the
834 original policy, subject to the requirements of s. 627.6561(6)
835 (11).
836 Section 19. Subsection (2) and paragraph (a) of subsection
837 (40) of section 641.31, Florida Statutes, are amended to read:
838 641.31 Health maintenance contracts.—
839 (2) The rates charged by any health maintenance
840 organization to its subscribers shall not be excessive,
841 inadequate, or unfairly discriminatory or follow a rating
842 methodology that is inconsistent, indeterminate, or ambiguous or
843 encourages misrepresentation or misunderstanding. A law
844 restricting or limiting deductibles, coinsurance, copayments, or
845 annual or lifetime maximum payments shall not apply to any
846 health maintenance organization contract that provides coverage
847 as described in s. 641.31071(5)(a)2., offered or delivered to an
848 individual or a group of 51 or more persons. The commission, in
849 accordance with generally accepted actuarial practice as applied
850 to health maintenance organizations, may define by rule what
851 constitutes excessive, inadequate, or unfairly discriminatory
852 rates and may require whatever information it deems necessary to
853 determine that a rate or proposed rate meets the requirements of
854 this subsection.
855 (40)(a) Any group rate, rating schedule, or rating manual
856 for a health maintenance organization policy, which provides
857 creditable coverage as defined in s. 627.6562(3) 627.6561(5),
858 filed with the office shall provide for an appropriate rebate of
859 premiums paid in the last policy year, contract year, or
860 calendar year when the majority of members of a health plan are
861 enrolled in and have maintained participation in any health
862 wellness, maintenance, or improvement program offered by the
863 group contract holder. The group must provide evidence of
864 demonstrative maintenance or improvement of his or her health
865 status as determined by assessments of agreed-upon health status
866 indicators between the group and the health insurer, including,
867 but not limited to, reduction in weight, body mass index, and
868 smoking cessation. Any rebate provided by the health maintenance
869 organization is presumed to be appropriate unless credible data
870 demonstrates otherwise, or unless the rebate program requires
871 the insured to incur costs to qualify for the rebate which
872 equals or exceeds the value of the rebate but the rebate may not
873 exceed 10 percent of paid premiums.
874 Section 20. Section 641.31071, Florida Statutes, is amended
875 to read:
876 641.31071 Preexisting conditions.—
877 (1) As used in this section, the term:
878 (a) “Enrollment date” means, with respect to an individual
879 covered under a group health maintenance organization contract,
880 the date of enrollment of the individual in the plan or coverage
881 or, if earlier, the first day of the waiting period of such
882 enrollment.
883 (b) “Late enrollee” means, with respect to coverage under a
884 group health maintenance organization contract, a participant or
885 beneficiary who enrolls under the contract other than during:
886 1. The first period in which the individual is eligible to
887 enroll under the plan.
888 2. A special enrollment period, as provided under s.
889 641.31072.
890 (c) “Waiting period” means, with respect to a group health
891 maintenance organization contract and an individual who is a
892 potential participant or beneficiary under the contract, the
893 period that must pass with respect to the individual before the
894 individual is eligible to be covered for benefits under the
895 terms of the contract.
896 (2) Subject to the exceptions specified in subsection (4),
897 a health maintenance organization that offers group coverage,
898 may, with respect to a participant or beneficiary, impose a
899 preexisting condition exclusion only if:
900 (a) Such exclusion relates to a physical or mental
901 condition, regardless of the cause of the condition, for which
902 medical advice, diagnosis, care, or treatment was recommended or
903 received within the 6-month period ending on the enrollment
904 date;
905 (b) Such exclusion extends for a period of not more than 12
906 months, or 18 months in the case of a late enrollee, after the
907 enrollment date; and
908 (c) The period of any such preexisting condition exclusion
909 is reduced by the aggregate of the periods of creditable
910 coverage, as defined in s. 627.6562(3) subsection (5),
911 applicable to the participant or beneficiary as of the
912 enrollment date.
913 (3) Genetic information shall not be treated as a condition
914 described in paragraph (2)(a) in the absence of a diagnosis of
915 the condition related to such information.
916 (4)(a) Subject to paragraph (b), a health maintenance
917 organization that offers group coverage may not impose any
918 preexisting condition exclusion in the case of:
919 1. An individual who, as of the last day of the 30-day
920 period beginning with the date of birth, is covered under
921 creditable coverage.
922 2. A child who is adopted or placed for adoption before
923 attaining 18 years of age and who, as of the last day of the 30
924 day period beginning on the date of the adoption or placement
925 for adoption, is covered under creditable coverage. This
926 provision shall not apply to coverage before the date of such
927 adoption or placement for adoption.
