House Bill hb0159e1
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HB 159, First Engrossed
1 A bill to be entitled
2 An act relating to health maintenance
3 organizations; amending s. 641.51, F.S.;
4 providing a licensure requirement for a
5 physician who renders an adverse determination
6 regarding services provided by another
7 state-licensed physician; clarifying the
8 authority of the Board of Medicine and the
9 Board of Osteopathic Medicine; eliminating
10 authority of certain out-of-state physicians to
11 render such determinations; amending s.
12 627.736, F.S.; relating to required personal
13 injury protection benefits; revising provisions
14 relating to personal injury protection
15 benefits; amending s. 627.410, F.S.; exempting
16 group health insurance policies insuring groups
17 of a certain size from rate filing
18 requirements; providing alternative rate filing
19 requirements for insurers with less than a
20 specified number of nationwide policyholders or
21 members; amending s. 627.411, F.S.; revising
22 the grounds for the disapproval of insurance
23 policy forms; amending s. 627.6515, F.S.;
24 providing additional experience requirements
25 and limitations for out-of-state groups;
26 providing construction; amending s. 627.6699,
27 F.S.; revising a definition; allowing carriers
28 to separate the experience of small employer
29 groups with fewer than two employees; revising
30 the rating factors that may be used by small
31 employer carriers; amending s. 627.9408, F.S.;
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HB 159, First Engrossed
1 authorizing the department to adopt by rule
2 certain provisions of the Long-Term Care
3 Insurance Model Regulation, as adopted by the
4 National Association of Insurance
5 Commissioners; amending s. 641.31, F.S.;
6 exempting contracts of group health maintenance
7 organizations covering a specified number of
8 persons from the requirements of filing with
9 the department; providing alternative rate
10 filing requirements for organizations with less
11 than a specified number of subscribers;
12 amending s. 641.3155, F.S.; specifying
13 nonapplication of certain provisions to certain
14 claims; providing for certain health flex
15 plans; providing legislative intent; providing
16 definitions; providing for a pilot program for
17 health flex plans for certain uninsured
18 persons; providing criteria; exempting approved
19 health flex plans from certain licensing
20 requirements; providing criteria for
21 eligibility to enroll in a health flex plan;
22 requiring health flex plan providers to
23 maintain certain records; providing
24 requirements for denial, nonrenewal, or
25 cancellation of coverage; specifying that
26 coverage under an approved health flex plan is
27 not an entitlement; providing for civil actions
28 against health plan entities by the Agency for
29 Health Care Administration under certain
30 circumstances; providing legislative findings;
31 creating the Workgroup on Out of State Group
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HB 159, First Engrossed
1 Policies; providing for membership; providing
2 purposes; requiring recommendations for
3 proposed legislation; providing an effective
4 date.
5
6 Be It Enacted by the Legislature of the State of Florida:
7
8 Section 1. Subsection (4) of section 641.51, Florida
9 Statutes, is amended to read:
10 641.51 Quality assurance program; second medical
11 opinion requirement.--
12 (4) The organization shall ensure that only a
13 physician with an active, unencumbered license licensed under
14 chapter 458 or chapter 459, or an allopathic or osteopathic
15 physician with an active, unencumbered license in another
16 state with similar licensing requirements may render an
17 adverse determination regarding a service provided by a
18 physician licensed in this state. The organization shall
19 submit to the treating provider and the subscriber written
20 notification regarding the organization's adverse
21 determination within 2 working days after the subscriber or
22 provider is notified of the adverse determination. The written
23 notification must include the utilization review criteria or
24 benefits provisions used in the adverse determination,
25 identify the physician who rendered the adverse determination,
26 and be signed by an authorized representative of the
27 organization or the physician who rendered the adverse
28 determination. The organization must include with the
29 notification of an adverse determination information
30 concerning the appeal process for adverse determinations.
