CODING: Words stricken are deletions; words underlined are additions.
SENATE AMENDMENT
Bill No. CS/HBs 1927 & 961, 1st Eng.
Amendment No.
CHAMBER ACTION
Senate House
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11 Senator Clary moved the following amendment:
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13 Senate Amendment (with title amendment)
14 Delete everything after the enacting clause,
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16 and insert:
17 Section 1. Paragraph (a) of subsection (5) of section
18 408.05, Florida Statutes, 1998 Supplement, is amended to read:
19 408.05 State Center for Health Statistics.--
20 (5) PUBLICATIONS; REPORTS; SPECIAL STUDIES.--The
21 center shall provide for the widespread dissemination of data
22 which it collects and analyzes. The center shall have the
23 following publication, reporting, and special study functions:
24 (a) The center shall publish and make available
25 periodically to agencies and individuals health statistics
26 publications of general interest, including HMO report cards;
27 publications providing health statistics on topical health
28 policy issues;, publications that which provide health status
29 profiles of the people in this state;, and other topical
30 health statistics publications.
31 Section 2. Subsections (2) and (11) of section
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SENATE AMENDMENT
Bill No. CS/HBs 1927 & 961, 1st Eng.
Amendment No.
1 408.7056, Florida Statutes, 1998 Supplement, are amended to
2 read:
3 408.7056 Statewide Provider and Subscriber Assistance
4 Program.--
5 (2) The agency shall adopt and implement a program to
6 provide assistance to subscribers and providers, including
7 those whose grievances are not resolved by the managed care
8 entity to the satisfaction of the subscriber or provider. The
9 program shall consist of one or more panels that meet as often
10 as necessary to timely review, consider, and hear grievances
11 and recommend to the agency or the department any actions that
12 should be taken concerning individual cases heard by the
13 panel. The panel shall hear every grievance filed by
14 subscribers and providers on behalf of subscribers, unless the
15 grievance:
16 (a) Relates to a managed care entity's refusal to
17 accept a provider into its network of providers;
18 (b) Is part of an internal grievance in a Medicare
19 managed care entity or a reconsideration appeal through the
20 Medicare appeals process which does not involve a quality of
21 care issue;
22 (c) Is related to a health plan not regulated by the
23 state such as an administrative services organization,
24 third-party administrator, or federal employee health benefit
25 program;
26 (d) Is related to appeals by in-plan suppliers and
27 providers, unless related to quality of care provided by the
28 plan;
29 (e) Is part of a Medicaid fair hearing pursued under
30 42 C.F.R. ss. 431.220 et seq.;
31 (f) Is the basis for an action pending in state or
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SENATE AMENDMENT
Bill No. CS/HBs 1927 & 961, 1st Eng.
Amendment No.
1 federal court;
2 (g) Is related to an appeal by nonparticipating
3 providers, unless related to the quality of care provided to a
4 subscriber by the managed care entity and the provider is
5 involved in the care provided to the subscriber;
6 (h) Was filed before the subscriber or provider
7 completed the entire internal grievance procedure of the
8 managed care entity, the managed care entity has complied with
9 its timeframes for completing the internal grievance
10 procedure, and the circumstances described in subsection (6)
11 do not apply;
12 (i) Has been resolved to the satisfaction of the
13 subscriber or provider who filed the grievance, unless the
14 managed care entity's initial action is egregious or may be
15 indicative of a pattern of inappropriate behavior;
16 (j) Is limited to seeking damages for pain and
17 suffering, lost wages, or other incidental expenses, including
18 accrued interest on unpaid balances, court costs, and
19 transportation costs associated with a grievance procedure;
20 (k) Is limited to issues involving conduct of a health
21 care provider or facility, staff member, or employee of a
22 managed care entity which constitute grounds for disciplinary
23 action by the appropriate professional licensing board and is
24 not indicative of a pattern of inappropriate behavior, and the
25 agency or department has reported these grievances to the
26 appropriate professional licensing board or to the health
27 facility regulation section of the agency for possible
28 investigation; or
29 (l) Is withdrawn by the subscriber or provider.
30 Failure of the subscriber or the provider to attend the
31 hearing shall be considered a withdrawal of the grievance.
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SENATE AMENDMENT
Bill No. CS/HBs 1927 & 961, 1st Eng.
Amendment No.
1 (11) The panel shall consist of members employed by
2 the agency and members employed by the department, chosen by
3 their respective agencies; a consumer appointed by the
4 Governor; a physician appointed by the Governor, as a standing
5 member; and physicians who have expertise relevant to the case
6 to be heard, on a rotating basis. The agency may contract with
7 a medical director and a primary care physician who shall
8 provide additional technical expertise to the panel. The
9 medical director shall be selected from a health maintenance
10 organization with a current certificate of authority to
11 operate in Florida.
