Florida Senate - 2016 SB 1170
By Senator Detert
28-00487C-16 20161170__
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; repealing s. 627.6011, F.S., relating
15 to mandated coverages; amending s. 627.602, F.S.;
16 revising applicability; repealing s. 627.642, F.S.,
17 relating to outline of coverage; amending s. 627.6425,
18 F.S.; redefining the term “individual health
19 insurance”; revising applicability; repealing s.
20 627.646, F.S., relating to conversion on termination
21 of eligibility; amending s. 627.6486, F.S.; conforming
22 a cross-reference; amending s. 627.6487, F.S.;
23 redefining terms; repealing s. 627.64871, F.S.,
24 relating to certification of coverage; amending s.
25 627.6488, F.S.; conforming cross-references; amending
26 s. 627.6498, F.S.; deleting a requirement that the
27 Office of Insurance Regulation establish certain
28 standard risk rates for coverages issued by the
29 Florida Comprehensive Health Association; amending s.
30 627.6512, F.S.; revising a provision specifying that
31 certain sections of the Florida Insurance Code do not
32 apply to a group health insurance policy as that
33 policy relates to specified benefits, under certain
34 circumstances; amending s. 627.6513, F.S.; excluding
35 applicability as to certain types of benefits or
36 coverages; amending s. 627.6515, F.S.; conforming a
37 cross-reference; deleting a provision relating to a
38 member’s entitlement to certain rights and options
39 after providing a specified notice of termination to
40 an insurer; repealing s. 627.6561, F.S., relating to
41 preexisting conditions; amending s. 627.6562, F.S.;
42 redefining the term “creditable coverage”; providing
43 exceptions and applicability; amending s. 627.65626,
44 F.S.; conforming a cross-reference; repealing s.
45 627.6675, F.S., relating to conversion on termination
46 of eligibility; amending s. 627.6699, F.S.; redefining
47 terms; deleting a provision that requires a certain
48 health benefit plan to comply with specified
49 preexisting condition provisions; conforming
50 provisions to changes made by the act; amending s.
51 627.6741, F.S.; conforming cross-references;
52 conforming a provision to changes made by the act;
53 amending s. 641.185, F.S.; revising certain standards
54 to remove requirements for a health maintenance
55 organization to provide specified coverage for
56 preexisting conditions, provide specified conversion
57 on termination of eligibility, and provide for
58 specified conversion contracts and conditions;
59 conforming provisions to changes made by the act;
60 amending s. 641.31, F.S.; deleting a provision
61 specifying that a law restricting or limiting
62 deductibles, coinsurance, copayments, or annual or
63 lifetime maximum payments may not apply to a certain
64 health maintenance organization contract; conforming a
65 cross-reference; repealing s. 641.31071, F.S.,
66 relating to preexisting conditions; amending s.
67 641.3111, F.S.; deleting a provision specifying that a
68 subscriber is not entitled to an extension of benefits
69 under certain circumstances after termination of a
70 group health maintenance contract; amending s.
71 641.312, F.S.; conforming a cross-reference; repealing
72 s. 641.3921, F.S., relating to conversion on
73 termination of eligibility; repealing s. 641.3922,
74 F.S., relating to conversion contracts and conditions;
75 providing an effective date.
76
77 Be It Enacted by the Legislature of the State of Florida:
78
79 Section 1. Paragraph (d) of subsection (2) of section
80 408.909, Florida Statutes, is amended to read:
81 408.909 Health flex plans.—
82 (2) DEFINITIONS.—As used in this section, the term:
83 (d) “Health care coverage” or “health flex plan coverage”
84 means health care services that are covered as benefits under an
85 approved health flex plan or that are otherwise provided, either
86 directly or through arrangements with other persons, via a
87 health flex plan on a prepaid per capita basis or on a prepaid
88 aggregate fixed-sum basis. The terms may also include one or
89 more of the excepted benefits under s. 627.6513(1)-(13) s.
90 627.6561(5)(b), the benefits under s. 627.6561(5)(c), if offered
91 separately, or the benefits under s. 627.6561(5)(d), if offered
92 as independent, noncoordinated benefits.
93 Section 2. Section 409.817, Florida Statutes, is amended to
94 read:
95 409.817 Approval of health benefits coverage; financial
96 assistance.—In order for health insurance coverage to qualify
97 for premium assistance payments for an eligible child under ss.
98 409.810-409.821, the health benefits coverage must:
99 (1) Be certified by the Office of Insurance Regulation of
100 the Financial Services Commission under s. 409.818 as meeting,
101 exceeding, or being actuarially equivalent to the benchmark
102 benefit plan;
103 (2) Be guarantee issued;
104 (3) Be community rated;
105 (4) Not impose any preexisting condition exclusion for
106 covered benefits; however, group health insurance plans may
107 permit the imposition of a preexisting condition exclusion, but
108 only insofar as it is permitted under s. 627.6561;
109 (5) Comply with the applicable limitations on premiums and
110 cost sharing in s. 409.816;
111 (6) Comply with the quality assurance and access standards
112 developed under s. 409.820; and
113 (7) Establish periodic open enrollment periods, which may
114 not occur more frequently than quarterly.
115 Section 3. Paragraph (b) of subsection (1) of section
116 624.123, Florida Statutes, is amended to read:
117 624.123 Certain international health insurance policies;
118 exemption from code.—
119 (1) International health insurance policies and
120 applications may be solicited and sold in this state at any
121 international airport to a resident of a foreign country. Such
122 international health insurance policies shall be solicited and
123 sold only by a licensed health insurance agent and underwritten
124 only by an admitted insurer. For purposes of this subsection:
125 (b) “International health insurance policy” means health
126 insurance, as provided defined in s. 627.6562(3)(a)2. s.
127 627.6561(5)(a)2., which is offered to an individual, covering
128 only a resident of a foreign country on an annual basis.
