HB 1573, Engrossed 1 2003
1	A bill to be entitled
2	An act relating to health insurance; amending s. 395.301,
3	F.S.; requiring certain licensed facilities to make certain
4	information public electronically; requiring notice;
5	requiring an electronic link to an agency website;
6	requiring certain health care facilities to provide
7	patients with reasonable estimates of prospective charges;
8	amending s. 408.909, F.S.; revising a definition;
9	authorizing plans to limit the term of coverage; extending
10	the required period without coverage before participation
11	eligibility; authorizing a business purchasing arrangement
12	sponsored by a local government subject to specified
13	limitations; extending a program expiration date; amending
14	s. 627.410, F.S.; exempting individuals and certain groups
15	from laws restricting or limiting coinsurance, copayments,
16	or annual or lifetime maximum payments; creating s.
17	627.6410, F.S.; providing for optional coverage in health
18	insurance policies for speech, language, swallowing, and
19	hearing disorders; providing exclusion; providing
20	exceptions; providing a limitation; amending s. 627.6487,
21	F.S.; revising a definition of "eligible individual" for
22	purposes of availability of individual health insurance
23	coverage; authorizing insurers to impose certain surcharges
24	or premium charges for creditable coverage earned in
25	certain states; amending s. 627.6561, F.S.; requiring
26	additional information in a certification relating to
27	certain creditable coverage for purposes of eligibility for
28	exclusion from preexisting condition requirements; amending
29	s. 627.667, F.S.; deleting a limitation on certain
30	application of extension of benefits provisions; creating
31	s. 627.66912, F.S.; providing for optional coverage in
32	group, blanket, and franchise health insurance policies for
33	speech, language, swallowing, and hearing disorders;
34	providing exclusion; providing exceptions; providing a
35	limitation; amending s. 627.6692, F.S.; extending a time
36	period for continuation of certain coverage under group
37	health plans; amending s. 627.6699, F.S.; revising certain
38	definitions; revising enrollment period criteria for
39	certain health benefit plans; requiring small employers to
40	provide certain health benefit plan information to
41	employees; providing a limitation; revising certain rate
42	adjustment criteria; authorizing separation of experience
43	of certain small employer groups for certain purposes;
44	amending s. 641.31, F.S.; specifying nonapplication of
45	certain health maintenance contract filing requirements to
46	certain group health insurance policies, with exceptions;
47	requiring health maintenance organizations to make available
48	coverage for certain speech, language, swallowing, and
49	hearing disorders or conditions, subject to certain
50	criteria and limits, effective July 1, 2004; requiring
51	health maintenance organizations to provide specific
52	information to subscribers; creating s. 641.31075, F.S.;
53	providing compliance requirements for health maintenance
54	organizations replacing certain coverages; amending s.
55	641.3111, F.S.; providing additional requirements for
56	extension of benefits under group health maintenance
57	contracts; amending s. 641.54, F.S.; requiring health
58	maintenance organizations to provide specific information
59	to subscribers; amending s. 641.19, F.S.; defining the term
60	"specialty" or "specialist" to exclude services by a
61	chiropractic physician; providing severability; providing
62	effective dates.
63
64	Be It Enacted by the Legislature of the State of Florida:
65
66	Section 1. Subsections (7) and (8) are added to section
67	395.301, Florida Statutes, to read:
68	395.301 Itemized patient bill; form and content prescribed
69	by the agency.--
70	(7) Each licensed facility not operated by the state shall
71	make available to the public on its Internet website or by other
72	electronic means a list of charges for the top 20 percent of the
73	most frequently used charge items in each hospital’s charge
74	master for both inpatient and outpatient services. The list
75	shall be updated monthly. The facility shall place a notice in
76	the reception areas that such information is available
77	electronically and the website address and provide an electronic
78	link to the agency's website to determine the average charge per
79	diagnosis-related groups that is available.
80	(8) Each licensed facility not operated by the state
81	shall, upon request of a prospective patient prior to the
82	provision of medical services, provide a reasonable estimate of
83	charges for the proposed service. Such estimate shall not
84	preclude the actual charges from exceeding the estimate based on
85	changes in the patient’s medical condition or the treatment
86	needs of the patient as determined by the attending and
87	consulting physicians.