12 Section 3. Present subsection (5) of section 627.6471,
13 Florida Statutes, is redesignated as subsection (6) and a new
14 subsection (5) is added to that section to read:
15 627.6471 Contracts for reduced rates of payment;
16 limitations; coinsurance and deductibles.--
17 (5) Any policy issued under this section which does
18 not provide direct patient access to a dermatologist must
19 conform to the requirements of s. 627.6472(16). This
20 subsection shall not be construed to affect the amount the
21 insured or patient must pay as a deductible or coinsurance
22 amount authorized under this section.
23 Section 4. Subsection (36) is added to section 641.31,
24 Florida Statutes, 1998 Supplement, to read:
25 641.31 Health maintenance contracts.--
26 (36)(a) Notwithstanding any other provision of this
27 part, a health maintenance organization that meets the
28 requirements of paragraph (b) may, through a point-of-service
29 rider to its contract providing comprehensive health care
30 services, include a point-of-service benefit. Under such a
31 rider, a subscriber or other covered person of the health
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SENATE AMENDMENT
Bill No. CS/HBs 1927 & 961, 1st Eng.
Amendment No.
1 maintenance organization may choose, at the time of covered
2 service, a provider with whom the health maintenance
3 organization does not have a health maintenance organization
4 provider contract. The rider may not require a referral from
5 the health maintenance organization for the point-of-service
6 benefits.
7 (b) A health maintenance organization offering a
8 point-of-service rider under this subsection must have a valid
9 certificate of authority issued under the provisions of the
10 chapter, must have been licensed under this chapter for a
11 minimum of 3 years, and must at all times that it has riders
12 in effect maintain a minimum surplus of $5 million.
13 (c) Premiums paid in for the point-of-service riders
14 may not exceed 15 percent of total premiums for all health
15 plan products sold by the health maintenance organization
16 offering the rider. If the premiums paid for point-of-service
17 riders exceed 15 percent, the health maintenance organization
18 must notify the department and, once this fact is known, must
19 immediately cease offering such a rider until it is in
20 compliance with the rider premium cap.
21 (d) Notwithstanding the limitations of deductibles and
22 copayment provisions in this part, a point-of-service rider
23 may require the subscriber to pay a reasonable copayment for
24 each visit for services provided by a noncontracted provider
25 chosen at the time of the service. The copayment by the
26 subscriber may either be a specific dollar amount or a
27 percentage of the reimbursable provider charges covered by the
28 contract and must be paid by the subscriber to the
29 noncontracted provider upon receipt of covered services. The
30 point-of-service rider may require that a reasonable annual
31 deductible for the expenses associated with the
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SENATE AMENDMENT
Bill No. CS/HBs 1927 & 961, 1st Eng.
Amendment No.
1 point-of-service rider be met and may include a lifetime
2 maximum benefit amount. The rider must include the language
3 required by s. 627.6044 and must comply with copayment limits
4 described in s. 627.6471. Section 641.315(2) and (3) does not
5 apply to a point-of-service rider authorized under this
6 subsection.
7 (e) The term "point of service" may not be used by a
8 health maintenance organization except with riders permitted
9 under this section or with forms approved by the department in
10 which a point-of-service product is offered with an indemnity
11 carrier.
12 (f) A point-of-service rider must be filed and
13 approved under ss. 627.410 and 627.411.
14 Section 5. Subsection (4) is added to section
15 641.3155, Florida Statutes, 1998 Supplement, to read:
16 641.3155 Provider contracts; payment of claims.--
17 (4) Any retroactive reductions of payments or demands
18 for refund of previous overpayments which are due to
19 retroactive review-of-coverage decisions or payment levels
20 must be reconciled to specific claims unless the parties agree
21 to other reconciliation methods and terms. Any retroactive
22 demands by providers for payment due to underpayments or
23 nonpayments for covered services must be reconciled to
24 specific claims unless the parties agree to other
25 reconciliation methods and terms. The look-back period may be
26 specified by the terms of the contract.
27 Section 6. The Director of the Agency for Health Care
28 Administration shall establish an advisory group composed of
29 eight members, with three members from health maintenance
30 organizations licensed in Florida, one representative from a
31 not-for-profit hospital, one representative from a for-profit
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SENATE AMENDMENT
Bill No. CS/HBs 1927 & 961, 1st Eng.
Amendment No.
1 hospital, one representative who is a licensed physician, one
2 representative from the Office of the Insurance Commissioner,
3 and one representative from the Agency for Health Care
4 Administration. The advisory group shall study and make
5 recommendations concerning:
6 (1) Trends and issues relating to legislative,
7 regulatory, or private-sector solutions for timely and
8 accurate submission and payment of health claims.
9 (2) Development of electronic billing and claims
10 processing for providers and health care facilities that
11 provide for electronic processing of eligibility requests;
12 benefit verification; authorizations; precertifications;
13 business expensing of assets, including software, used for
14 electronic billing and claims processing; and claims status,
15 including use of models such as those compatible with federal
16 billing systems.
17 (3) The form and content of claims.
18 (4) Measures to reduce fraud and abuse relating to the
19 submission and payment of claims.