928 3. Pregnancy.
929 (b) Subparagraphs (a)1. and 2. do not apply to an
930 individual after the end of the first 63-day period during all
931 of which the individual was not covered under any creditable
932 coverage.
933 (5)(a) The term “creditable coverage” means, with respect
934 to an individual, coverage of the individual under any of the
935 following:
936 1. A group health plan, as defined in s. 2791 of the Public
937 Health Service Act.
938 2. Health insurance coverage consisting of medical care,
939 provided directly, through insurance or reimbursement or
940 otherwise, and including terms and services paid for as medical
941 care, under any hospital or medical service policy or
942 certificate, hospital or medical service plan contract, or
943 health maintenance contract offered by a health insurance
944 issuer.
945 3. Part A or part B of Title XVIII of the Social Security
946 Act.
947 4. Title XIX of the Social Security Act, other than
948 coverage consisting solely of benefits under s. 1928.
949 5. Chapter 55 of Title 10, United States Code.
950 6. A medical care program of the Indian Health Service or
951 of a tribal organization.
952 7. The Florida Comprehensive Health Association or another
953 state health benefit risk pool.
954 8. A health plan offered under chapter 89 of Title 5,
955 United States Code.
956 9. A public health plan as defined by rule of the
957 commission. To the greatest extent possible, such rules must be
958 consistent with regulations adopted by the United States
959 Department of Health and Human Services.
960 10. A health benefit plan under s. 5(e) of the Peace Corps
961 Act (22 U.S.C. s. 2504(e)).
962 (b) Creditable coverage does not include coverage that
963 consists solely of one or more or any combination thereof of the
964 following excepted benefits:
965 1. Coverage only for accident, or disability income
966 insurance, or any combination thereof.
967 2. Coverage issued as a supplement to liability insurance.
968 3. Liability insurance, including general liability
969 insurance and automobile liability insurance.
970 4. Workers’ compensation or similar insurance.
971 5. Automobile medical payment insurance.
972 6. Credit-only insurance.
973 7. Coverage for onsite medical clinics.
974 8. Other similar insurance coverage, specified in rules
975 adopted by the commission, under which benefits for medical care
976 are secondary or incidental to other insurance benefits. To the
977 greatest extent possible, such rules must be consistent with
978 regulations adopted by the United States Department of Health
979 and Human Services.
980 (c) The following benefits are not subject to the
981 creditable coverage requirements, if offered separately;
982 1. Limited scope dental or vision benefits.
983 2. Benefits or long-term care, nursing home care, home
984 health care, community-based care, or any combination of these.
985 3. Such other similar, limited benefits as are specified in
986 rules adopted by the commission. To the greatest extent
987 possible, such rules must be consistent with regulations adopted
988 by the United States Department of Health and Human Services.
989 (d) The following benefits are not subject to creditable
990 coverage requirements if offered as independent, noncoordinated
991 benefits:
992 1. Coverage only for a specified disease or illness.
993 2. Hospital indemnity or other fixed indemnity insurance.
994 (e) Benefits provided through Medicare supplemental health
995 insurance, as defined under s. 1882(g)(1) of the Social Security
996 Act, coverage supplemental to the coverage provided under
997 chapter 55 of Title 10, United States Code, and similar
998 supplemental coverage provided to coverage under a group health
999 plan are not considered creditable coverage if offered as a
1000 separate insurance policy.
1001 (6)(a) A period of creditable coverage may not be counted,
1002 with respect to enrollment of an individual under a group health
1003 maintenance organization contract, if, after such period and
1004 before the enrollment date, there was a 63-day period during all
1005 of which the individual was not covered under any creditable
1006 coverage.
1007 (b) Any period during which an individual is in a waiting
1008 period, or in an affiliation period as defined in subsection
1009 (9), for any coverage under a group health maintenance
1010 organization contract may not be taken into account in
1011 determining the 63-day period under paragraph (a) or paragraph
1012 (4)(b).
1013 (7)(a) Except as otherwise provided under paragraph (b), a
1014 health maintenance organization shall count a period of
1015 creditable coverage without regard to the specific benefits
1016 covered under the period.
1017 (b) A health maintenance organization may elect to count as
1018 creditable coverage, coverage of benefits within each of several
1019 classes or categories of benefits specified in rules adopted by
1020 the commission rather than as provided under paragraph (a). Such
1021 election shall be made on a uniform basis for all participants
1022 and beneficiaries. Under such election, a health maintenance
1023 organization shall count a period of creditable coverage with
1024 respect to any class or category of benefits if any level of
1025 benefits is covered within such class or category.
