HOUSE AMENDMENT
Bill No. HB 1573 CS
   
1 CHAMBER ACTION
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Senate House
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12          Representative Stargel offered the following:
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14          Amendment to Amendment (209863) (with directory and title
15    amendments)
16          Between lines 618-619, insert:
17          Section 25. Subsection (2) of section 627.6515, Florida
18    Statutes, is amended, and subsections (9), (10), and (11) are
19    added to said section, to read:
20          627.6515 Out-of-state groups.--
21          (2) This part does not apply to a group health insurance
22    policy issued or delivered outside this state under which a
23    resident of this state is provided coverage if the master policy
24    met the filing requirements of the state of policy situs and was
25    available for sale in the state of policy situs and:
26          (a) The policy is issued to an employee group the
27    composition of which is substantially as described in s.
28    627.653; a labor union group or association group the
29    composition of which is substantially as described in s.
30    627.654; an additional group the composition of which is
31    substantially as described in s. 627.656; a group insured under
32    a blanket health policy when the composition of the group is
33    substantially in compliance with s. 627.659; a group insured
34    under a franchise health policy when the composition of the
35    group is substantially in compliance with s. 627.663; an
36    association group to cover persons associated in any other
37    common group, which common group is formed primarily for
38    purposes other than providing insurance; a group that is
39    established primarily for the purpose of providing group
40    insurance, provided the benefits are reasonable in relation to
41    the premiums charged thereunder and the issuance of the group
42    policy has resulted, or will result, in economies of
43    administration; or a group of insurance agents of an insurer,
44    which insurer is the policyholder;
45          (b) Certificates evidencing coverage under the policy are
46    issued to residents of this state and contain in contrasting
47    color and not less than 10-point type the following statement:
48    "The benefits of the policy providing your coverage are governed
49    primarily by the law of a state other than Florida"; and
50          (c) The policy provides the benefits specified in ss.
51    627.419, 627.6574, 627.6575, 627.6579, 627.6612, 627.66121,
52    627.66122, 627.6613, 627.667, 627.6675, 627.6691, and 627.66911
53    (d) Applications for certificates of coverage offered to
54    residents of this state contain in contrasting color and not
55    less than 12-point type the following statement on the same page
56    as the applicant signature: “This policy is primarily governed
57    by the laws of {insert state where the master policy is filed}.
58    As a result, all of the rating laws applicable to policies filed
59    in Florida do not apply to this coverage, which may result in
60    increases in your premium at renewal that would not be
61    permissible under a Florida-approved policy. Any purchase of
62    individual health insurance should be considered carefully, as
63    future medical conditions may make it impossible to qualify for
64    another individual health policy. For information concerning
65    individual health coverage under a Florida-approved policy,
66    consult your agent or the Florida Department of Financial
67    Services.” The provisions of this paragraph only apply to group
68    certificates for health insurance coverage, as described in s.
69    627.6561(5) (a) 2., which require individual underwriting to
70    determine coverage eligibility for an individual or premium
71    rates to be charged to an individual.
72          (9)(a) For purposes of this section, any insurer that
73    issues any group health benefit plan, as defined in s. 627.6699
74    (3)(k), except for policies issued to provide coverage to groups
75    of persons all of whom are in the same or functionally related
76    licensed professions, and providing coverage only to such
77    licensed professionals, their employees or their dependents, to
78    a resident of this state requiring individual underwriting to
79    determine eligibility for coverage or initial premiums rates to
80    be charged, shall not take into account the individual claims
81    experience or any change in the personal health status of a
82    covered person that occurs after the initial issuance of the
83    health benefit plan to determine his or her renewal premium
84    rates. No premium increase, including a reduced premium
85    increasing the form of a discount, may be implemented for an
86    insured individual under existing group health plan coverage
87    subsequent to the initial effective date of coverage under such
88    policy or certificate to the extent that such reduction in
89    benefits is determined based upon a change in a health-status
90    related factor of the individual insured or the past or
91    prospective claim experience of the individual insured. No
92    modifications to contractual terms and conditions may be
93    implemented for an insured individual under existing group
94    health coverage subsequent to the initial effective date of
95    coverage under such policy or certificate to the extent that
96    such modifications to contractual terms and conditions are
97    determined based upon a change in a health-status related factor
98    of the individual insured or the past or prospective claim
99    experience of the individual insured. Nothing in this section
100    shall be construed to require uniform premium rates, to restrict
101    the use of any rating factors, or to restrict experience-based
102    renewal premium rating practices that are applied to all
103    individual insureds by a particular health benefit plan or group
104    of health benefit plans The stated intent and purpose of this
105    subsection is to prohibit renewal premium practices that are
106    based exclusively upon a covered person’s individual claim
107    experience or a change in a covered person’s personal health
108    status. A certification shall be made by a qualified actuary
109    who is a member of the Society of Actuaries or the American
110    Academy of Actuaries and who is qualified in the area of health
111    insurance that the insurer’s premium structure complies with
112    this subsection.