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21 The advisory group shall be appointed and convened by July 1,
22 1999, and shall meet in Tallahassee. Members of the advisory
23 group shall not receive per diem or travel reimbursement. The
24 advisory group shall submit its recommendations in a report,
25 by January 1, 2000, to the President of the Senate and the
26 Speaker of the House of Representatives.
27 Section 7. Subsections (8), (9), and (10) of section
28 641.51, Florida Statutes, are amended to read:
29 641.51 Quality assurance program; second medical
30 opinion requirement.--
31 (8) Each organization shall release to the agency data
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SENATE AMENDMENT
Bill No. CS/HBs 1927 & 961, 1st Eng.
Amendment No.
1 that which are indicators of access and quality of care. The
2 agency shall develop rules specifying data-reporting
3 requirements for these indicators. The indicators shall
4 include the following characteristics:
5 (a) They must relate to access and quality of care
6 measures.
7 (b) They must be consistent with data collected
8 pursuant to accreditation activities and standards.
9 (c) They must be consistent with frequency
10 requirements under the accreditation process.
11 (d) They must include measures of the management of
12 chronic diseases.
13 (e) They must include preventive health care for
14 adults and children.
15 (f) They must include measures of prenatal care.
16 (g) They must include measures of health checkups for
17 children.
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19 The agency shall develop by rule a uniform format for
20 publication of the data for the public which shall contain
21 explanations of the data collected and the relevance of such
22 data. The agency shall publish such data no less frequently
23 than every 2 years.
24 (9) Each organization shall conduct a standardized
25 customer satisfaction survey, as developed by the agency by
26 rule, of its membership at intervals specified by the agency.
27 The survey shall be consistent with surveys required by
28 accrediting organizations and may contain up to 10 additional
29 questions based on concerns specific to Florida. Survey data
30 shall be submitted to the agency, which shall make comparative
31 findings available to the public.
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Bill No. CS/HBs 1927 & 961, 1st Eng.
Amendment No.
1 (9)(10) Each organization shall adopt recommendations
2 for preventive pediatric health care which are consistent with
3 the early periodic screening, diagnosis, and treatment
4 requirements for health checkups for children developed for
5 the Medicaid program. Each organization shall establish goals
6 to achieve 80-percent compliance by July 1, 1998, and
7 90-percent compliance by July 1, 1999, for their enrolled
8 pediatric population.
9 Section 8. Subsection (4) of section 641.58, Florida
10 Statutes, is amended to read:
11 641.58 Regulatory assessment; levy and amount; use of
12 funds; tax returns; penalty for failure to pay.--
13 (4) The moneys so received and deposited into the
14 Health Care Trust Fund shall be used to defray the expenses of
15 the agency in the discharge of its administrative and
16 regulatory powers and duties under this part, including
17 conducting an annual survey of the satisfaction of members of
18 health maintenance organizations; contracting with physician
19 consultants for the Statewide Provider and Subscriber
20 Assistance Panel; the maintaining of offices and necessary
21 supplies, essential equipment, and other materials, salaries
22 and expenses of required personnel;, and discharging all other
23 legitimate expenses relating to the discharge of the
24 administrative and regulatory powers and duties imposed under
25 this such part.
26 Section 9. Subsections (4) and (7) of section 409.910,
27 Florida Statutes, 1998 Supplement, are amended to read:
28 409.910 Responsibility for payments on behalf of
29 Medicaid-eligible persons when other parties are liable.--
30 (4) After the department has provided medical
31 assistance under the Medicaid program, it shall seek recovery
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Bill No. CS/HBs 1927 & 961, 1st Eng.
Amendment No.
1 of reimbursement from third-party benefits to the limit of
2 legal liability and for the full amount of third-party
3 benefits, but not in excess of the amount of medical
4 assistance paid by Medicaid, as to:
5 (a) Claims for which the department has a waiver
6 pursuant to federal law; or
7 (b) Situations in which the department learns of the
8 existence of a liable third party or in which third-party
9 benefits are discovered or become available after medical
10 assistance has been provided by Medicaid.
11 (7) The department shall recover the full amount of
12 all medical assistance provided by Medicaid on behalf of the
13 recipient to the full extent of third-party benefits.
14 (a) Recovery of such benefits shall be collected
15 directly from:
16 1. Any third party;
17 2. The recipient or legal representative, if he or she
18 has received third-party benefits;
19 3. The provider of a recipient's medical services if
20 third-party benefits have been recovered by the provider;
21 notwithstanding any provision of this section, to the
22 contrary, however, no provider shall be required to refund or
23 pay to the department any amount in excess of the actual
24 third-party benefits received by the provider from a
25 third-party payor for medical services provided to the
26 recipient; or
27 4. Any person who has received the third-party
28 benefits.
29 (b) Upon receipt of any recovery or other collection
30 pursuant to this section, the department shall distribute the
31 amount collected as follows:
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Bill No. CS/HBs 1927 & 961, 1st Eng.
Amendment No.
1 1. To itself, an amount equal to the state Medicaid
2 expenditures for the recipient plus any incentive payment made
3 in accordance with paragraph (14)(a).