88	Section 2. Paragraph (e) of subsection (2), subsection
89	(3), paragraph(c) of subsection (5), and subsection (10) of
90	section 408.909, Florida Statutes, are amended to read:
91	408.909 Health flex plans.--
92	(2) DEFINITIONS.--As used in this section, the term:
93	(e) "Health flex plan" means a health plan approved under
94	subsection (3) which guarantees payment for specified health
95	care coverage provided to the enrollee who purchases coverage
96	directly from the plan or through a small business purchasing
97	arrangement sponsored by a local government.
98	(3) PILOT PROGRAM.--The agency and the department shall
99	each approve or disapprove health flex plans that provide health
100	care coverage for eligible participants who reside in the three
101	areas of the state that have the highest number of uninsured
102	persons, as identified in the Florida Health Insurance Study
103	conducted by the agency and in Indian River County. A health
104	flex plan may limit or exclude benefits otherwise required by
105	law for insurers offering coverage in this state, may cap the
106	total amount of claims paid per year per enrollee, may limit the
107	number of enrollees or the term of coverage, or may take any
108	combination of those actions.
109	(a) The agency shall develop guidelines for the review of
110	applications for health flex plans and shall disapprove or
111	withdraw approval of plans that do not meet or no longer meet
112	minimum standards for quality of care and access to care.
113	(b) The department shall develop guidelines for the review
114	of health flex plan applications and shall disapprove or shall
115	withdraw approval of plans that:
116	1. Contain any ambiguous, inconsistent, or misleading
117	provisions or any exceptions or conditions that deceptively
118	affect or limit the benefits purported to be assumed in the
119	general coverage provided by the health flex plan;
120	2. Provide benefits that are unreasonable in relation to
121	the premium charged or contain provisions that are unfair or
122	inequitable or contrary to the public policy of this state, that
123	encourage misrepresentation, or that result in unfair
124	discrimination in sales practices; or
125	3. Cannot demonstrate that the health flex plan is
126	financially sound and that the applicant is able to underwrite
127	or finance the health care coverage provided.
128	(c) The agency and the department may adopt rules as
129	needed to administer this section.
130	(5) ELIGIBILITY.--Eligibility to enroll in an approved
131	health flex plan is limited to residents of this state who:
132	(c) Are not covered by a private insurance policy and are
133	not eligible for coverage through a public health insurance
134	program, such as Medicare or Medicaid, or another public health
135	care program, such as KidCare, and have not been covered at any
136	time during the past 6 months, except that a small business
137	purchasing arrangement sponsored by a local government may limit
138	enrollment to residents of this state who have not been covered
139	at any time during the past 12 months; and
140	(10) EXPIRATION.--This section expires July 1, 20082004.
141	Section 3. Paragraph (b) of subsection (6) of section
142	627.410, Florida Statutes, is amended to read:
143	627.410 Filing, approval of forms.--
144	(6)
145	(b) The department may establish by rule, for each type of
146	health insurance form, procedures to be used in ascertaining the
147	reasonableness of benefits in relation to premium rates and may,
148	by rule, exempt from any requirement of paragraph (a) any health
149	insurance policy form or type thereof (as specified in such
150	rule) to which form or type such requirements may not be
151	practically applied or to which form or type the application of
152	such requirements is not desirable or necessary for the
153	protection of the public. A law restricting or limiting
154	deductibles, coinsurance, copayments, or annual or lifetime
155	maximum payments shall not apply to any health plan policy
156	offered or delivered to an individual or to a group of 51 or
157	more persons that provides coverage as described in s.
158	627.6561(5)(a)2.With respect to any health insurance policy
159	form or type thereof which is exempted by rule from any
160	requirement of paragraph (a), premium rates filed pursuant to
161	ss. 627.640 and 627.662 shall be for informational purposes.
162	Section 4. Effective July 1, 2004, section 627.6410,
163	Florida Statutes, is amended to read:
164	627.6410 Optional coverage for speech, language,
165	swallowing, and hearing disorders.--
166	(1) Insurers issuing individual health insurance policies
167	in this state shall make available to the policyholder as part
168	of the application for any such policy of insurance, for an
169	appropriate additional premium, the benefits or levels of
170	benefits specified in the December 1999 Florida Medicaid Therapy
171	Services Handbook for genetic or congenital disorders or
172	conditions involving speech, language, swallowing, and hearing
173	and a hearing aid and earmolds benefit at the level of benefits
174	specified in the January 2001 Florida Medicaid Hearing Services
175	Handbook.
176	(2) This section does not apply to specified accident,
177	specified disease, hospital indemnity, limited benefit,
178	disability income, or long-term care insurance policies.