129 Section 4. Subsection (2) of section 627.402, Florida
130 Statutes, is amended to read:
131 627.402 Definitions.—As used in this part, the term:
132 (2) “Nongrandfathered health plan” is a health insurance
133 policy or health maintenance organization contract that is not a
134 grandfathered health plan and does not provide the benefits or
135 coverages specified under s. 627.6513(1)-(14) s. 627.6561(5)(b)
136 (e).
137 Section 5. Subsection (3) of section 627.411, Florida
138 Statutes, is amended to read:
139 627.411 Grounds for disapproval.—
140 (3)(a) For health insurance coverage as described in s.
141 627.6561(5)(a)2., the minimum loss ratio standard of incurred
142 claims to earned premium for the form shall be 65 percent.
143 (b) Incurred claims are claims occurring within a fixed
144 period, whether or not paid during the same period, under the
145 terms of the policy period.
146 1. Claims include scheduled benefit payments or services
147 provided by a provider or through a provider network for dental,
148 vision, disability, and similar health benefits.
149 2. Claims do not include state assessments, taxes, company
150 expenses, or any expense incurred by the company for the cost of
151 adjusting and settling a claim, including the review,
152 qualification, oversight, management, or monitoring of a claim
153 or incentives or compensation to providers for other than the
154 provisions of health care services.
155 3. A company may at its discretion include costs that are
156 demonstrated to reduce claims, such as fraud intervention
157 programs or case management costs, which are identified in each
158 filing, are demonstrated to reduce claims costs, and do not
159 result in increasing the experience period loss ratio by more
160 than 5 percent.
161 4. For scheduled claim payments, such as disability income
162 or long-term care, the incurred claims shall be the present
163 value of the benefit payments discounted for continuance and
164 interest.
165 Section 6. Section 627.6011, Florida Statutes, is repealed.
166 Section 7. Paragraph (h) of subsection (1) of section
167 627.602, Florida Statutes, is amended to read:
168 627.602 Scope, format of policy.—
169 (1) Each health insurance policy delivered or issued for
170 delivery to any person in this state must comply with all
171 applicable provisions of this code and all of the following
172 requirements:
173 (h) Section 641.312 and the provisions of the Employee
174 Retirement Income Security Act of 1974, as implemented by 29
175 C.F.R. s. 2560.503-1, relating to internal grievances. This
176 paragraph does not apply to a health insurance policy that is
177 subject to the Subscriber Assistance Program under s. 408.7056
178 or to the types of benefits or coverages provided under s.
179 627.6513(1)-(14) s. 627.6561(5)(b)-(e) issued in any market.
180 Section 8. Section 627.642, Florida Statutes, is repealed.
181 Section 9. Subsections (1), (6), and (7) of section
182 627.6425, Florida Statutes, are amended, and present subsection
183 (8) of that section is renumbered as subsection (6), to read:
184 627.6425 Renewability of individual coverage.—
185 (1) Except as otherwise provided in this section, an
186 insurer that provides individual health insurance coverage to an
187 individual shall renew or continue in force such coverage at the
188 option of the individual. For the purpose of this section, the
189 term “individual health insurance” means health insurance
190 coverage, as described in s. 624.603 s. 627.6561(5)(a)2.,
191 offered to an individual in this state, including certificates
192 of coverage offered to individuals in this state as part of a
193 group policy issued to an association outside this state, but
194 the term does not include short-term limited duration insurance
195 or excepted benefits specified in s. 627.6513(1)-(14) subsection
196 (6) or subsection (7).
197 (6) The requirements of this section do not apply to any
198 health insurance coverage in relation to its provision of
199 excepted benefits described in s. 627.6561(5)(b).
200 (7) The requirements of this section do not apply to any
201 health insurance coverage in relation to its provision of
202 excepted benefits described in s. 627.6561(5)(c), (d), or (e),
203 if the benefits are provided under a separate policy,
204 certificate, or contract of insurance.
205 Section 10. Section 627.646, Florida Statutes, is repealed.
206 Section 11. Paragraph (h) of subsection (2) of section
207 627.6486, Florida Statutes, is amended to read:
208 627.6486 Eligibility.—
209 (2)
210 (h) All eligible persons who are classified as high-risk
211 individuals pursuant to s. 627.6498(4)(a)3. s. 627.6498(4)(a)4.
212 shall, upon application or renewal, agree to be placed in a case
213 management system when it is determined by the board and the
214 plan case manager that such system will be cost-effective and
215 provide quality care to the individual.
216 Section 12. Paragraph (b) of subsection (2) and subsection
217 (3) of section 627.6487, Florida Statutes, are amended to read:
218 627.6487 Guaranteed availability of individual health
219 insurance coverage to eligible individuals.—
220 (2) For the purposes of this section:
221 (b) “Individual health insurance” means health insurance,
222 as defined in s. 624.603 s. 627.6561(5)(a)2., which is offered
223 to an individual, including certificates of coverage offered to
224 individuals in this state as part of a group policy issued to an
225 association outside this state, but the term does not include
226 short-term limited duration insurance or excepted benefits
227 specified in s. 627.6513(1)-(14) s. 627.6561(5)(b) or, if the
228 benefits are provided under a separate policy, certificate, or
229 contract, the term does not include excepted benefits specified
230 in s. 627.6561(5)(c), (d), or (e).
231 (3) For the purposes of this section, the term “eligible
232 individual” means an individual:
233 (a)1. For whom, as of the date on which the individual
234 seeks coverage under this section, the aggregate of the periods
235 of creditable coverage, as defined in s. 627.6562(3) s.