4 2. To the Federal Government, the federal share of the
5 state Medicaid expenditures minus any incentive payment made
6 in accordance with paragraph (14)(a) and federal law, and
7 minus any other amount permitted by federal law to be
8 deducted.
9 3. To the recipient, after deducting any known amounts
10 owed to the department for any related medical assistance or
11 to health care providers, any remaining amount. This amount
12 shall be treated as income or resources in determining
13 eligibility for Medicaid.
14
15 The provisions of this subsection do not apply to any proceeds
16 received by the state, or any agency thereof, pursuant to a
17 final order, judgment, or settlement agreement, in any matter
18 in which the state asserts claims brought on its own behalf,
19 and not as a subrogee of a recipient, or under other theories
20 of liability. The provisions of this subsection do not apply
21 to any proceeds received by the state, or an agency thereof,
22 pursuant to a final order, judgment, or settlement agreement,
23 in any matter in which the state asserted both claims as a
24 subrogee and additional claims, except as to those sums
25 specifically identified in the final order, judgment, or
26 settlement agreement as reimbursements to the recipient as
27 expenditures for the named recipient on the subrogation claim.
28 Section 10. The amendments to section 409.910, Florida
29 Statutes, 1998 Supplement, made by this act are intended to
30 clarify existing law and are remedial in nature. As such,
31 they are specifically made retroactive to October 1, 1990, and
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Bill No. CS/HBs 1927 & 961, 1st Eng.
Amendment No.
1 shall apply to all causes of action arising on or after
2 October 1, 1990.
3 Section 11. Subsection (1) of section 627.6645,
4 Florida Statutes, is amended and subsection (5) is added to
5 that section to read:
6 627.6645 Notification of cancellation, expiration,
7 nonrenewal, or change in rates.--
8 (1) Every insurer delivering or issuing for delivery a
9 group health insurance policy under the provisions of this
10 part shall give the policyholder at least 45 days' advance
11 notice of cancellation, expiration, nonrenewal, or a change in
12 rates. Such notice shall be mailed to the policyholder's last
13 address as shown by the records of the insurer. However, if
14 cancellation is for nonpayment of premium, only the
15 requirements of subsection (5) this section shall not apply.
16 Upon receipt of such notice, the policyholder shall forward,
17 as soon as practicable, the notice of expiration,
18 cancellation, or nonrenewal to each certificateholder covered
19 under the policy.
20 (5) If cancellation is due to nonpayment of premium,
21 the insurer may not retroactively cancel the policy to a date
22 prior to the date that notice of cancellation was provided to
23 the policyholder unless the insurer mails notice of
24 cancellation to the policyholder prior to 45 days after the
25 date the premium was due. Such notice must be mailed to the
26 policyholder's last address as shown by the records of the
27 insurer and may provide for a retroactive date of cancellation
28 no earlier than midnight of the date that the premium was due.
29 Section 12. Section 627.6675, Florida Statutes, 1998
30 Supplement, is amended to read:
31 627.6675 Conversion on termination of
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SENATE AMENDMENT
Bill No. CS/HBs 1927 & 961, 1st Eng.
Amendment No.
1 eligibility.--Subject to all of the provisions of this
2 section, a group policy delivered or issued for delivery in
3 this state by an insurer or nonprofit health care services
4 plan that provides, on an expense-incurred basis, hospital,
5 surgical, or major medical expense insurance, or any
6 combination of these coverages, shall provide that an employee
7 or member whose insurance under the group policy has been
8 terminated for any reason, including discontinuance of the
9 group policy in its entirety or with respect to an insured
10 class, and who has been continuously insured under the group
11 policy, and under any group policy providing similar benefits
12 that the terminated group policy replaced, for at least 3
13 months immediately prior to termination, shall be entitled to
14 have issued to him or her by the insurer a policy or
15 certificate of health insurance, referred to in this section
16 as a "converted policy." A group insurer may meet the
17 requirements of this section by contracting with another
18 insurer, authorized in this state, to issue an individual
19 converted policy, which policy has been approved by the
20 department under s. 627.410. An employee or member shall not
21 be entitled to a converted policy if termination of his or her
22 insurance under the group policy occurred because he or she
23 failed to pay any required contribution, or because any
24 discontinued group coverage was replaced by similar group
25 coverage within 31 days after discontinuance.
26 (1) TIME LIMIT.--Written application for the converted
27 policy shall be made and the first premium must be paid to the
28 insurer, not later than 63 days after termination of the group
29 policy. However, if termination was the result of failure to
30 pay any required premium or contribution and such nonpayment
31 of premium was due to acts of an employer or policyholder
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Bill No. CS/HBs 1927 & 961, 1st Eng.
Amendment No.
1 other than the employee or certificateholder, written
2 application for the converted policy must be made and the
3 first premium must be paid to the insurer not later than 63
4 days after notice of termination is mailed by the insurer or
5 the employer, whichever is earlier, to the employee's or
6 certificateholder's last address as shown by the record of the
7 insurer or the employer, whichever is applicable. In such case
8 of termination due to nonpayment of premium by the employer or
9 policyholder, the premium for the converted policy may not
10 exceed the rate for the prior group coverage for the period of
11 coverage under the converted policy prior to the date notice
12 of termination is mailed to the employee or certificateholder.