113          (b) If an insurer has ever utilized the renewal premium
114    adjustments prohibited above, the insurer must file new renewal
115    premium rates with the department for informational purposes
116    only. The new rates must eliminate the effects of the prohibited
117    renewal premium adjustments on a revenue neutral basis. This new
118    renewal premium rate filing must be accompanied by a
119    certification by a qualified actuary who is a member of the
120    Society of Actuaries or the American Academy of Actuaries that
121    the filing complies with the requirements of this act. The
122    filing must be made within 90 days after the effective day of
123    this act. The new renewal premium rates must be implemented
124    within 90 days after the filing. This provision shall not
125    prohibit adjustments in an individual’s premiums in lieu of a
126    rescission that would be allowed under applicable law due to a
127    fraudulent or material misstatement in an application or based
128    upon changes required by law, benefit changes requested by the
129    insured, or a requested reinstatement of lapsed coverage.
130          (c) For purposes of this subsection, group health benefit
131    plan means any hospital or medical policy, hospital or medical
132    service plan contract, or health maintenance organization
133    subscriber contract. The term does not include accidental death,
134    accidental death and dismemberment, accident-only, vision-only,
135    dental-only, hospital indemnity, hospital accident, cancer,
136    specified disease, Medicare supplement, products that supplement
137    Medicare, long-term care, or disability income insurance,
138    similar supplemental plans provided under a separate policy,
139    certificate, or contract of insurance, which can not duplicate
140    coverage under an underlying health plan and are specifically
141    designed to fill gaps in the underlying health plan,
142    coinsurance, or deductibles; coverage issued as a supplement to
143    liability insurance, worker's compensation or similar insurance,
144    or automobile medical-payment insurance.
145          (d) For purposes of this subsection, any insurer that
146    issues any group health benefit plan as defined in s.
147    627.6699(3)(k), except for policies issued to provide coverage
148    to groups of persons of whom are in the same or functionally
149    related licensed professions, and providing coverage only to
150    such licensed professionals, their employees or their
151    dependents, under which a resident of this state is provided
152    coverage which has been in force for a period of three years,
153    and which applies individual underwriting to determine
154    eligibility or premium rates charged, shall not increase premium
155    rate tables charged to a resident of this state by a percentage
156    greater than the percentage increases applied to premium rate
157    tables charged to a resident of this state for coverage which
158    has been in force for a period of three years under any
159    substantially similar group health benefit plan. The commission
160    may adopt rules to establish the meaning of “substantially
161    similar benefits.” During the first 3 years of coverage, the
162    percentage increase in the premium rate charged to an individual
163    member of an association group for a new rating period may not
164    exceed the sum of the following:
165          1. The percentage change in the new business premium rate
166    measured from the first day of the prior rating period to the
167    first day of the new rating period. In the case of a carrier
168    which is not issuing new health benefit plans covering members
169    of an association group, the carrier shall use the percentage
170    change in the base premium rate.
171          2. An adjustment, not to exceed 20 percent annually and
172    adjusted pro-rata for rating period of less than one year, due
173    to the claim experience, health status or duration of coverage
174    of all individuals with coverage under health benefit plans with
175    the same or similar benefits.
176          3. Any adjustment due to change in coverage or change in
177    the case characteristic of the insured individuals. “Case
178    characteristics” mean demographic or other relevant
179    characteristics of individuals which are considered by the
180    carrier in the determination of premium rates, which may
181    include, but are not limited to, age, gender, geography, family
182    composition, occupation, tobacco-usage, and healthy lifestyle
183    discounts. Case characteristics shall not include claim
184    experience, health status and duration of coverage since issue.
185         
186          Nothing herein shall be construed to require uniform rates for
187    substantially similar policies or certificates after their third
188    year of duration, it being the intent and purpose of this law to
189    require uniform maximum percentage rate increases for such
190    policies or certificates issued after the effective date of this
191    subsection. This subsection shall apply to all policies issued
192    or renewed after the effective date of this act. A certification
193    shall be made by a qualified actuary who is a member of the
194    Society of Actuaries or the American Academy of Actuaries and
195    who is qualified in the area of health insurance that the
196    insurer’s premium structure complies with this subsection.
197          (e) For purposes of this subsection, group health benefit
198    plan means any hospital or medical policy, hospital or medical
199    service plan contract, or health maintenance organization
200    subscriber contract. The term does not include accidental
201    death, accidental death and dismemberment, accident-only,
202    vision-only, dental only, hospital indemnity, hospital accident,
203    cancer, specified disease, Medicare supplement, products that
204    supplement Medicare, long-term care, or disability income
205    insurance, similar supplemental plans provided under a separate
206    policy, certificate, or contract of insurance, which can not
207    duplicate coverage under an underlying health plan and are
208    specifically designed to fill gaps in the underlying health
209    plan, coinsurance, or deductibles; coverage issued as a
210    supplement to liability insurance; worker’s compensation, or
211    similar insurance; or automobile medical payment insurance.