179	(3) Such optional coverage is not required to be offered
180	when substantially similar benefits are included in the policy
181	of insurance issued to the policyholder.
182	(4) This section does not require or prohibit the use of a
183	provider network.
184	(5) This section does not prohibit an insurer from
185	requiring prior authorization for the benefits under this
186	section.
187	Section 5. Paragraph (b) of subsection (3) of section
188	627.6487, Florida Statutes, is amended, and paragraph (c) is
189	added to subsection (4) of said section, to read:
190	627.6487 Guaranteed availability of individual health
191	insurance coverage to eligible individuals.--
192	(3) For the purposes of this section, the term "eligible
193	individual" means an individual:
194	(b) Who is not eligible for coverage under:
195	1. A group health plan, as defined in s. 2791 of the
196	Public Health Service Act;
197	2. A conversion policy or contract issued by an authorized
198	insurer or health maintenance organization under s. 627.6675 or
199	s. 641.3921, respectively, offered to an individual who is no
200	longer eligible for coverage under either an insured or self-
201	insured group healthemployer plan or group health insurance
202	policy;
203	3. Part A or part B of Title XVIII of the Social Security
204	Act; or
205	4. A state plan under Title XIX of such act, or any
206	successor program, and does not have other health insurance
207	coverage;
208	(4)
209	(c) If the individual’s most recent period of creditable
210	coverage was earned in a state other than this state, an insurer
211	issuing a policy that complies with paragraph (a) may impose a
212	surcharge or charge a premium for such policy equal to that
213	permitted in the state in which such creditable coverage was
214	earned.
215	Section 6. Paragraph (c) of subsection (8) of section
216	627.6561, Florida Statutes, is amended to read:
217	627.6561 Preexisting conditions.--
218	(8)
219	(c) The certification described in this section is a
220	written certification that must include:
221	1. The period of creditable coverage of the individual
222	under the policy and the coverage, if any, under such COBRA
223	continuation provision or continuation pursuant to s. 627.6692.;
224	and
225	2. The waiting period, if any, imposed with respect to the
226	individual for any coverage under such policy.
227	3. A statement that the creditable coverage was provided
228	under a group health plan, a group or individual health
229	insurance policy, or a health maintenance organization contract,
230	the state in which such coverage was provided, and whether or
231	not such individual was eligible for a conversion policy under
232	such coverage.
233	Section 7. Subsection (6) of section 627.667, Florida
234	Statutes, is amended to read:
235	627.667 Extension of benefits.--
236	(6) This section also applies to holders of group
237	certificates which are renewed, delivered, or issued for
238	delivery to residents of this state under group policies
239	effectuated or delivered outside this state, unless a succeeding
240	carrier under a group policy has agreed to assume liability for
241	the benefits.
242	Section 8. Effective July 1, 2004, section 627.66912,
243	Florida Statutes, is created to read:
244	627.66912 Optional coverage for speech, language,
245	swallowing, and hearing disorders.--
246	(1) Insurers issuing group health insurance policies in
247	this state shall make available to the policyholder as part of
248	the application for any such policy of insurance, for an
249	appropriate additional premium, the benefits or levels of
250	benefits specified in the December 1999 Florida Medicaid Therapy
251	Services Handbook for genetic or congenital disorders or
252	conditions involving speech, language, swallowing, and hearing
253	and a hearing aid and earmolds benefit at the level of benefits
254	specified in the January 2001 Florida Medicaid Hearing Services
255	Handbook.
256	(2) This section does not apply to specified accident,
257	specified disease, hospital indemnity, limited benefit,
258	disability income, or long-term care insurance policies.
259	(3) Such optional coverage is not required to be offered
260	when substantially similar benefits are included in the policy
261	of insurance issued to the policyholder.
262	(4) This section does not require or prohibit the use of a
263	provider network.