13 For the period of coverage after such date, the premium for
14 the converted policy is subject to the requirements of
15 subsection (3).
16 (2) EVIDENCE OF INSURABILITY.--The converted policy
17 shall be issued without evidence of insurability.
18 (3) CONVERSION PREMIUM; EFFECT ON PREMIUM RATES FOR
19 GROUP COVERAGE.--
20 (a) The premium for the converted policy shall be
21 determined in accordance with premium rates applicable to the
22 age and class of risk of each person to be covered under the
23 converted policy and to the type and amount of insurance
24 provided. However, the premium for the converted policy may
25 not exceed 200 percent of the standard risk rate as
26 established by the department, pursuant to this subsection.
27 (b) Actual or expected experience under converted
28 policies may be combined with such experience under group
29 policies for the purposes of determining premium and loss
30 experience and establishing premium rate levels for group
31 coverage.
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Bill No. CS/HBs 1927 & 961, 1st Eng.
Amendment No.
1 (c) The department shall annually determine standard
2 risk rates, using reasonable actuarial techniques and
3 standards adopted by the department by rule. The standard risk
4 rates must be determined as follows:
5 1. Standard risk rates for individual coverage must be
6 determined separately for indemnity policies, preferred
7 provider/exclusive provider policies, and health maintenance
8 organization contracts.
9 2. The department shall survey insurers and health
10 maintenance organizations representing at least an 80 percent
11 market share, based on premiums earned in the state for the
12 most recent calendar year, for each of the categories
13 specified in subparagraph 1.
14 3. Standard risk rate schedules must be determined,
15 computed as the average rates charged by the carriers
16 surveyed, giving appropriate weight to each carrier's
17 statewide market share of earned premiums.
18 4. The rate schedule shall be determined from analysis
19 of the one county with the largest market share in the state
20 of all such carriers.
21 5. The rate for other counties must be determined by
22 using the weighted average of each carrier's county factor
23 relationship to the county determined in subparagraph 4.
24 6. The rate schedule must be determined for different
25 age brackets and family size brackets.
26 (4) EFFECTIVE DATE OF COVERAGE.--The effective date of
27 the converted policy shall be the day following the
28 termination of insurance under the group policy.
29 (5) SCOPE OF COVERAGE.--The converted policy shall
30 cover the employee or member and his or her dependents who
31 were covered by the group policy on the date of termination of
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Bill No. CS/HBs 1927 & 961, 1st Eng.
Amendment No.
1 insurance. At the option of the insurer, a separate converted
2 policy may be issued to cover any dependent.
3 (6) OPTIONAL COVERAGE.--The insurer shall not be
4 required to issue a converted policy covering any person who
5 is or could be covered by Medicare. The insurer shall not be
6 required to issue a converted policy covering a person if
7 paragraphs (a) and (b) apply to the person:
8 (a) If any of the following apply to the person:
9 1. The person is covered for similar benefits by
10 another hospital, surgical, medical, or major medical expense
11 insurance policy or hospital or medical service subscriber
12 contract or medical practice or other prepayment plan, or by
13 any other plan or program.
14 2. The person is eligible for similar benefits,
15 whether or not actually provided coverage, under any
16 arrangement of coverage for individuals in a group, whether on
17 an insured or uninsured basis.
18 3. Similar benefits are provided for or are available
19 to the person under any state or federal law.
20 (b) If the benefits provided under the sources
21 referred to in subparagraph (a)1. or the benefits provided or
22 available under the sources referred to in subparagraphs (a)2.
23 and 3., together with the benefits provided by the converted
24 policy, would result in overinsurance according to the
25 insurer's standards. The insurer's standards must bear some
26 reasonable relationship to actual health care costs in the
27 area in which the insured lives at the time of conversion and
28 must be filed with the department prior to their use in
29 denying coverage.
30 (7) INFORMATION REQUESTED BY INSURER.--
31 (a) A converted policy may include a provision under
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Bill No. CS/HBs 1927 & 961, 1st Eng.
Amendment No.
1 which the insurer may request information, in advance of any
2 premium due date, of any person covered thereunder as to
3 whether:
4 1. The person is covered for similar benefits by
5 another hospital, surgical, medical, or major medical expense
6 insurance policy or hospital or medical service subscriber
7 contract or medical practice or other prepayment plan or by
8 any other plan or program.
9 2. The person is covered for similar benefits under
10 any arrangement of coverage for individuals in a group,
11 whether on an insured or uninsured basis.
12 3. Similar benefits are provided for or are available
13 to the person under any state or federal law.
14 (b) The converted policy may provide that the insurer
15 may refuse to renew the policy or the coverage of any person
16 only for one or more of the following reasons:
17 1. Either the benefits provided under the sources
18 referred to in subparagraphs (a)1. and 2. for the person or
19 the benefits provided or available under the sources referred
20 to in subparagraph (a)3. for the person, together with the
21 benefits provided by the converted policy, would result in
22 overinsurance according to the insurer's standards on file
23 with the department.