236 627.6561(5) and (6), is 18 or more months; and
237 2.a. Whose most recent prior creditable coverage was under
238 a group health plan, governmental plan, or church plan, or
239 health insurance coverage offered in connection with any such
240 plan; or
241 b. Whose most recent prior creditable coverage was under an
242 individual plan issued in this state by a health insurer or
243 health maintenance organization, which coverage is terminated
244 due to the insurer or health maintenance organization becoming
245 insolvent or discontinuing the offering of all individual
246 coverage in the State of Florida, or due to the insured no
247 longer living in the service area in the State of Florida of the
248 insurer or health maintenance organization that provides
249 coverage through a network plan in the State of Florida;
250 (b) Who is not eligible for coverage under:
251 1. A group health plan, as defined in s. 2791 of the Public
252 Health Service Act;
253 2. A conversion policy or contract issued by an authorized
254 insurer or health maintenance organization under s. 627.6675 or
255 s. 641.3921, respectively, offered to an individual who is no
256 longer eligible for coverage under either an insured or self
257 insured employer plan;
258 2.3. Part A or part B of Title XVIII of the Social Security
259 Act; or
260 3.4. A state plan under Title XIX of such act, or any
261 successor program, and does not have other health insurance
262 coverage;
263 (c) With respect to whom the most recent coverage within
264 the coverage period described in paragraph (a) was not
265 terminated based on a factor described in s. 627.6571(2)(a) or
266 (b), relating to nonpayment of premiums or fraud, unless such
267 nonpayment of premiums or fraud was due to acts of an employer
268 or person other than the individual;
269 (d) Who, having been offered the option of continuation
270 coverage under a COBRA continuation provision or under s.
271 627.6692, elected such coverage; and
272 (e) Who, if the individual elected such continuation
273 provision, has exhausted such continuation coverage under such
274 provision or program.
275 Section 13. Section 627.64871, Florida Statutes, is
276 repealed.
277 Section 14. Paragraph (h) of subsection (4) of section
278 627.6488, Florida Statutes, is amended to read:
279 627.6488 Florida Comprehensive Health Association.—
280 (4) The association shall:
281 (h) Contract with preferred provider organizations and
282 health maintenance organizations giving due consideration to the
283 preferred provider organizations and health maintenance
284 organizations which have contracted with the state group health
285 insurance program pursuant to s. 110.123. If cost-effective and
286 available in the county where the policyholder resides, the
287 board, upon application or renewal of a policy, shall place a
288 high-risk individual, as established under s. 627.6498(4)(a)3.
289 s. 627.6498(4)(a)4., with the plan case manager who shall
290 determine the most cost-effective quality care system or health
291 care provider and shall place the individual in such system or
292 with such health care provider. If cost-effective and available
293 in the county where the policyholder resides, the board, with
294 the consent of the policyholder, may place a low-risk or medium
295 risk individual, as established under s. 627.6498(4)(a)3. s.
296 627.6498(4)(a)4., with the plan case manager who may determine
297 the most cost-effective quality care system or health care
298 provider and shall place the individual in such system or with
299 such health care provider. Prior to and during the
300 implementation of case management, the plan case manager shall
301 obtain input from the policyholder, parent, or guardian.
302 Section 15. Paragraph (a) of subsection (4) of section
303 627.6498, Florida Statutes, is amended to read:
304 627.6498 Minimum benefits coverage; exclusions; premiums;
305 deductibles.—
306 (4) PREMIUMS, DEDUCTIBLES, AND COINSURANCE.—
307 (a) The plan shall provide for annual deductibles for major
308 medical expense coverage in the amount of $1,000 or any higher
309 amounts proposed by the board and approved by the office, plus
310 the benefits payable under any other type of insurance coverage
311 or workers’ compensation. The schedule of premiums and
312 deductibles shall be established by the association. With regard
313 to any preferred provider arrangement utilized by the
314 association, the deductibles provided in this paragraph shall be
315 the minimum deductibles applicable to the preferred providers
316 and higher deductibles, as approved by the office, may be
317 applied to providers who are not preferred providers.
318 1. Separate schedules of premium rates based on age may
319 apply for individual risks.
320 2. Rates are subject to approval by the office.
321 3. Standard risk rates for coverages issued by the
322 association shall be established by the office, pursuant to s.
323 627.6675(3).
324 3.4. The board shall establish separate premium schedules
325 for low-risk individuals, medium-risk individuals, and high-risk
326 individuals and shall revise premium schedules annually
327 beginning January 1999. No rate shall exceed 200 percent of the
328 standard risk rate for low-risk individuals, 225 percent of the
329 standard risk rate for medium-risk individuals, or 250 percent
330 of the standard risk rate for high-risk individuals. For the
331 purpose of determining what constitutes a low-risk individual,
332 medium-risk individual, or high-risk individual, the board shall
333 consider the anticipated claims payment for individuals based
334 upon an individual’s health condition.
335 Section 16. Section 627.6512, Florida Statutes, is amended
336 to read:
337 627.6512 Exemption of certain group health insurance
338 policies.—Sections 627.6561, 627.65615, 627.65625, and 627.6571
339 do not apply to:
340 (1) any group insurance policy in relation to its provision
341 of excepted benefits described in s. 627.6513(1)-(14) s.
342 627.6561(5)(b).
343 (2) Any group health insurance policy in relation to its
344 provision of excepted benefits described in s. 627.6561(5)(c),
345 if the benefits:
346 (a) Are provided under a separate policy, certificate, or
347 contract of insurance; or
348 (b) Are otherwise not an integral part of the policy.
349 (3) Any group health insurance policy in relation to its
350 provision of excepted benefits described in s. 627.6561(5)(d),
351 if all of the following conditions are met:
352 (a) The benefits are provided under a separate policy,
353 certificate, or contract of insurance;
354 (b) There is no coordination between the provision of such
355 benefits and any exclusion of benefits under any group policy
356 maintained by the same policyholder; and
357 (c) Such benefits are paid with respect to an event without
358 regard to whether benefits are provided with respect to such an
359 event under any group health policy maintained by the same
360 policyholder.