31
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HB 159, First Engrossed
1 Section 2. Paragraphs (b) and (f) of subsection (4),
2 and paragraph (b) of subsection (5) and paragraph (a) of
3 subsection (7) of section 627.736, Florida Statutes, are
4 amended to read:
5 627.736 Required personal injury protection benefits;
6 exclusions; priority; claims.--
7 (4) BENEFITS; WHEN DUE.--Benefits due from an insurer
8 under ss. 627.730-627.7405 shall be primary, except that
9 benefits received under any workers' compensation law shall be
10 credited against the benefits provided by subsection (1) and
11 shall be due and payable as loss accrues, upon receipt of
12 reasonable proof of such loss and the amount of expenses and
13 loss incurred which are covered by the policy issued under ss.
14 627.730-627.7405. When the Agency for Health Care
15 Administration provides, pays, or becomes liable for medical
16 assistance under the Medicaid program related to injury,
17 sickness, disease, or death arising out of the ownership,
18 maintenance, or use of a motor vehicle, benefits under ss.
19 627.730-627.7405 shall be subject to the provisions of the
20 Medicaid program.
21 (b) Personal injury protection insurance benefits paid
22 pursuant to this section shall be overdue if not paid within
23 30 days after the insurer is furnished written notice of the
24 fact of a covered loss and of the amount of same. If such
25 written notice is not furnished to the insurer as to the
26 entire claim, any partial amount supported by written notice
27 is overdue if not paid within 30 days after such written
28 notice is furnished to the insurer. Any part or all of the
29 remainder of the claim that is subsequently supported by
30 written notice is overdue if not paid within 30 days after
31 such written notice is furnished to the insurer. However, any
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HB 159, First Engrossed
1 payment shall not be deemed overdue when the insurer has
2 reasonable proof to establish that the insurer is not
3 responsible for the payment that written notice has been
4 furnished to the insurer. For the purpose of calculating the
5 extent to which any benefits are overdue, payment shall be
6 treated as being made on the date a draft or other valid
7 instrument which is equivalent to payment was placed in the
8 United States mail in a properly addressed, postpaid envelope
9 or, if not so posted, on the date of delivery. This paragraph
10 does not preclude or limit the ability of the insurer to
11 assert that the claim was unrelated, was not medically
12 necessary, or was unreasonable or that the amount of the
13 charge was in excess of that permitted under, or in violation
14 of, subsection (5). Such assertion by the insurer may be made
15 at any time, including after payment of the claim or after the
16 30-day time period for payment set forth in this paragraph.
17 (f) Medical payments insurance, if available in a
18 policy of motor vehicle insurance, shall pay the portion of
19 any claim for personal injury protection medical benefits
20 which is otherwise covered but is not payable due to the
21 coinsurance provision of paragraph (1)(a), regardless of
22 whether the full amount of personal injury protection coverage
23 has been exhausted. The benefits shall not be payable for the
24 amount of any deductible which has been selected.
25 (5) CHARGES FOR TREATMENT OF INJURED PERSONS.--
26 (b) With respect to any treatment or service, other
27 than medical services billed by a hospital or other provider
28 for emergency services as defined in s. 395.002 or inpatient
29 services rendered at a hospital-owned facility, the statement
30 of charges must be furnished to the insurer by the provider
31 and may not include, and the insurer is not required to pay,
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1 charges for treatment or services rendered more than 35 30
2 days before the postmark date of the statement, except for
3 past due amounts previously billed on a timely basis under
4 this paragraph, and except that, if the provider submits to
5 the insurer a notice of initiation of treatment within 21 days
6 after its first examination or treatment of the claimant, the
7 statement may include charges for treatment or services
8 rendered up to, but not more than, 75 60 days before the
9 postmark date of the statement. The injured party is not
10 liable for, and the provider shall not bill the injured party
11 for, charges that are unpaid because of the provider's failure
12 to comply with this paragraph. Any agreement requiring the
13 injured person or insured to pay for such charges is
14 unenforceable. If, however, the insured fails to furnish the
15 provider with the correct name and address of the insured's
16 personal injury protection insurer, the provider has 35 days
17 from the date the provider obtains the correct information to
18 furnish the insurer with a statement of the charges. The
19 insurer is not required to pay for such charges, unless the
20 provider includes with the statement documentary evidence that
21 was provided by the insured during the 35-day period
22 demonstrating that the provider reasonably relied on erroneous
23 information from the insured and either:
24 1. A denial letter from the incorrect insurer; or
25 2. Proof of mailing, which may include an affidavit
26 under penalty of perjury, reflecting timely mailing to the
27 incorrect address or insurer. For emergency services and care
28 as defined in s. 395.002 rendered in a hospital emergency
29 department or for transport and treatment rendered by an
30 ambulance provider licensed pursuant to part III of chapter
31 401, the provider is not required to furnish the statement of
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HB 159, First Engrossed
1 charges within the time periods established by this paragraph;