24 2. The converted policyholder fails to provide the
25 information requested pursuant to paragraph (a).
26 3. Fraud or intentional misrepresentation in applying
27 for any benefits under the converted policy.
28 4. Other reasons approved by the department.
29 (8) BENEFITS OFFERED.--
30 (a) An insurer shall not be required to issue a
31 converted policy that provides benefits in excess of those
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Bill No. CS/HBs 1927 & 961, 1st Eng.
Amendment No.
1 provided under the group policy from which conversion is made.
2 (b) An insurer shall offer the benefits specified in
3 s. 627.668 and the benefits specified in s. 627.669 if those
4 benefits were provided in the group plan.
5 (c) An insurer shall offer maternity benefits and
6 dental benefits if those benefits were provided in the group
7 plan.
8 (9) PREEXISTING CONDITION PROVISION.--The converted
9 policy shall not exclude a preexisting condition not excluded
10 by the group policy. However, the converted policy may provide
11 that any hospital, surgical, or medical benefits payable under
12 the converted policy may be reduced by the amount of any such
13 benefits payable under the group policy after the termination
14 of covered under the group policy. The converted policy may
15 also provide that during the first policy year the benefits
16 payable under the converted policy, together with the benefits
17 payable under the group policy, shall not exceed those that
18 would have been payable had the individual's insurance under
19 the group policy remained in force.
20 (10) REQUIRED OPTION FOR MAJOR MEDICAL
21 COVERAGE.--Subject to the provisions and conditions of this
22 part, the employee or member shall be entitled to obtain a
23 converted policy providing major medical coverage under a plan
24 meeting the following requirements:
25 (a) A maximum benefit equal to the lesser of the
26 policy limit of the group policy from which the individual
27 converted or $500,000 per covered person for all covered
28 medical expenses incurred during the covered person's
29 lifetime.
30 (b) Payment of benefits at the rate of 80 percent of
31 covered medical expenses which are in excess of the
18
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Bill No. CS/HBs 1927 & 961, 1st Eng.
Amendment No.
1 deductible, until 20 percent of such expenses in a benefit
2 period reaches $2,000, after which benefits will be paid at
3 the rate of 90 percent during the remainder of the contract
4 year unless the insured is in the insurer's case management
5 program, in which case benefits shall be paid at the rate of
6 100 percent during the remainder of the contract year. For
7 the purposes of this paragraph, "case management program"
8 means the specific supervision and management of the medical
9 care provided or prescribed for a specific individual, which
10 may include the use of health care providers designated by the
11 insurer. Payment of benefits for outpatient treatment of
12 mental illness, if provided in the converted policy, may be at
13 a lesser rate but not less than 50 percent.
14 (c) A deductible for each calendar year that must be
15 $500, $1,000, or $2,000, at the option of the policyholder.
16 (d) The term "covered medical expenses," as used in
17 this subsection, shall be consistent with those customarily
18 offered by the insurer under group or individual health
19 insurance policies but is not required to be identical to the
20 covered medical expenses provided in the group policy from
21 which the individual converted.
22 (11) ALTERNATIVE PLANS.--The insurer shall, in
23 addition to the option required by subsection (10), offer the
24 standard health benefit plan, as established pursuant to s.
25 627.6699(12). The insurer may, at its option, also offer
26 alternative plans for group health conversion in addition to
27 the plans required by this section.
28 (12) RETIREMENT COVERAGE.--If coverage would be
29 continued under the group policy on an employee following the
30 employee's retirement prior to the time he or she is or could
31 be covered by Medicare, the employee may elect, instead of
19
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SENATE AMENDMENT
Bill No. CS/HBs 1927 & 961, 1st Eng.
Amendment No.
1 such continuation of group insurance, to have the same
2 conversion rights as would apply had his or her insurance
3 terminated at retirement by reason or termination of
4 employment or membership.
5 (13) REDUCTION OF COVERAGE DUE TO MEDICARE.--The
6 converted policy may provide for reduction of coverage on any
7 person upon his or her eligibility for coverage under Medicare
8 or under any other state or federal law providing for benefits
9 similar to those provided by the converted policy.
10 (14) CONVERSION PRIVILEGE ALLOWED.--The conversion
11 privilege shall also be available to any of the following:
12 (a) The surviving spouse, if any, at the death of the
13 employee or member, with respect to the spouse and the
14 children whose coverages under the group policy terminate by
15 reason of the death, otherwise to each surviving child whose
16 coverage under the group policy terminates by reason of such
17 death, or, if the group policy provides for continuation of
18 dependents' coverages following the employee's or member's
19 death, at the end of such continuation.
20 (b) The former spouse whose coverage would otherwise
21 terminate because of annulment or dissolution of marriage, if
22 the former spouse is dependent for financial support.