264	(5) This section does not prohibit an insurer from
265	requiring prior authorization for the benefits under this
266	section.
267	Section 9. Paragraph (e) of subsection (5) of section
268	627.6692, Florida Statutes, is amended to read:
269	627.6692 Florida Health Insurance Coverage Continuation
270	Act.--
271	(5) CONTINUATION OF COVERAGE UNDER GROUP HEALTH PLANS.--
272	(e)1. A covered employee or other qualified beneficiary
273	who wishes continuation of coverage must pay the initial premium
274	and elect such continuation in writing to the insurance carrier
275	issuing the employer's group health plan within 6330days after
276	receiving notice from the insurance carrier under paragraph (d).
277	Subsequent premiums are due by the grace period expiration date.
278	The insurance carrier or the insurance carrier's designee shall
279	process all elections promptly and provide coverage
280	retroactively to the date coverage would otherwise have
281	terminated. The premium due shall be for the period beginning on
282	the date coverage would have otherwise terminated due to the
283	qualifying event. The first premium payment must include the
284	coverage paid to the end of the month in which the first payment
285	is made. After the election, the insurance carrier must bill the
286	qualified beneficiary for premiums once each month, with a due
287	date on the first of the month of coverage and allowing a 30-day
288	grace period for payment.
289	2. Except as otherwise specified in an election, any
290	election by a qualified beneficiary shall be deemed to include
291	an election of continuation of coverage on behalf of any other
292	qualified beneficiary residing in the same household who would
293	lose coverage under the group health plan by reason of a
294	qualifying event. This subparagraph does not preclude a
295	qualified beneficiary from electing continuation of coverage on
296	behalf of any other qualified beneficiary.
297	Section 10. Paragraphs (h) and (u) of subsection (3),
298	paragraph(c) of subsection (5), and paragraph (b) of
299	subsection(6) of section 627.6699, Florida Statutes, are
300	amended, and paragraph (k) is added to subsection (5) of said
301	section, to read:
302	627.6699 Employee Health Care Access Act.--
303	(3) DEFINITIONS.--As used in this section, the term:
304	(h) "Eligible employee" means an employee who works full
305	time, having a normal workweek of 25 or more hours and is paid
306	wages or a salary at least equal to the federal minimum hourly
307	wage applicable to such employee, and who has met any applicable
308	waiting-period requirements or other requirements of this act.
309	The term includes a self-employed individual, a sole proprietor,
310	a partner of a partnership, or an independent contractor, if the
311	sole proprietor, partner, or independent contractor is included
312	as an employee under a health benefit plan of a small employer,
313	but does not include a part-time, temporary, or substitute
314	employee.
315	(u) "Self-employed individual" means an individual or sole
316	proprietor who derives his or her income from a trade or
317	business carried on by the individual or sole proprietor which
318	necessitates that the individual file federal income tax forms,
319	with supporting schedules and accompanying income reporting
320	formsresults in taxable income as indicated on IRS Form 1040,
321	schedule C or F, and which generated taxable income in one of
322	the 2 previous years.
323	(5) AVAILABILITY OF COVERAGE.--
324	(c) Every small employer carrier must, as a condition of
325	transacting business in this state:
326	1. Beginning July 1, 2000, offer and issue all small
327	employer health benefit plans on a guaranteed-issue basis to
328	every eligible small employer, with 2 to 50 eligible employees,
329	that elects to be covered under such plan, agrees to make the
330	required premium payments, and satisfies the other provisions of
331	the plan. A rider for additional or increased benefits may be
332	medically underwritten and may only be added to the standard
333	health benefit plan. The increased rate charged for the
334	additional or increased benefit must be rated in accordance with
335	this section.
336	2. Beginning July 1, 2000, and until July 31, 2001, offer
337	and issue basic and standard small employer health benefit plans
338	on a guaranteed-issue basis to every eligible small employer
339	which is eligible for guaranteed renewal, has less than two
340	eligible employees, is not formed primarily for the purpose of
341	buying health insurance, elects to be covered under such plan,
342	agrees to make the required premium payments, and satisfies the
343	other provisions of the plan. A rider for additional or
344	increased benefits may be medically underwritten and may be
345	added only to the standard benefit plan. The increased rate
346	charged for the additional or increased benefit must be rated in
347	accordance with this section. For purposes of this subparagraph,
348	a person, his or her spouse, and his or her dependent children
349	shall constitute a single eligible employee if that person and
350	spouse are employed by the same small employer and either one
351	has a normal work week of less than 25 hours.