361 (4) Any group health policy in relation to its provision of
362 excepted benefits described in s. 627.6561(5)(e), if the
363 benefits are provided under a separate policy, certificate, or
364 contract of insurance.
365 Section 17. Section 627.6513, Florida Statutes, is amended
366 to read:
367 627.6513 Scope.—Section 641.312 and the provisions of the
368 Employee Retirement Income Security Act of 1974, as implemented
369 by 29 C.F.R. s. 2560.503-1, relating to internal grievances,
370 apply to all group health insurance policies issued under this
371 part. This section does not apply to a group health insurance
372 policy that is subject to the Subscriber Assistance Program in
373 s. 408.7056 or to: the types of benefits or coverages provided
374 under s. 627.6561(5)(b)-(e) issued in any market.
375 (1) Coverage only for accident insurance or disability
376 income insurance, or any combination thereof.
377 (2) Coverage issued as a supplement to liability insurance.
378 (3) Liability insurance, including general liability
379 insurance and automobile liability insurance.
380 (4) Workers’ compensation or similar insurance.
381 (5) Automobile medical payment insurance.
382 (6) Credit-only insurance.
383 (7) Coverage for onsite medical clinics, including prepaid
384 health clinics under part II of chapter 641.
385 (8) Other similar insurance coverage, specified in rules
386 adopted by the commission, under which benefits for medical care
387 are secondary or incidental to other insurance benefits. To the
388 extent possible, such rules must be consistent with regulations
389 adopted by the United States Department of Health and Human
390 Services.
391 (9) Limited scope dental or vision benefits, if offered
392 separately.
393 (10) Benefits for long-term care, nursing home care, home
394 health care, or community-based care, or any combination
395 thereof, if offered separately.
396 (11) Other similar limited benefits, if offered separately,
397 as specified in rules adopted by the commission.
398 (12) Coverage only for a specified disease or illness, if
399 offered as independent, noncoordinated benefits.
400 (13) Hospital indemnity or other fixed indemnity insurance,
401 if offered as independent, noncoordinated benefits.
402 (14) Benefits provided through a Medicare supplemental
403 health insurance policy, as defined under s. 1882(g)(1) of the
404 Social Security Act, coverage supplemental to the coverage
405 provided under 10 U.S.C. chapter 55, and similar supplemental
406 coverage provided to coverage under a group health plan, which
407 are offered as a separate insurance policy and as independent,
408 noncoordinated benefits.
409 Section 18. Subsections (2) and (9) of section 627.6515,
410 Florida Statutes, are amended to read:
411 627.6515 Out-of-state groups.—
412 (2) Except as otherwise provided in this part, this part
413 does not apply to a group health insurance policy issued or
414 delivered outside this state under which a resident of this
415 state is provided coverage if:
416 (a) The policy is issued to an employee group the
417 composition of which is substantially as described in s.
418 627.653; a labor union group or association group the
419 composition of which is substantially as described in s.
420 627.654; an additional group the composition of which is
421 substantially as described in s. 627.656; a group insured under
422 a blanket health policy when the composition of the group is
423 substantially in compliance with s. 627.659; a group insured
424 under a franchise health policy when the composition of the
425 group is substantially in compliance with s. 627.663; an
426 association group to cover persons associated in any other
427 common group, which common group is formed primarily for
428 purposes other than providing insurance; a group that is
429 established primarily for the purpose of providing group
430 insurance, provided the benefits are reasonable in relation to
431 the premiums charged thereunder and the issuance of the group
432 policy has resulted, or will result, in economies of
433 administration; or a group of insurance agents of an insurer,
434 which insurer is the policyholder;
435 (b) Certificates evidencing coverage under the policy are
436 issued to residents of this state and contain in contrasting
437 color and not less than 10-point type the following statement:
438 “The benefits of the policy providing your coverage are governed
439 primarily by the law of a state other than Florida”; and
440 (c) The policy provides the benefits specified in ss.
441 627.419, 627.6574, 627.6575, 627.6579, 627.6612, 627.66121,
442 627.66122, 627.6613, 627.667, 627.6675, 627.6691, and 627.66911,
443 and complies with the requirements of s. 627.66996.
444 (d) Applications for certificates of coverage offered to
445 residents of this state must contain, in contrasting color and
446 not less than 12-point type, the following statement on the same
447 page as the applicant’s signature:
448
449 “This policy is primarily governed by the laws of
450 ...insert state where the master policy is filed....
451 As a result, all of the rating laws applicable to
452 policies filed in this state do not apply to this
453 coverage, which may result in increases in your
454 premium at renewal that would not be permissible under
455 a Florida-approved policy. Any purchase of individual
456 health insurance should be considered carefully, as
457 future medical conditions may make it impossible to
458 qualify for another individual health policy. For
459 information concerning individual health coverage
460 under a Florida-approved policy, consult your agent or
461 the Florida Department of Financial Services.”
462
463 This paragraph applies only to group certificates providing
464 health insurance coverage which require individualized
465 underwriting to determine coverage eligibility for an individual
466 or premium rates to be charged to an individual except for the
467 following:
468 1. Policies issued to provide coverage to groups of persons
469 all of whom are in the same or functionally related licensed
470 professions, and providing coverage only to such licensed
471 professionals, their employees, or their dependents;
472 2. Policies providing coverage to small employers as
473 defined by s. 627.6699. Such policies shall be subject to, and
474 governed by, the provisions of s. 627.6699;
475 3. Policies issued to a bona fide association, as defined
476 by s. 627.6571(5), provided that there is a person or board
477 acting as a fiduciary for the benefit of the members, and such
478 association is not owned, controlled by, or otherwise associated
479 with the insurance company; or
480 4. Any accidental death, accidental death and
481 dismemberment, accident-only, vision-only, dental-only, hospital
482 indemnity-only, hospital accident-only, cancer, specified
483 disease, Medicare supplement, products that supplement Medicare,
484 long-term care, or disability income insurance, or similar
485 supplemental plans provided under a separate policy,
486 certificate, or contract of insurance, which cannot duplicate
487 coverage under an underlying health plan, coinsurance, or
488 deductibles or coverage issued as a supplement to workers’
489 compensation or similar insurance, or automobile medical-payment
490 insurance.