1026 (c) In the case of an election with respect to a health
1027 maintenance organization under paragraph (b), the organization
1028 shall:
1029 1. Prominently state in 10-point type or larger in any
1030 disclosure statements concerning the contract, and state to each
1031 enrollee at the time of enrollment under the contract, that the
1032 organization has made such election; and
1033 2. Include in such statements a description of the effect
1034 of this election.
1035 (8)(a) Periods of creditable coverage with respect to an
1036 individual shall be established through presentation of
1037 certifications described in this subsection or in such other
1038 manner as may be specified in rules adopted by the commission.
1039 (b) A health maintenance organization that offers group
1040 coverage shall provide the certification described in paragraph
1041 (a):
1042 1. At the time an individual ceases to be covered under the
1043 plan or otherwise becomes covered under a COBRA continuation
1044 provision or continuation pursuant to s. 627.6692.
1045 2. In the case of an individual becoming covered under a
1046 COBRA continuation provision or pursuant to s. 627.6692, at the
1047 time the individual ceases to be covered under such a provision.
1048 3. Upon the request on behalf of an individual made not
1049 later than 24 months after the date of cessation of the coverage
1050 described in this paragraph.
1051
1052 The certification under subparagraph 1. may be provided, to the
1053 extent practicable, at a time consistent with notices required
1054 under any applicable COBRA continuation provision or
1055 continuation pursuant to s. 627.6692.
1056 (c) The certification is a written certification of:
1057 1. The period of creditable coverage of the individual
1058 under the contract and the coverage, if any, under such COBRA
1059 continuation provision or continuation pursuant to s. 627.6692;
1060 and
1061 2. The waiting period, if any, imposed with respect to the
1062 individual for any coverage under such contract.
1063 (d) In the case of an election described in subsection (7)
1064 by a health maintenance organization, if the organization
1065 enrolls an individual for coverage under the plan and the
1066 individual provides a certification of coverage of the
1067 individual, as provided by this subsection:
1068 1. Upon request of such health maintenance organization,
1069 the insurer or health maintenance organization that issued the
1070 certification provided by the individual shall promptly disclose
1071 to such requesting organization information on coverage of
1072 classes and categories of health benefits available under such
1073 insurer’s or health maintenance organization’s plan or coverage.
1074 2. Such insurer or health maintenance organization may
1075 charge the requesting organization for the reasonable cost of
1076 disclosing such information.
1077 (e) The commission shall adopt rules to prevent an
1078 insurer’s or health maintenance organization’s failure to
1079 provide information under this subsection with respect to
1080 previous coverage of an individual from adversely affecting any
1081 subsequent coverage of the individual under another group health
1082 plan or health maintenance organization coverage.
1083 (9)(a) A health maintenance organization may provide for an
1084 affiliation period with respect to coverage through the
1085 organization only if:
1086 1. No preexisting condition exclusion is imposed with
1087 respect to coverage through the organization;
1088 2. The period is applied uniformly without regard to any
1089 health-status-related factors; and
1090 3. Such period does not exceed 2 months or 3 months in the
1091 case of a late enrollee.
1092 (b) For the purposes of this section, the term “affiliation
1093 period” means a period that, under the terms of the coverage
1094 offered by the health maintenance organization, must expire
1095 before the coverage becomes effective. The organization is not
1096 required to provide health care services or benefits during such
1097 period, and no premium may be charged to the participant or
1098 beneficiary for any coverage during the period. Such period
1099 begins on the enrollment date and runs concurrently with any
1100 waiting period under the plan.
1101 (c) As an alternative to the method authorized by paragraph
1102 (a), a health maintenance organization may address adverse
1103 selection in a method approved by the office.
1104 (10)(a) Except as provided in paragraph (b), no period
1105 before July 1, 1996, shall be taken into account in determining
1106 creditable coverage.
1107 (b) The commission shall adopt rules that provide a process
1108 whereby individuals who need to establish creditable coverage
1109 for periods before July 1, 1996, and who would have such
1110 coverage credited but for paragraph (a), may be given credit for
1111 creditable coverage for such periods through the presentation of
1112 documents or other means.
1113 (11) Except as otherwise provided in this subsection, the
1114 requirements of paragraph (8)(b) shall apply to events that
1115 occur on or after July 1, 1996.
1116 (a) In no case is a certification required to be provided
1117 under paragraph (8)(b) prior to June 1, 1997.