23 (c) The spouse of the employee or member upon
24 termination of coverage of the spouse, while the employee or
25 member remains insured under the group policy, by reason of
26 ceasing to be a qualified family member under the group
27 policy, with respect to the spouse and the children whose
28 coverages under the group policy terminate at the same time.
29 (d) A child solely with respect to himself or herself
30 upon termination of his or her coverage by reason of ceasing
31 to be a qualified family member under the group policy, if a
20
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SENATE AMENDMENT
Bill No. CS/HBs 1927 & 961, 1st Eng.
Amendment No.
1 conversion privilege is not otherwise provided in this
2 subsection with respect to such termination.
3 (15) BENEFIT LEVELS.--If the benefit levels required
4 in subsection (10) exceed the benefit levels provided under
5 the group policy, the conversion policy may offer benefits
6 which are substantially similar to those provided under the
7 group policy in lieu of those required in subsection (10).
8 (16) GROUP COVERAGE INSTEAD OF INDIVIDUAL
9 COVERAGE.--The insurer may elect to provide group insurance
10 coverage instead of issuing a converted individual policy.
11 (17) NOTIFICATION.--A notification of the conversion
12 privilege shall be included in each certificate of coverage.
13 The insurer shall mail an election and premium notice form,
14 including an outline of coverage, on a form approved by the
15 department, within 14 days after an individual who is eligible
16 for a converted policy gives notice to the insurer that the
17 individual is considering applying for the converted policy or
18 otherwise requests such information. The outline of coverage
19 must contain a description of the principal benefits and
20 coverage provided by the policy and its principal exclusions
21 and limitations, including, but not limited to, deductibles
22 and coinsurance.
23 (18) OUTSIDE CONVERSIONS.--A converted policy that is
24 delivered outside of this state must be on a form that could
25 be delivered in the other jurisdiction as a converted policy
26 had the group policy been issued in that jurisdiction.
27 (19) APPLICABILITY.--This section does not require
28 conversion on termination of eligibility for a policy or
29 contract that provides benefits for specified diseases, or for
30 accidental injuries only, disability income, Medicare
31 supplement, hospital indemnity, limited benefit,
21
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SENATE AMENDMENT
Bill No. CS/HBs 1927 & 961, 1st Eng.
Amendment No.
1 nonconventional, or excess policies.
2 (20) Nothing in this section or in the incorporation
3 of it into insurance policies shall be construed to require
4 insurers to provide benefits equal to those provided in the
5 group policy from which the individual converted, provided,
6 however, that comprehensive benefits are offered which shall
7 be subject to approval by the Insurance Commissioner.
8 Section 13. Section 641.3108, Florida Statutes, is
9 amended to read:
10 641.3108 Notice of cancellation of contract.--
11 (1) Except for nonpayment of premium or termination of
12 eligibility, no health maintenance organization may cancel or
13 otherwise terminate or fail to renew a health maintenance
14 contract without giving the subscriber at least 45 days'
15 notice in writing of the cancellation, termination, or
16 nonrenewal of the contract. The written notice shall state the
17 reason or reasons for the cancellation, termination, or
18 nonrenewal. All health maintenance contracts shall contain a
19 clause which requires that this notice be given.
20 (2) If cancellation is due to nonpayment of premium,
21 the health maintenance organization may not retroactively
22 cancel the contract to a date prior to the date that notice of
23 cancellation was provided to the subscriber unless the
24 organization mails notice of cancellation to the subscriber
25 prior to 45 days after the date the premium was due. Such
26 notice must be mailed to the subscriber's last address as
27 shown by the records of the organization and may provide for a
28 retroactive date of cancellation no earlier than midnight of
29 the date that the premium was due.
30 (3) In the case of a health maintenance contract
31 issued to an employer or person holding the contract on behalf
22
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SENATE AMENDMENT
Bill No. CS/HBs 1927 & 961, 1st Eng.
Amendment No.
1 of the subscriber group, the health maintenance organization
2 may make the notification through the employer or group
3 contract holder, and, if the health maintenance organization
4 elects to take this action through the employer or group
5 contract holder, the organization shall be deemed to have
6 complied with the provisions of this section upon notifying
7 the employer or group contract holder of the requirements of
8 this section and requesting the employer or group contract
9 holder to forward to all subscribers the notice required
10 herein.
11 Section 14. Subsection (1) of section 641.3922,
12 Florida Statutes, 1998 Supplement, is amended to read:
13 641.3922 Conversion contracts; conditions.--Issuance
14 of a converted contract shall be subject to the following
15 conditions:
16 (1) TIME LIMIT.--Written application for the converted
17 contract shall be made and the first premium paid to the
18 health maintenance organization not later than 63 days after
19 such termination. However, if termination was the result of
20 failure to pay any required premium or contribution and such
21 nonpayment of premium was due to acts of an employer or group
22 contract holder other than the employee or individual
23 subscriber, written application for the contract must be made
24 and the first premium must be paid not later than 63 days
25 after notice of termination is mailed by the organization or
26 the employer, whichever is earlier, to the employee's or
27 individual's last address as shown by the record of the
28 organization or the employer, whichever is applicable. In such
29 case of termination due to non-payment of premium by the
30 employer or group contract holder, the premium for the
31 converted contract may not exceed the rate for the prior group
23
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SENATE AMENDMENT
Bill No. CS/HBs 1927 & 961, 1st Eng.