491 (9) Any insured shall be able to terminate membership or
492 affiliation with the group to whom the master policy is issued.
493 An insured that elects to terminate his or her membership or
494 affiliation with the group shall provide written notice to the
495 insurer. Upon providing the written notice, the member shall be
496 entitled to the rights and options provided by s. 627.6675.
497 Section 19. Section 627.6561, Florida Statutes, is
498 repealed.
499 Section 20. Subsection (3) of section 627.6562, Florida
500 Statutes, is amended to read:
501 627.6562 Dependent coverage.—
502 (3) If, pursuant to subsection (2), a child is provided
503 coverage under the parent’s policy after the end of the calendar
504 year in which the child reaches age 25 and coverage for the
505 child is subsequently terminated, the child is not eligible to
506 be covered under the parent’s policy unless the child was
507 continuously covered by other creditable coverage without a gap
508 in coverage of more than 63 days.
509 (a) For the purposes of this subsection, the term
510 “creditable coverage” means, with respect to an individual,
511 coverage of the individual under any of the following: has the
512 same meaning as provided in s. 627.6561(5).
513 1. A group health plan, as defined in s. 2791 of the Public
514 Health Service Act.
515 2. Health insurance coverage consisting of medical care
516 provided directly through insurance or reimbursement or
517 otherwise, and including terms and services paid for as medical
518 care, under any hospital or medical service policy or
519 certificate, hospital or medical service plan contract, or
520 health maintenance contract offered by a health insurance
521 issuer.
522 3. Part A or part B of Title XVIII of the Social Security
523 Act.
524 4. Title XIX of the Social Security Act, other than
525 coverage consisting solely of benefits under s. 1928.
526 5. 10 U.S.C. chapter 55.
527 6. A medical care program of the Indian Health Service or
528 of a tribal organization.
529 7. The Florida Comprehensive Health Association or another
530 state health benefit risk pool.
531 8. A health plan offered under 5 U.S.C. chapter 89.
532 9. A public health plan as defined by rules adopted by the
533 commission. To the greatest extent possible, such rules must be
534 consistent with regulations adopted by the United States
535 Department of Health and Human Services.
536 10. A health benefit plan under s. 5(e) of the Peace Corps
537 Act, 22 U.S.C. s. 2504(e).
538 (b) Creditable coverage does not include coverage that
539 consists of one or more, or any combination thereof, of the
540 following excepted benefits:
541 1. Coverage only for accident insurance or disability
542 income insurance, or any combination thereof.
543 2. Coverage issued as a supplement to liability insurance.
544 3. Liability insurance, including general liability
545 insurance and automobile liability insurance.
546 4. Workers’ compensation or similar insurance.
547 5. Automobile medical payment insurance.
548 6. Credit-only insurance.
549 7. Coverage for onsite medical clinics, including prepaid
550 health clinics under part II of chapter 641.
551 8. Other similar insurance coverage specified in rules
552 adopted by the commission under which benefits for medical care
553 are secondary or incidental to other insurance benefits. To the
554 extent possible, such rules must be consistent with regulations
555 adopted by the United States Department of Health and Human
556 Services.
557 (c) The following benefits are not subject to the
558 creditable coverage requirements, if offered separately:
559 1. Limited scope dental or vision benefits.
560 2. Benefits for long-term care, nursing home care, home
561 health care, or community-based care, or any combination
562 thereof.
563 3. Other similar, limited benefits specified in rules
564 adopted by the commission.
565 (d) The following benefits are not subject to creditable
566 coverage requirements if offered as independent, noncoordinated
567 benefits:
568 1. Coverage only for a specified disease or illness.
569 2. Hospital indemnity or other fixed indemnity insurance.
570 (e) Benefits provided through a Medicare supplemental
571 health insurance policy, as defined under s. 1882(g)(1) of the
572 Social Security Act, coverage supplemental to the coverage
573 provided under 10 U.S.C. chapter 55, and similar supplemental
574 coverage provided to coverage under a group health plan are not
575 considered creditable coverage if offered as a separate
576 insurance policy.
577 Section 21. Subsection (1) of section 627.65626, Florida
578 Statutes, is amended to read:
579 627.65626 Insurance rebates for healthy lifestyles.—
580 (1) Any rate, rating schedule, or rating manual for a
581 health insurance policy that provides creditable coverage as
582 defined in s. 627.6562(3) s. 627.6561(5) filed with the office
583 shall provide for an appropriate rebate of premiums paid in the
584 last policy year, contract year, or calendar year when the
585 majority of members of a health plan have enrolled and
586 maintained participation in any health wellness, maintenance, or
587 improvement program offered by the group policyholder and health
588 plan. The rebate may be based upon premiums paid in the last
589 calendar year or policy year. The group must provide evidence of
590 demonstrative maintenance or improvement of the enrollees’
591 health status as determined by assessments of agreed-upon health
592 status indicators between the policyholder and the health
593 insurer, including, but not limited to, reduction in weight,
594 body mass index, and smoking cessation. The group or health
595 insurer may contract with a third-party administrator to
596 assemble and report the health status required in this
597 subsection between the policyholder and the health insurer. Any
598 rebate provided by the health insurer is presumed to be
599 appropriate unless credible data demonstrates otherwise, or
600 unless the rebate program requires the insured to incur costs to
601 qualify for the rebate which equal or exceed the value of the
602 rebate, but the rebate may not exceed 10 percent of paid
603 premiums.