352	3. Beginning June 1, 2004August 1, 2001, offer and issue
353	basic and standard small employer health benefit plans on a
354	guaranteed-issue basis, during a 30-day open enrollment period
355	of June 1 through June 30 and during a31-day open enrollment
356	period of DecemberAugust 1 through DecemberAugust31 of each
357	year, to every eligible small employer, with fewer than two
358	eligible employees, which small employer is not formed primarily
359	for the purpose of buying health insurance and which elects to
360	be covered under such plan, agrees to make the required premium
361	payments, and satisfies the other provisions of the plan.
362	Coverage provided under this subparagraph shall begin 60 days
363	afteron October 1 of the same year asthe date of enrollment,
364	unless the small employer carrier and the small employer agree
365	to a different date. A rider for additional or increased
366	benefits may be medically underwritten and may only be added to
367	the standard health benefit plan. The increased rate charged for
368	the additional or increased benefit must be rated in accordance
369	with this section. For purposes of this subparagraph, a person,
370	his or her spouse, and his or her dependent children constitute
371	a single eligible employee if that person and spouse are
372	employed by the same small employer and either that person or
373	his or her spouse has a normal work week of less than 25 hours.
374	4. This paragraph does not limit a carrier's ability to
375	offer other health benefit plans to small employers if the
376	standard and basic health benefit plans are offered and
377	rejected.
378	(k) Beginning January 1, 2004, every small employer shall
379	provide, on an annual basis, information on at least three
380	different health benefit plans for employees. Nothing in this
381	paragraph shall be construed as requiring a small employer to
382	provide the health benefit plan or contribute to the cost of
383	such plan. Nothing in this paragraph shall be construed as
384	requiring a small employer or an individual carrier to offer
385	these health plan benefits on a guaranteed-issue basis.
386	(6) RESTRICTIONS RELATING TO PREMIUM RATES.--
387	(b) For all small employer health benefit plans that are
388	subject to this section and are issued by small employer
389	carriers on or after January 1, 1994, premium rates for health
390	benefit plans subject to this section are subject to the
391	following:
392	1. Small employer carriers must use a modified community
393	rating methodology in which the premium for each small employer
394	must be determined solely on the basis of the eligible
395	employee's and eligible dependent's gender, age, family
396	composition, tobacco use, or geographic area as determined under
397	paragraph (5)(j) and in which the premium may be adjusted as
398	permitted by this paragraph.
399	2. Rating factors related to age, gender, family
400	composition, tobacco use, or geographic location may be
401	developed by each carrier to reflect the carrier's experience.
402	The factors used by carriers are subject to department review
403	and approval.
404	3. Small employer carriers may not modify the rate for a
405	small employer for 12 months from the initial issue date or
406	renewal date, unless the composition of the group changes or
407	benefits are changed. However, a small employer carrier may
408	modify the rate one time prior to 12 months after the initial
409	issue date for a small employer who enrolls under a previously
410	issued group policy that has a common anniversary date for all
411	employers covered under the policy if:
412	a. The carrier discloses to the employer in a clear and
413	conspicuous manner the date of the first renewal and the fact
414	that the premium may increase on or after that date.
415	b. The insurer demonstrates to the department that
416	efficiencies in administration are achieved and reflected in the
417	rates charged to small employers covered under the policy.
418	4. A carrier may issue a group health insurance policy to
419	a small employer health alliance or other group association with
420	rates that reflect a premium credit for expense savings
421	attributable to administrative activities being performed by the
422	alliance or group association if such expense savings are
423	specifically documented in the insurer's rate filing and are
424	approved by the department. Any such credit may not be based on
425	different morbidity assumptions or on any other factor related
426	to the health status or claims experience of any person covered
427	under the policy. Nothing in this subparagraph exempts an
428	alliance or group association from licensure for any activities
429	that require licensure under the insurance code. A carrier
430	issuing a group health insurance policy to a small employer
431	health alliance or other group association shall allow any
432	properly licensed and appointed agent of that carrier to market
433	and sell the small employer health alliance or other group
434	association policy. Such agent shall be paid the usual and
435	customary commission paid to any agent selling the policy.