2 and the insurer shall not be considered to have been furnished
3 with notice of the amount of covered loss for purposes of
4 paragraph (4)(b) until it receives a statement complying with
5 paragraph (e) (5)(d), or copy thereof, which specifically
6 identifies the place of service to be a hospital emergency
7 department or an ambulance in accordance with billing
8 standards recognized by the Health Care Finance
9 Administration. Each notice of insured's rights under s.
10 627.7401 must include the following statement in type no
11 smaller than 12 points:
12 BILLING REQUIREMENTS.--Florida Statutes provide
13 that with respect to any treatment or services,
14 other than certain hospital and emergency
15 services, the statement of charges furnished to
16 the insurer by the provider may not include,
17 and the insurer and the injured party are not
18 required to pay, charges for treatment or
19 services rendered more than 35 30 days before
20 the postmark date of the statement, except for
21 past due amounts previously billed on a timely
22 basis, and except that, if the provider submits
23 to the insurer a notice of initiation of
24 treatment within 21 days after its first
25 examination or treatment of the claimant, the
26 statement may include charges for treatment or
27 services rendered up to, but not more than, 75
28 60 days before the postmark date of the
29 statement.
30 (7) MENTAL AND PHYSICAL EXAMINATION OF INJURED PERSON;
31 REPORTS.--
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1 (a) Whenever the mental or physical condition of an
2 injured person covered by personal injury protection is
3 material to any claim that has been or may be made for past or
4 future personal injury protection insurance benefits, such
5 person shall, upon the request of an insurer, submit to mental
6 or physical examination by a physician or physicians. The
7 costs of any examinations requested by an insurer shall be
8 borne entirely by the insurer. Such examination shall be
9 conducted within the municipality where the insured is
10 receiving treatment, or in a location reasonably accessible to
11 the insured, which, for purposes of this paragraph, means any
12 location within the municipality in which the insured resides,
13 or any location within 10 miles by road of the insured's
14 residence, provided such location is within the county in
15 which the insured resides. If the examination is to be
16 conducted in a location reasonably accessible to the insured,
17 and if there is no qualified physician to conduct the
18 examination in a location reasonably accessible to the
19 insured, then such examination shall be conducted in an area
20 of the closest proximity to the insured's residence. Personal
21 protection insurers are authorized to include reasonable
22 provisions in personal injury protection insurance policies
23 for mental and physical examination of those claiming personal
24 injury protection insurance benefits. An insurer may not
25 withdraw payment of a treating physician without the consent
26 of the injured person covered by the personal injury
27 protection, unless the insurer first obtains a valid report by
28 a physician licensed under the same chapter as the treating
29 physician whose treatment authorization is sought to be
30 withdrawn, stating that treatment was not reasonable, related,
31 or necessary. A valid report is one prepared and signed by
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1 the physician examining the injured person or reviewing the
2 treatment records of the injured person and is factually
3 supported by the examination or treatment records, if
4 reviewed, and which has not been modified by anyone other than
5 the physician. The physician preparing the report must be in
6 active practice, unless the physician is physically disabled.
7 Active practice means that during the 3 years immediately
8 preceding the date of the physical examination or review of
9 the treatment record, the physician devoted professional time
10 to the active clinical practice of evaluation, diagnosis, or
11 treatment of medical conditions; or the instruction of
12 students in an accredited health professional school or
13 accredited residency, or at a clinical research program or a
14 clinical research program affiliated with an accredited health
15 professional school or teaching hospital, or a clinical
16 research program affiliated with an accredited health
17 professional school or accredited residency, or clinical
18 research program.