604 Section 22. Section 627.6675, Florida Statutes, is
605 repealed.
606 Section 23. Paragraphs (e), (l), and (n) of subsection (3),
607 paragraphs (c) and (d) of subsection (5), and paragraph (b) of
608 subsection (6) of section 627.6699, Florida Statutes, are
609 amended to read:
610 627.6699 Employee Health Care Access Act.—
611 (3) DEFINITIONS.—As used in this section, the term:
612 (e) “Creditable coverage” has the same meaning ascribed in
613 s. 627.6562(3) s. 627.6561.
614 (l) “Late enrollee” means an eligible employee or dependent
615 who, with respect to coverage under a group health policy, is a
616 participant or beneficiary who enrolls under the policy other
617 than during:
618 1. The first period in which the individual is eligible to
619 enroll under the policy.
620 2. A special enrollment period, as provided under s.
621 627.65615 as defined under s. 627.6561(1)(b).
622 (n) “Modified community rating” means a method used to
623 develop carrier premiums which spreads financial risk across a
624 large population; allows the use of separate rating factors for
625 age, gender, family composition, tobacco usage, and geographic
626 area as determined under paragraph (5)(e) (5)(f); and allows
627 adjustments for: claims experience, health status, or duration
628 of coverage as permitted under subparagraph (6)(b)5.; and
629 administrative and acquisition expenses as permitted under
630 subparagraph (6)(b)5.
631 (5) AVAILABILITY OF COVERAGE.—
632 (c) Except as provided in paragraph (d), a health benefit
633 plan covering small employers must comply with preexisting
634 condition provisions specified in s. 627.6561 or, for health
635 maintenance contracts, in s. 641.31071.
636 (c)(d) A health benefit plan covering small employers,
637 issued or renewed on or after January 1, 1994, must comply with
638 the following conditions:
639 1. All health benefit plans must be offered and issued on a
640 guaranteed-issue basis. Additional or increased benefits may
641 only be offered by riders.
642 2. Paragraph (c) applies to health benefit plans issued to
643 a small employer who has two or more eligible employees and to
644 health benefit plans that are issued to a small employer who has
645 fewer than two eligible employees and that cover an employee who
646 has had creditable coverage continually to a date not more than
647 63 days before the effective date of the new coverage.
648 2.3. For health benefit plans that are issued to a small
649 employer who has fewer than two employees and that cover an
650 employee who has not been continually covered by creditable
651 coverage within 63 days before the effective date of the new
652 coverage, preexisting condition provisions must not exclude
653 coverage for a period beyond 24 months following the employee’s
654 effective date of coverage and may relate only to:
655 a. Conditions that, during the 24-month period immediately
656 preceding the effective date of coverage, had manifested
657 themselves in such a manner as would cause an ordinarily prudent
658 person to seek medical advice, diagnosis, care, or treatment or
659 for which medical advice, diagnosis, care, or treatment was
660 recommended or received; or
661 b. A pregnancy existing on the effective date of coverage.
662 (6) RESTRICTIONS RELATING TO PREMIUM RATES.—
663 (b) For all small employer health benefit plans that are
664 subject to this section and issued by small employer carriers on
665 or after January 1, 1994, premium rates for health benefit plans
666 are subject to the following:
667 1. Small employer carriers must use a modified community
668 rating methodology in which the premium for each small employer
669 is determined solely on the basis of the eligible employee’s and
670 eligible dependent’s gender, age, family composition, tobacco
671 use, or geographic area as determined under paragraph (5)(e)
672 (5)(f) and in which the premium may be adjusted as permitted by
673 this paragraph. A small employer carrier is not required to use
674 gender as a rating factor for a nongrandfathered health plan.
675 2. Rating factors related to age, gender, family
676 composition, tobacco use, or geographic location may be
677 developed by each carrier to reflect the carrier’s experience.
678 The factors used by carriers are subject to office review and
679 approval.
680 3. Small employer carriers may not modify the rate for a
681 small employer for 12 months from the initial issue date or
682 renewal date, unless the composition of the group changes or
683 benefits are changed. However, a small employer carrier may
684 modify the rate one time within the 12 months after the initial
685 issue date for a small employer who enrolls under a previously
686 issued group policy that has a common anniversary date for all
687 employers covered under the policy if:
688 a. The carrier discloses to the employer in a clear and
689 conspicuous manner the date of the first renewal and the fact
690 that the premium may increase on or after that date.
691 b. The insurer demonstrates to the office that efficiencies
692 in administration are achieved and reflected in the rates
693 charged to small employers covered under the policy.
694 4. A carrier may issue a group health insurance policy to a
695 small employer health alliance or other group association with
696 rates that reflect a premium credit for expense savings
697 attributable to administrative activities being performed by the
698 alliance or group association if such expense savings are
699 specifically documented in the insurer’s rate filing and are
700 approved by the office. Any such credit may not be based on
701 different morbidity assumptions or on any other factor related
702 to the health status or claims experience of any person covered
703 under the policy. This subparagraph does not exempt an alliance
704 or group association from licensure for activities that require
705 licensure under the insurance code. A carrier issuing a group
706 health insurance policy to a small employer health alliance or
707 other group association shall allow any properly licensed and
708 appointed agent of that carrier to market and sell the small
709 employer health alliance or other group association policy. Such
710 agent shall be paid the usual and customary commission paid to
711 any agent selling the policy.
712 5. Any adjustments in rates for claims experience, health
713 status, or duration of coverage may not be charged to individual
714 employees or dependents. For a small employer’s policy, such
715 adjustments may not result in a rate for the small employer
716 which deviates more than 15 percent from the carrier’s approved
717 rate. Any such adjustment must be applied uniformly to the rates
718 charged for all employees and dependents of the small employer.