Amendment No.
1 coverage for the period of coverage under the converted
2 contract prior to the date notice of termination is mailed to
3 the employee or individual subscriber. For the period of
4 coverage after such date, the premium for the converted
5 contract is subject to the requirements of subsection (3).
6 Section 15. Subsection (9) is added to section 20.41,
7 Florida Statutes, to read:
8 20.41 Department of Elderly Affairs.--There is created
9 a Department of Elderly Affairs.
10 (9) Area agencies on aging are subject to chapter 119,
11 relating to public records, and, when considering any
12 contracts requiring the expenditure of funds, are subject to
13 ss. 286.011-286.012, relating to public meetings.
14 Section 16. There is appropriated to the Agency for
15 Health Care Administration for fiscal year 1999-2000
16 $1,439,000 from the Health Care Trust Fund for 12 months of
17 funding for the purpose of implementing this act.
18 Section 17. This act shall take effect upon becoming a
19 law.
20
21
22 ================ T I T L E A M E N D M E N T ===============
23 And the title is amended as follows:
24 Delete everything before the enacting clause,
25
26 and insert:
27 A bill to be entitled
28 An act relating to governmental agencies;
29 amending s. 20.41, F.S.; providing that area
30 agencies on aging are subject to ch. 119 and
31 ss. 286.011-286.012, F.S., as specified;
24
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Bill No. CS/HBs 1927 & 961, 1st Eng.
Amendment No.
1 amending s. 408.05, F.S., relating to the State
2 Center for Health Statistics; requiring the
3 Agency for Health Care Administration to
4 publish health maintenance organization report
5 cards; amending s. 408.7056, F.S.; excluding
6 certain additional grievances from
7 consideration by a statewide provider and
8 subscriber assistance panel; revising the
9 membership of the panel; amending s. 627.6471,
10 F.S.; requiring preferred provider organization
11 policies which do not provide direct patient
12 access for dermatological services to conform
13 to certain requirements imposed on exclusive
14 provider organization contracts; amending s.
15 627.6645, F.S.; revising the notice
16 requirements for cancellation or nonrenewal of
17 a group health insurance policy; specifying
18 conditions under which the insurer may
19 retroactively cancel coverage due to nonpayment
20 of premium; amending s. 627.6675, F.S.;
21 revising the time limits for an employee or
22 group member to apply for an individual
23 converted policy when termination of group
24 coverage is due to failure of the employer to
25 pay the premium; revising the requirements for
26 the premium for the converted policy; allowing
27 a group insurer to contract with another
28 insurer to issue an individual converted policy
29 under certain conditions; amending s. 641.3108,
30 F.S.; revising the notice requirements for
31 cancellation or nonrenewal of a health
25
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SENATE AMENDMENT
Bill No. CS/HBs 1927 & 961, 1st Eng.
Amendment No.
1 maintenance organization contract; specifying
2 conditions under which the organization may
3 retroactively cancel coverage due to nonpayment
4 of premium; amending s. 641.3922, F.S.;
5 revising the time limits for an employee or
6 group member to apply for a converted contract
7 from a health maintenance organization when
8 termination of group coverage is due to failure
9 of the employer to pay the premium; revising
10 the requirements for the premium for the
11 converted contract; amending s. 641.31, F.S.,
12 relating to health maintenance contracts;
13 providing for a point-of-service benefit rider
14 on a health maintenance contract; providing
15 requirements; providing restrictions;
16 authorizing reasonable copayment and annual
17 deductible; providing exceptions relating to
18 subscriber liability for services received;
19 amending s. 641.3155, F.S., relating to health
20 maintenance organization provider contracts and
21 payment of claims; requiring health maintenance
22 organizations to reconcile retroactive
23 reductions of payment to specific claims;
24 requiring providers to reconcile retroactive
25 demands for underpayment or nonpayment to
26 specific claims; providing an exception;
27 providing for the contract to specify the
28 look-back period; providing for an advisory
29 group established in the Agency for Health Care
30 Administration; requiring a report; amending s.
31 641.51, F.S.; requiring that health maintenance
26
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Bill No. CS/HBs 1927 & 961, 1st Eng.
Amendment No.
1 organizations provide additional information to
2 the Agency for Health Care Administration
3 indicating quality of care; removing a
4 requirement that organizations conduct customer
5 satisfaction surveys; revising requirements for
6 preventive pediatric health care provided by
7 health maintenance organizations; amending s.
8 641.58, F.S.; providing for moneys in the
9 Health Care Trust Fund to be used for
10 additional purposes; amending s. 409.910, F.S.;
11 clarifying that the state may recover and
12 retain damages in excess of Medicaid payments
13 made under certain circumstances; providing for
14 retroactive application; providing an
15 appropriation; providing an effective date.
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