19 Section 3. Paragraph (a) of subsection (6) of section
20 627.410, Florida Statutes, is amended, and paragraph (f) is
21 added to subsection (7) of said section, to read:
22 627.410 Filing, approval of forms.--
23 (6)(a) An insurer shall not deliver or issue for
24 delivery or renew in this state any health insurance policy
25 form until it has filed with the department a copy of every
26 applicable rating manual, rating schedule, change in rating
27 manual, and change in rating schedule; if rating manuals and
28 rating schedules are not applicable, the insurer must file
29 with the department applicable premium rates and any change in
30 applicable premium rates. This paragraph does not apply to
31 group health insurance policies insuring groups of 51 or more
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HB 159, First Engrossed
1 persons, except for Medicare supplement insurance, long-term
2 care insurance, and any coverage under which the increase in
3 claims costs over the lifetime of the contract due to
4 advancing age or duration is prefunded in the premium.
5 (7)
6 (f) Insurers with fewer than 1,000 nationwide
7 policyholders or insured group members or subscribers covered
8 under any form or pooled group of forms with health insurance
9 coverage, as described in s. 627.6561(5)(a)2., excluding
10 Medicare supplement insurance coverage under part VIII, at the
11 time of a rate filing made pursuant to subparagraph (b)1., may
12 file for an annual rate increase limited to medical trend as
13 adopted by the department pursuant to s. 627.411(5). The
14 filing is in lieu of the actuarial memorandum required for a
15 rate filing prescribed by paragraph (6)(b). The filing must
16 include forms adopted by the department and a certification by
17 an officer of the company that the filing includes all similar
18 forms.
19 Section 4. Paragraph (e) of subsection (1) of section
20 627.411, Florida Statutes, is amended to read:
21 627.411 Grounds for disapproval.--
22 (1) The department shall disapprove any form filed
23 under s. 627.410, or withdraw any previous approval thereof,
24 only if the form:
25 (e) Is for health insurance, and:
26 1. Provides benefits that which are unreasonable in
27 relation to the premium charged;,
28 2. Contains provisions that which are unfair or
29 inequitable or contrary to the public policy of this state or
30 that which encourage misrepresentation;, or
31
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1 3. Contains provisions that which apply rating
2 practices that which result in premium escalations that are
3 not viable for the policyholder market or result in unfair
4 discrimination pursuant to s. 626.9541(1)(g)2.; in sales
5 practices.
6 Section 5. Subsection (9) is added to section
7 627.6515, Florida Statutes, to read:
8 627.6515 Out-of-state groups.--
9 (9) For purposes of this section, any insurer that
10 issues any group health insurance policy or group certificate
11 for health insurance to a resident of this state and requires
12 individual underwriting to determine coverage eligibility or
13 premium rates to be charged shall combine the experience of
14 all association-based group policies or association-based
15 group certificates which are substantially similar with
16 respect to type and level of benefits and marketing method
17 issued in this state after the policy form has been in force
18 for a period of 5 years to calculate uniform percentage rate
19 increases. For purposes of this section, policy forms that
20 have different cost-sharing arrangements or different riders
21 are considered to be different policy forms. Nothing in this
22 subsection shall be construed to require uniform rates for
23 policies or certificates after their fifth duration, it being
24 the intent and purpose of this law to require uniform
25 percentage rate increases for such policies or certificates.
26 Furthermore, nothing in this subsection shall be construed to
27 eliminate changes in rates by age for attained age policies or
28 certificates. The provisions of this subsection shall apply to
29 policies or certificates issued after July 1, 2001. For
30 purposes of this subsection, a group health policy or group
31 certificate for health insurance means any hospital or medical
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1 policy or certificate, hospital or medical service plan
2 contract, or health maintenance organization subscriber
3 contract. The term does not include accident-only, specified
4 disease, individual hospital indemnity, credit, dental-only,
5 vision-only, Medicare supplement, long-term care, or
6 disability income insurance; similar supplemental plans
7 provided under a separate policy, certificate, or contract of
8 insurance, which cannot duplicate coverage under an underlying
9 health plan and are specifically designed to fill gaps in the
10 underlying health plan, coinsurance, or deductibles; coverage
11 issued as a supplement to liability insurance; workers'
12 compensation or similar insurance; or automobile
13 medical-payment insurance.