719 A small employer carrier may make an adjustment to a small
720 employer’s renewal premium, up to 10 percent annually, due to
721 the claims experience, health status, or duration of coverage of
722 the employees or dependents of the small employer. If the
723 aggregate resulting from the application of such adjustment
724 exceeds the premium that would have been charged by application
725 of the approved modified community rate by 4 percent for the
726 current policy term, the carrier shall limit the application of
727 such adjustments only to minus adjustments. For any subsequent
728 policy term, if the total aggregate adjusted premium actually
729 charged does not exceed the premium that would have been charged
730 by application of the approved modified community rate by 4
731 percent, the carrier may apply both plus and minus adjustments.
732 A small employer carrier may provide a credit to a small
733 employer’s premium based on administrative and acquisition
734 expense differences resulting from the size of the group. Group
735 size administrative and acquisition expense factors may be
736 developed by each carrier to reflect the carrier’s experience
737 and are subject to office review and approval.
738 6. A small employer carrier rating methodology may include
739 separate rating categories for one dependent child, for two
740 dependent children, and for three or more dependent children for
741 family coverage of employees having a spouse and dependent
742 children or employees having dependent children only. A small
743 employer carrier may have fewer, but not greater, numbers of
744 categories for dependent children than those specified in this
745 subparagraph.
746 7. Small employer carriers may not use a composite rating
747 methodology to rate a small employer with fewer than 10
748 employees. For the purposes of this subparagraph, the term
749 “composite rating methodology” means a rating methodology that
750 averages the impact of the rating factors for age and gender in
751 the premiums charged to all of the employees of a small
752 employer.
753 8. A carrier may separate the experience of small employer
754 groups with fewer than 2 eligible employees from the experience
755 of small employer groups with 2-50 eligible employees for
756 purposes of determining an alternative modified community
757 rating.
758 a. If a carrier separates the experience of small employer
759 groups, the rate to be charged to small employer groups of fewer
760 than 2 eligible employees may not exceed 150 percent of the rate
761 determined for small employer groups of 2-50 eligible employees.
762 However, the carrier may charge excess losses of the experience
763 pool consisting of small employer groups with less than 2
764 eligible employees to the experience pool consisting of small
765 employer groups with 2-50 eligible employees so that all losses
766 are allocated and the 150-percent rate limit on the experience
767 pool consisting of small employer groups with less than 2
768 eligible employees is maintained.
769 b. Notwithstanding s. 627.411(1), the rate to be charged to
770 a small employer group of fewer than 2 eligible employees,
771 insured as of July 1, 2002, may be up to 125 percent of the rate
772 determined for small employer groups of 2-50 eligible employees
773 for the first annual renewal and 150 percent for subsequent
774 annual renewals.
775 9. A carrier shall separate the experience of grandfathered
776 health plans from nongrandfathered health plans for determining
777 rates.
778 Section 24. Subsection (1) and paragraph (c) of subsection
779 (2) of section 627.6741, Florida Statutes, are amended to read:
780 627.6741 Issuance, cancellation, nonrenewal, and
781 replacement.—
782 (1)(a) An insurer issuing Medicare supplement policies in
783 this state shall offer the opportunity of enrolling in a
784 Medicare supplement policy, without conditioning the issuance or
785 effectiveness of the policy on, and without discriminating in
786 the price of the policy based on, the medical or health status
787 or receipt of health care by the individual:
788 1. To any individual who is 65 years of age or older, or
789 under 65 years of age and eligible for Medicare by reason of
790 disability or end-stage renal disease, and who resides in this
791 state, upon the request of the individual during the 6-month
792 period beginning with the first month in which the individual
793 has attained 65 years of age and is enrolled in Medicare Part B,
794 or is eligible for Medicare by reason of a disability or end
795 stage renal disease, and is enrolled in Medicare Part B; or
796 2. To any individual who is 65 years of age or older, or
797 under 65 years of age and eligible for Medicare by reason of a
798 disability or end-stage renal disease, who is enrolled in
799 Medicare Part B, and who resides in this state, upon the request
800 of the individual during the 2-month period following
801 termination of coverage under a group health insurance policy.
802 (b) The 6-month period to enroll in a Medicare supplement
803 policy for an individual who is under 65 years of age and is
804 eligible for Medicare by reason of disability or end-stage renal
805 disease and otherwise eligible under subparagraph (a)1. or
806 subparagraph (a)2. and first enrolled in Medicare Part B before
807 October 1, 2009, begins on October 1, 2009.
808 (c) A company that has offered Medicare supplement policies
809 to individuals under 65 years of age who are eligible for
810 Medicare by reason of disability or end-stage renal disease
811 before October 1, 2009, may, for one time only, effect a rate
812 schedule change that redefines the age bands of the premium
813 classes without activating the period of discontinuance required
814 by s. 627.410(6)(e)2.
815 (d) As a part of an insurer’s rate filings, before and
816 including the insurer’s first rate filing for a block of policy
817 forms in 2015, notwithstanding the provisions of s.
818 627.410(6)(e)3., an insurer shall consider the experience of the
819 policies or certificates for the premium classes including
820 individuals under 65 years of age and eligible for Medicare by
821 reason of disability or end-stage renal disease separately from
822 the balance of the block so as not to affect the other premium
823 classes. For filings in such time period only, credibility of
824 that experience shall be as follows: if a block of policy forms
825 has 1,250 or more policies or certificates in force in the age
826 band including ages under 65 years of age, full or 100-percent
827 credibility shall be given to the experience; and if fewer than
828 250 policies or certificates are in force, no or zero-percent
829 credibility shall be given. Linear interpolation shall be used
830 for in-force amounts between the low and high values. Florida
831 only experience shall be used if it is 100-percent credible. If
832 Florida-only experience is not 100-percent credible, a
833 combination of Florida-only and nationwide experience shall be
834 used. If Florida-only experience is zero-percent credible,
835 nationwide experience shall be used. The insurer may file its
836 initial rates and any rate adjustment based upon the experience
837 of these policies or certificates or based upon expected claim
838 experience using experience data of the same company, other
839 companies in the same or other states, or using data publicly
840 available from the Centers for Medicaid and Medicare Services if
841 the insurer’s combined Florida and nationwide experience is not
842 100-percent credible, separate from the balance of all other
843 Medicare supplement policies.
844
845 A Medicare supplement policy issued to an individual under
846 subparagraph (a)1. or subparagraph (a)2. may not exclude
847 benefits based on a preexisting condition if the individual has
848 a continuous period of creditable coverage, as defined in s.