212          (11) Any person insured under a certificate issued through
213    a group health benefit plan who voluntarily terminates such
214    certificate shall not be eligible for coverage under any other
215    group health insurance policy issued by the same insurer to that
216    same association for a period of six months from the date such
217    certificate was terminated, unless such new policy is available
218    to all other insureds under the existing policy without regard
219    to health status and at the same rate for all similarly situated
220    individuals. This subsection shall not apply to short-term
221    limited duration health insurance or to new coverage options
222    made available as a result of a change in law subsequent to the
223    initial issuance of a certificate.
224          Section 26. Paragraph (a) of subsection (6) of section
225    627.410, Florida Statutes, is amended to read:
226          627.410 Filing, approval of forms.--
227          (6)(a) An insurer shall not deliver or issue for delivery
228    or renew in this state any health insurance policy form until it
229    has filed with the department a copy of every applicable rating
230    manual, rating schedule, change in rating manual, and change in
231    rating schedule; if rating manuals and rating schedules are not
232    applicable, the insurer must file with the department applicable
233    premium rates and any change in applicable premium rates.
234          (b) This subsectionparagraphdoes not apply to group
235    health insurance policies:,
236          1.Effectuated and delivered in this state, insuring
237    groups of 51 or more persons, except for Medicare supplement
238    insurance, long-term care insurance, and any coverage under
239    which the increase in claim costs over the lifetime of the
240    contract due to advancing age or duration is prefunded in the
241    premium.
242          2.a. Effectuated and delivered outside this state, but
243    covering residents of this state, except for policies issued to
244    provide coverage to groups of persons all of whom are in the
245    same or functionally related licensed professions, and providing
246    coverage only to such licensed professionals, their employees or
247    their dependents, if the insurer meet the requirements of s.
248    627.6515, files its rates with the Office of Insurance
249    Regulation for information purposes only, and the filing of
250    rates is accompanied by an actuarial certification that the loss
251    ratios for the certificates delivered or issue for delivery in
252    this state meet or exceed a loss ratio in each year following
253    the third year of duration for incurred claims to earned premium
254    of 65 percent for group policies, and certificates reflecting
255    coverage thereunder, issued on or after the effective date of
256    this Act. The 65 percent loss ratio does not apply to accidental
257    death, accidental death and dismemberment, accident-only,
258    vision-only, dental only, hospital indemnity, hospital accident,
259    cancer, specified disease, or disability income insurance,
260    similar supplemental plans provided under a separate policy,
261    certificate, or contract of insurance, which can not duplicate
262    coverage under an underlying health plan and are specifically
263    designed to fill gaps in the underlying health plan,
264    coinsurance, or deductibles; coverage issued as a supplement to
265    liability insurance; worker’s compensation, or similar
266    insurance; or automobile medical payment insurance.
267          b. As used in this subsection, the actuarial certification
268    shall be made by a qualified actuary who is a member of the
269    Society of Actuaries or the American Academy of Actuaries and
270    who is qualified in the area of health insurance.
271          b. For purposes of this subsection, group health insurance
272    policy means any hospital or medical policy, hospital or medical
273    service plan contract, or health maintenance organization
274    subscriber contract.  The term does not include accidental
275    death, accidental death and dismemberment, accident-only,
276    vision-only, dental-only, hospital indemnity, hospital accident,
277    cancer, specified disease, limited-benefit, disability income
278    insurance, or similar supplemental plans provided under a
279    separate policy, certificate, or contract of insurance, which
280    can not duplicate coverage under an underlying health plan and
281    are specifically designed to fill gaps in the underlying health
282    plan, coinsurance, or deductibles; coverage issued as a
283    supplement to liability insurance; worker's compensation, or
284    similar insurance; or automobile medical-payment insurance."
285          3. Effectuated and delivered to a bona fide association
286    which means, with respect to health insurance coverage offered
287    in a State, an association which:
288          a. Has been actively in existence for at least 5 years.
289          b. Has been formed and maintained in good faith for
290    purposes other than obtaining insurance.
291          c. Does not condition membership in the association on any
292    health status-related factor relating to an individual,
293    including an employee of an employer or a dependent of an
294    employee.
295          d. Makes health insurance coverage offered through the
296    association available to all members regardless of any health
297    status-related factor relating to such members, or individuals
298    eligible for coverage through a member.
299          e. Does not make health insurance coverage offered through
300    the association available other than in connection with a member
301    of the association.
302         
303         
304         
305    ================= T I T L E A M E N D M E N T =================
306          Remove line(s) 66, and insert:
307          to subscribers; amending s. 627.6515, F.S.; limiting application
308    of certain provisions to group health insurance policies issued
309    or delivered outside the state; providing requirements for
310    certain applications for certificates of coverage; specifying
311    requirements, criteria, and limitations on issuing group health
312    benefit plans; authorizing the commission to adopt rules;
313    providing premium rate increase limitations; providing
314    construction; providing definitions; limiting coverage
315    eligibility under certain circumstances; amending s. 627.410,
316    F.S.; providing additional limitations on applications to group
317    health insurance policies; providing definitions; providing an
318    effective date.