14 Section 6. Paragraph (n) of subsection (3) and
15 paragraph (b) of subsection (6) of section 627.6699, Florida
16 Statutes, are amended to read:
17 627.6699 Employee Health Care Access Act.--
18 (3) DEFINITIONS.--As used in this section, the term:
19 (n) "Modified community rating" means a method used to
20 develop carrier premiums which spreads financial risk across a
21 large population; allows the use of separate rating factors
22 for age, gender, family composition, tobacco usage, and
23 geographic area as determined under paragraph (5)(j); and
24 allows adjustments for: claims experience, health status, or
25 duration of coverage as permitted under subparagraph (6)(b)5.;
26 and administrative and acquisition expenses as permitted under
27 subparagraph (6)(b)5. A carrier may separate the experience of
28 small employer groups with less than 2 eligible employees from
29 the experience of small employer groups with 2 through 50
30 eligible employees.
31 (6) RESTRICTIONS RELATING TO PREMIUM RATES.--
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1 (b) For all small employer health benefit plans that
2 are subject to this section and are issued by small employer
3 carriers on or after January 1, 1994, premium rates for health
4 benefit plans subject to this section are subject to the
5 following:
6 1. Small employer carriers must use a modified
7 community rating methodology in which the premium for each
8 small employer must be determined solely on the basis of the
9 eligible employee's and eligible dependent's gender, age,
10 family composition, tobacco use, or geographic area as
11 determined under paragraph (5)(j) and in which the premium may
12 be adjusted as permitted by subparagraphs 6. 5. and 7. 6.
13 2. Rating factors related to age, gender, family
14 composition, tobacco use, or geographic location may be
15 developed by each carrier to reflect the carrier's experience.
16 The factors used by carriers are subject to department review
17 and approval.
18 3. If the modified community rate is determined from
19 two experience pools as authorized by paragraph (3)(n), the
20 rate to be charged to small employer groups of less than 2
21 eligible employees may not exceed 150 percent of the rate
22 determined for groups of 2 through 50 eligible employees;
23 however, the carrier may charge excess losses of the less than
24 2 eligible employee experience pool to the experience pool of
25 the 2 through 50 eligible employees so that all losses are
26 allocated and the 150-percent rate limit on the less than 2
27 eligible employee experience pool is maintained.
28 4.3. Small employer carriers may not modify the rate
29 for a small employer for 12 months from the initial issue date
30 or renewal date, unless the composition of the group changes
31 or benefits are changed. However, a small employer carrier may
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1 modify the rate one time prior to 12 months after the initial
2 issue date for a small employer who enrolls under a previously
3 issued group policy that has a common anniversary date for all
4 employers covered under the policy if:
5 a. The carrier discloses to the employer in a clear
6 and conspicuous manner the date of the first renewal and the
7 fact that the premium may increase on or after that date.
8 b. The insurer demonstrates to the department that
9 efficiencies in administration are achieved and reflected in
10 the rates charged to small employers covered under the policy.
11 5.4. A carrier may issue a group health insurance
12 policy to a small employer health alliance or other group
13 association with rates that reflect a premium credit for
14 expense savings attributable to administrative activities
15 being performed by the alliance or group association if such
16 expense savings are specifically documented in the insurer's
17 rate filing and are approved by the department. Any such
18 credit may not be based on different morbidity assumptions or
19 on any other factor related to the health status or claims
20 experience of any person covered under the policy. Nothing in
21 this subparagraph exempts an alliance or group association
22 from licensure for any activities that require licensure under
23 the insurance code. A carrier issuing a group health insurance
24 policy to a small employer health alliance or other group
25 association shall allow any properly licensed and appointed
26 agent of that carrier to market and sell the small employer
27 health alliance or other group association policy. Such agent
28 shall be paid the usual and customary commission paid to any
29 agent selling the policy.