849 627.6562(3) s. 627.6561(5), of at least 6 months as of the date
850 of application for coverage.
851 (2) For both individual and group Medicare supplement
852 policies:
853 (c) If a Medicare supplement policy or certificate replaces
854 another Medicare supplement policy or certificate or creditable
855 coverage as defined in s. 627.6562(3) s. 627.6561(5), the
856 replacing insurer shall waive any time periods applicable to
857 preexisting conditions, waiting periods, elimination periods,
858 and probationary periods in the new Medicare supplement policy
859 for similar benefits to the extent such time was spent under the
860 original policy, subject to the requirements of s. 627.6561(6)
861 (11).
862 Section 25. Paragraphs (f) and (h) of subsection (1) of
863 section 641.185, Florida Statutes, are amended to read:
864 641.185 Health maintenance organization subscriber
865 protections.—
866 (1) With respect to the provisions of this part and part
867 III, the principles expressed in the following statements shall
868 serve as standards to be followed by the commission, the office,
869 the department, and the Agency for Health Care Administration in
870 exercising their powers and duties, in exercising administrative
871 discretion, in administrative interpretations of the law, in
872 enforcing its provisions, and in adopting rules:
873 (f) A health maintenance organization subscriber should
874 receive the flexibility to transfer to another Florida health
875 maintenance organization, regardless of health status, pursuant
876 to ss. 641.228, 641.3104, and 641.3107, 641.3111, 641.3921, and
877 641.3922.
878 (h) A health maintenance organization that issues a group
879 health contract must: provide coverage for preexisting
880 conditions pursuant to s. 641.31071; guarantee renewability of
881 coverage pursuant to s. 641.31074,; provide notice of
882 cancellation pursuant to s. 641.3108, and; provide extension of
883 benefits pursuant to s. 641.3111; provide for conversion on
884 termination of eligibility pursuant to s. 641.3921; and provide
885 for conversion contracts and conditions pursuant to s. 641.3922.
886 Section 26. Subsection (2) and paragraph (a) of subsection
887 (40) of section 641.31, Florida Statutes, are amended to read:
888 641.31 Health maintenance contracts.—
889 (2) The rates charged by any health maintenance
890 organization to its subscribers shall not be excessive,
891 inadequate, or unfairly discriminatory or follow a rating
892 methodology that is inconsistent, indeterminate, or ambiguous or
893 encourages misrepresentation or misunderstanding. A law
894 restricting or limiting deductibles, coinsurance, copayments, or
895 annual or lifetime maximum payments shall not apply to any
896 health maintenance organization contract that provides coverage
897 as described in s. 641.31071(5)(a)2., offered or delivered to an
898 individual or a group of 51 or more persons. The commission, in
899 accordance with generally accepted actuarial practice as applied
900 to health maintenance organizations, may define by rule what
901 constitutes excessive, inadequate, or unfairly discriminatory
902 rates and may require whatever information it deems necessary to
903 determine that a rate or proposed rate meets the requirements of
904 this subsection.
905 (40)(a) Any group rate, rating schedule, or rating manual
906 for a health maintenance organization policy, which provides
907 creditable coverage as defined in s. 627.6562(3) s. 627.6561(5),
908 filed with the office shall provide for an appropriate rebate of
909 premiums paid in the last policy year, contract year, or
910 calendar year when the majority of members of a health plan are
911 enrolled in and have maintained participation in any health
912 wellness, maintenance, or improvement program offered by the
913 group contract holder. The group must provide evidence of
914 demonstrative maintenance or improvement of his or her health
915 status as determined by assessments of agreed-upon health status
916 indicators between the group and the health insurer, including,
917 but not limited to, reduction in weight, body mass index, and
918 smoking cessation. Any rebate provided by the health maintenance
919 organization is presumed to be appropriate unless credible data
920 demonstrates otherwise, or unless the rebate program requires
921 the insured to incur costs to qualify for the rebate which
922 equals or exceeds the value of the rebate but the rebate may not
923 exceed 10 percent of paid premiums.
924 Section 27. Section 641.31071, Florida Statutes, is
925 repealed.
926 Section 28. Subsection (4) of section 641.3111, Florida
927 Statutes, is amended to read:
928 641.3111 Extension of benefits.—
929 (4) Except as provided in subsection (1), no subscriber is
930 entitled to an extension of benefits if the termination of the
931 contract by the health maintenance organization is based upon
932 any event referred to in s. 641.3922(7)(a), (b), or (e).
933 Section 29. Section 641.312, Florida Statutes, is amended
934 to read:
935 641.312 Scope.—The Office of Insurance Regulation may adopt
936 rules to administer the provisions of the National Association
937 of Insurance Commissioners’ Uniform Health Carrier External
938 Review Model Act, issued by the National Association of
939 Insurance Commissioners and dated April 2010. This section does
940 not apply to a health maintenance contract that is subject to
941 the Subscriber Assistance Program under s. 408.7056 or to the
942 types of benefits or coverages provided under s. 627.6513(1)
943 (14) s. 627.6561(5)(b)-(e) issued in any market.
944 Section 30. Section 641.3921, Florida Statutes, is
945 repealed.
946 Section 31. Section 641.3922, Florida Statutes, is
947 repealed.
948 Section 32. This act shall take effect July 1, 2016.