1118 (b) In the case of an event that occurs on or after July 1,
1119 1996, and before October 1, 1996, a certification is not
1120 required to be provided under paragraph (8)(b), unless an
1121 individual, with respect to whom the certification is required
1122 to be made, requests such certification in writing.
1123 (12) In the case of an individual who seeks to establish
1124 creditable coverage for any period for which certification is
1125 not required because it relates to an event occurring before
1126 July 1, 1996:
1127 (a) The individual may present other creditable coverage in
1128 order to establish the period of creditable coverage.
1129 (b) A health maintenance organization is not subject to any
1130 penalty or enforcement action with respect to the organization’s
1131 crediting, or not crediting, such coverage if the organization
1132 has sought to comply in good faith with applicable provisions of
1133 this section.
1134 (13) For purposes of subsection (10), any plan amendment
1135 made pursuant to a collective bargaining agreement relating to
1136 the plan which amends the plan solely to conform to any
1137 requirement of this section may not be treated as a termination
1138 of such collective bargaining agreement.
1139 Section 21. Subsections (1), (3), and (4) of section
1140 641.31074, Florida Statutes, are amended to read:
1141 641.31074 Guaranteed renewability of coverage.—
1142 (1) Except as otherwise provided in this section, a health
1143 maintenance organization that issues a group health insurance
1144 contract must renew or continue in force such coverage at the
1145 option of the contract holder.
1146 (3)(a) A health maintenance organization may discontinue
1147 offering a particular contract form for group coverage offered
1148 in the small group market or large group market only if:
1149 1. The health maintenance organization provides notice to
1150 each contract holder provided coverage of this form in such
1151 market, and participants and beneficiaries covered under such
1152 coverage, of such discontinuation at least 90 days prior to the
1153 date of the nonrenewal of such coverage;
1154 2. The health maintenance organization offers to each
1155 contract holder provided coverage of this form in such market
1156 the option to purchase all, or in the case of the large group
1157 market, any other health insurance coverage currently being
1158 offered by the health maintenance organization in such market;
1159 and
1160 3. In exercising the option to discontinue coverage of this
1161 form and in offering the option of coverage under subparagraph
1162 2., the health maintenance organization acts uniformly without
1163 regard to the claims experience of those contract holders or any
1164 health-status-related factor that relates to any participants or
1165 beneficiaries covered or new participants or beneficiaries who
1166 may become eligible for such coverage.
1167 (b)1. In any case in which a health maintenance
1168 organization elects to discontinue offering all coverage in the
1169 individual market, the small group market, or the large group
1170 market, or any combination thereof both, in this state, coverage
1171 may be discontinued by the insurer only if:
1172 a. The health maintenance organization provides notice to
1173 the office and to each contract holder, and participants and
1174 beneficiaries covered under such coverage, of such
1175 discontinuation at least 180 days prior to the date of the
1176 nonrenewal of such coverage; and
1177 b. All health insurance issued or delivered for issuance in
1178 this state in such market is discontinued and coverage under
1179 such health insurance coverage in such market is not renewed.
1180 2. In the case of a discontinuation under subparagraph 1.
1181 in a market, the health maintenance organization may not provide
1182 for the issuance of any health maintenance organization contract
1183 coverage in the market in this state during the 5-year period
1184 beginning on the date of the discontinuation of the last
1185 insurance contract not renewed.
1186 (4) At the time of coverage renewal, a health maintenance
1187 organization may modify the coverage for a product offered:
1188 (a) In the large group market; or
1189 (b) In the small group market if, for coverage that is
1190 available in such market other than only through one or more
1191 bona fide associations, as defined in s. 627.6571(5), such
1192 modification is consistent with s. 627.6699 and effective on a
1193 uniform basis among group health plans with that product; or
1194 (c) In the individual market if the modification is
1195 consistent with the laws of this state and effective on a
1196 uniform basis among all individuals with that policy form.
1197 Section 22. Section 641.312, Florida Statutes, is amended
1198 to read:
1199 641.312 Scope.—The Office of Insurance Regulation may adopt
1200 rules to administer the provisions of the National Association
1201 of Insurance Commissioners’ Uniform Health Carrier External
1202 Review Model Act, issued by the National Association of
1203 Insurance Commissioners and dated April 2010. This section does
1204 not apply to a health maintenance contract that is subject to
1205 the Subscriber Assistance Program under s. 408.7056 or to the
1206 types of benefits or coverages provided under s. 627.6513(1)
1207 (14) s. 627.6561(5)(b)-(e) issued in any market.
1208 Section 23. This act shall take effect July 1, 2016.