30 6.5. Any adjustments in rates for claims experience,
31 health status, or duration of coverage may not be charged to
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1 individual employees or dependents. For a small employer's
2 policy, such adjustments may not result in a rate for the
3 small employer which deviates more than 15 percent from the
4 carrier's approved rate. Any such adjustment must be applied
5 uniformly to the rates charged for all employees and
6 dependents of the small employer. A small employer carrier may
7 make an adjustment to a small employer's renewal premium, not
8 to exceed 10 percent annually, due to the claims experience,
9 health status, or duration of coverage of the employees or
10 dependents of the small employer. Semiannually, small group
11 carriers shall report information on forms adopted by rule by
12 the department, to enable the department to monitor the
13 relationship of aggregate adjusted premiums actually charged
14 policyholders by each carrier to the premiums that would have
15 been charged by application of the carrier's approved modified
16 community rates. If the aggregate resulting from the
17 application of such adjustment exceeds the premium that would
18 have been charged by application of the approved modified
19 community rate by 5 percent for the current reporting period,
20 the carrier shall limit the application of such adjustments
21 only to minus adjustments beginning not more than 60 days
22 after the report is sent to the department. For any subsequent
23 reporting period, if the total aggregate adjusted premium
24 actually charged does not exceed the premium that would have
25 been charged by application of the approved modified community
26 rate by 5 percent, the carrier may apply both plus and minus
27 adjustments. A small employer carrier may provide a credit to
28 a small employer's premium based on administrative and
29 acquisition expense differences resulting from the size of the
30 group. Group size administrative and acquisition expense
31 factors may be developed by each carrier to reflect the
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HB 159, First Engrossed
1 carrier's experience and are subject to department review and
2 approval.
3 7.6. A small employer carrier rating methodology may
4 include separate rating categories for one dependent child,
5 for two dependent children, and for three or more dependent
6 children for family coverage of employees having a spouse and
7 dependent children or employees having dependent children
8 only. A small employer carrier may have fewer, but not
9 greater, numbers of categories for dependent children than
10 those specified in this subparagraph.
11 8.7. Small employer carriers may not use a composite
12 rating methodology to rate a small employer with fewer than 10
13 employees. For the purposes of this subparagraph, a "composite
14 rating methodology" means a rating methodology that averages
15 the impact of the rating factors for age and gender in the
16 premiums charged to all of the employees of a small employer.
17 Section 7. Section 627.9408, Florida Statutes, is
18 amended to read:
19 627.9408 Rules.--
20 (1) The department may has authority to adopt rules
21 pursuant to ss. 120.536(1) and 120.54 to administer implement
22 the provisions of this part.
23 (2) The department may adopt by rule the provisions of
24 the Long-Term Care Insurance Model Regulation adopted by the
25 National Association of Insurance Commissioners in the second
26 quarter of the year 2000 which are not in conflict with the
27 Florida Insurance Code.
28 Section 8. Paragraph (b) of subsection (3) of section
29 641.31, Florida Statutes, is amended, and paragraph (f) is
30 added to said subsection, to read:
31 641.31 Health maintenance contracts.--
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1 (3)
2 (b) Any change in the rate is subject to paragraph (d)
3 and requires at least 30 days' advance written notice to the
4 subscriber. In the case of a group member, there may be a
5 contractual agreement with the health maintenance organization
6 to have the employer provide the required notice to the
7 individual members of the group. This paragraph does not apply
8 to a group contract covering 51 or more persons unless the
9 rate is for any coverage under which the increase in claim
10 costs over the lifetime of the contract due to advancing age
11 or duration is prefunded in the premium.
12 (f) A health maintenance organization with fewer than
13 1,000 covered subscribers under all individual or group
14 contracts, at the time of a rate filing, may file for an
15 annual rate increase limited to annual medical trend, as
16 adopted by the department. The filing is in lieu of the
17 actuarial memorandum otherwise required for the rate filing.
18 The filing must include forms adopted by the department and a
19 certification by an officer of the company that the filing
20 includes all similar forms.
21 Section 9. Paragraphs (a) and (b) of subsection (1) of
22 section 641.3155, Florida Statutes, are amended to read:
23 641.3155 Payment of claims.--
24 (1)(a) As used in this section, the term "clean claim"
25 for a noninstitutional provider means a claim submitted on a
26 HCFA 1500 form which has no defect or impropriety, including
27 lack of required substantiating documentation for
28 noncontracted providers and suppliers, or particular
29 circumstances requiring special treatment which prevent timely
30 payment from being made on the claim. A claim may not be
31 considered not clean solely because a health maintenance
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1 organization refers the claim to a medical specialist within
2 the health maintenance organization for examination. If
3 additional substantiating documentation, such as the medical
4 record or encounter data, is required from a source outside
5 the health maintenance organization, the claim is considered
6 not clean. This paragraph does not apply to claims which
7 include potential coordination of benefits for third-party
8 liability or subrogation, as evidenced by the information
9 provided on the claim form related to coordination of
10 benefits. This definition of "clean claim" is repealed on the
11 effective date of rules adopted by the department which define
12 the term "clean claim."
13 (b) Absent a written definition that is agreed upon
14 through contract, the term "clean claim" for an institutional
15 claim is a properly and accurately completed paper or
16 electronic billing instrument that consists of the UB-92 data
17 set or its successor with entries stated as mandatory by the
18 National Uniform Billing Committee. This paragraph does not
19 apply to claims which include potential coordination of
20 benefits for third-party liability or subrogation, as
21 evidenced by the information provided on the claim form
22 related to coordination of benefits.
23 Section 10. Health flex plans.--
24 (1) INTENT.--The Legislature finds that a significant
25 portion of the residents of this state are not able to obtain
26 affordable health insurance coverage. Therefore, it is the
27 intent of the Legislature to expand the availability of health
28 care options for lower income uninsured state residents by
29 encouraging health insurers, health maintenance organizations,
30 health care provider sponsored organizations, local
31 governments, health care districts, or other public or private
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1 community-based organizations to develop alternative
2 approaches to traditional health insurance which emphasize
3 coverage for basic and preventive health care services. To
4 the maximum extent possible, such options should be
5 coordinated with existing governmental or community-based
6 health services programs in a manner that is consistent with
7 the objectives and requirements of such programs.
8 (2) DEFINITIONS.--As used in this section:
9 (a) "Agency" means the Agency for Health Care
10 Administration.
11 (b) "Approved plan" means a health flex plan approved
12 under subsection (3) which guarantees payment by the health
13 plan entity for specified health care services provided to the
14 enrollee.
15 (c) "Enrollee" means an individual who has been
16 determined eligible for and is receiving health benefits under
17 a health flex plan approved under this section.
18 (d) "Health care coverage" means payment for health
19 care services covered as benefits under an approved plan or
20 that otherwise provides, either directly or through
21 arrangements with other persons, covered health care services
22 on a prepaid per-capita basis or on a prepaid aggregate
23 fixed-sum basis.
24 (e) "Health plan entity" means a health insurer,
25 health maintenance organization, health care provider
26 sponsored organization, local government, health care
27 districts, or other public or private community-based
28 organization that develops and implements an approved plan and
29 is responsible for financing and paying all claims by
30 enrollees of the plan.
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HB 159, First Engrossed
1 (3) PILOT PROGRAM.--The agency and the Department of
2 Insurance shall jointly approve or disapprove health flex
3 plans which provide health care coverage for eligible
4 participants residing in the three areas of the state having
5 the highest number of uninsured residents as determined by the
6 agency. A plan may limit or exclude benefits otherwise
7 required by law for insurers offering coverage in this state,
8 cap the total amount of claims paid in 1 year per enrollee, or
9 limit the number of enrollees covered. The agency and the
10 Department of Insurance shall not approve or shall withdraw
11 approval of a plan which:
12 (a) Contains any ambiguous, inconsistent, or
13 misleading provisions, or exceptions or conditions that
14 deceptively affect or limit the benefits purported to be
15 assumed in the general coverage provided by the plan;
16 (b) Provides benefits that are unreasonable in
17 relation to the premium charged, contains provisions that are
18 unfair or inequitable or contrary to the public policy of this
19 state or that encourage misrepresentation, or result in unfair
20 discrimination in sales practices; or
21 (c) Cannot demonstrate that the plan is financially
22 sound and the applicant has the ability to underwrite or
23 finance the benefits provided.
24 (4) LICENSE NOT REQUIRED.--A health flex plan approved
25 under this section shall not be subject to the licensing
26 requirements of the Florida Insurance Code or chapter 641,
27 Florida Statutes, relating to health maintenance
28 organizations, unless expressly made applicable. However, for
29 the purposes of prohibiting unfair trade practices, health
30 flex plans shall be considered insurance subject to the
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HB 159, First Engrossed
1 applicable provisions of part IX of chapter 626, Florida
2 Statutes, except as otherwise provided in this section.
3 (5) ELIGIBILITY.--Eligibility to enroll in an approved
4 health flex plan is limited to residents of this state who:
5 (a) Are 64 years of age or younger;
6 (b) Have a family income equal to or less than 200
7 percent of the federal poverty level;
8 (c) Are not covered by a private insurance policy and
9 are not eligible for coverage through a public health
10 insurance program such as Medicare or Medicaid, or other
11 public health care program, including, but not limited to,
12 Kidcare, and have not been covered at any time during the past
13 6 months; and
14 (d) Have applied for health care benefits through an
15 approved health flex plan and agree to make any payments
16 required for participation, including, but not limited to,
17 periodic payments and payments due at the time health care
18 services are provided.
19 (6) RECORDS.--Every health flex plan provider shall
20 maintain reasonable records of its loss, expense, and claims
21 experience and shall make such records reasonably available to
22 enable the agency and the Department of Insurance to monitor
23 and determine the financial viability of the plan, as
24 necessary.
25 (7) NOTICE.--The denial of coverage by the health plan
26 entity shall be accompanied by the specific reasons for
27 denial, nonrenewal, or cancellation. Notice of nonrenewal or
28 cancellation shall be provided at least 45 days in advance of
29 such nonrenewal or cancellation except that 10 days' written
30 notice shall be given for cancellation due to nonpayment of
31 premiums. If the health plan entity fails to give the
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HB 159, First Engrossed
1 required notice, the plan shall remain in effect until notice
2 is appropriately given.
3 (8) NONENTITLEMENT.--Coverage under an approved health
4 flex plan is not an entitlement and no cause of action shall
5 arise against the state, local governmental entity, or other
6 political subdivision of this state or the agency for failure
7 to make coverage available to eligible persons under this
8 section.
9 (9) CIVIL ACTIONS.--In addition to an administrative
10 action initiated under subsection (4), the agency may seek any
11 remedy provided by law, including, but not limited to, the
12 remedies provided in s. 812.035, Florida Statutes, if the
13 agency finds that a health plan entity has engaged in any act
14 resulting in injury to an enrollee covered by a plan approved
15 under this section.
16 Section 11. The Legislature finds that the
17 affordability and availability of health insurance is one of
18 the most important and complex issues in this state and that
19 coverage issued to a state resident under group health
20 insurance policies issued outside the state is an important
21 factor in meeting the needs of the citizens of this state.
22 The Legislature also finds that it is important to ensure that
23 those policies are adequately regulated in order to maintain
24 the quality of the coverage offered to citizens of this state.
25 Therefore, the Workgroup on Out of State Group Policies is
26 hereby created to study the regulatory environment in which
27 these policies are now offered and recommend any statutory
28 changes that may be necessary to maintain the quality of the
29 insurance offered in this state. There shall be four members
30 from the House of Representatives appointed by the Speaker of
31 the House of Representatives and four members from the Senate
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1 appointed by the President of the Senate. The group shall
2 begin its meetings by July 1, 2001, and complete its meetings
3 by November 15, 2001. Recommendations for suggested
4 legislation shall be delivered to the Speaker of the House of
5 Representatives and the President of the Senate by December
6 15, 2001. At its first meeting, the group shall elect a chair
7 from among its members.
8 Section 12. This act shall take effect July 1, 2001.
9 This provision does not create authority for the Board of
10 Medicine or the Board of Osteopathic Medicine to regulate the
11 organization; however, the Board of Medicine and the Board of
12 Osteopathic Medicine continue to have jurisdiction over
13 licensees of their respective boards.
14 Section 13. This act shall take effect January 1,
15 2002.
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