436	5. Any adjustments in rates for claims experience, health
437	status, or duration of coverage may not be charged to individual
438	employees or dependents. For a small employer's policy, such
439	adjustments may not result in a rate for the small employer
440	which deviates more than 15 percent from the carrier's approved
441	rate. Any such adjustment must be applied uniformly to the rates
442	charged for all employees and dependents of the small employer.
443	A small employer carrier may make an adjustment to a small
444	employer's renewal premium, not to exceed 10 percent annually,
445	due to the claims experience, health status, or duration of
446	coverage of the employees or dependents of the small employer.
447	Semiannually, small group carriers shall report information on
448	forms adopted by rule by the department, to enable the
449	department to monitor the relationship of aggregate adjusted
450	premiums actually charged policyholders by each carrier to the
451	premiums that would have been charged by application of the
452	carrier's approved modified community rates. If the aggregate
453	resulting from the application of such adjustment exceeds the
454	premium that would have been charged by application of the
455	approved modified community rate by 35percent for the current
456	reporting period, the carrier shall limit the application of
457	such adjustments only to minus adjustments beginning not more
458	than 60 days after the report is sent to the department. For any
459	subsequent reporting period, if the total aggregate adjusted
460	premium actually charged does not exceed the premium that would
461	have been charged by application of the approved modified
462	community rate by 35percent, the carrier may apply both plus
463	and minus adjustments. A small employer carrier may provide a
464	credit to a small employer's premium based on administrative and
465	acquisition expense differences resulting from the size of the
466	group. Group size administrative and acquisition expense factors
467	may be developed by each carrier to reflect the carrier's
468	experience and are subject to department review and approval.
469	6. A small employer carrier rating methodology may include
470	separate rating categories for one dependent child, for two
471	dependent children, and for three or more dependent children for
472	family coverage of employees having a spouse and dependent
473	children or employees having dependent children only. A small
474	employer carrier may have fewer, but not greater, numbers of
475	categories for dependent children than those specified in this
476	subparagraph.
477	7. Small employer carriers may not use a composite rating
478	methodology to rate a small employer with fewer than 10
479	employees. For the purposes of this subparagraph, a "composite
480	rating methodology" means a rating methodology that averages the
481	impact of the rating factors for age and gender in the premiums
482	charged to all of the employees of a small employer.
483	8.a. A carrier may separate the experience of small
484	employer groups with less than 2 eligible employees from the
485	experience of small employer groups with 2-50 eligible employees
486	for purposes of determining an alternative modified community
487	rating.
488	b. If a carrier separates the experience of small employer
489	groups as provided in sub-subparagraph a., the rate to be
490	charged to small employer groups of less than 2 eligible
491	employees may not exceed 150 percent of the rate determined for
492	small employer groups of 2-50 eligible employees. However, the
493	carrier may charge excess losses of the experience pool
494	consisting of small employer groups with less than 2 eligible
495	employees to the experience pool consisting of small employer
496	groups with 2-50 eligible employees so that all losses are
497	allocated and the 150-percent rate limit on the experience pool
498	consisting of small employer groups with less than 2 eligible
499	employees is maintained. Notwithstanding s. 627.411(1), the rate
500	to be charged to a small employer group of fewer than 2 eligible
501	employees, insured as of July 1, 2002, may be up to 125 percent
502	of the rate determined for small employer groups of 2-50
503	eligible employees for the first annual renewal and 150 percent
504	for subsequent annual renewals.
505	9. In addition to the separation allowed under sub-
506	subparagraph 8.a., a carrier may also separate the experience of
507	small employer groups of 1-50 eligible employees using a health
508	reimbursement arrangement, as defined in Internal Revenue
509	Service Notice 2002-45, 2002-28 Internal Revenue Bulletin 93,
510	and Revenue Ruling 2002-41, 2002-28 Internal Revenue Bulletin
511	75, from the experience of small employer groups of 1-50
512	eligible employees not using such a health reimbursement
513	arrangement for purposes of determining an alternative modified
514	community rating.
515	Section 11. Subsection (2) and paragraph (d) of subsection
516	(3) of section 641.31, Florida Statutes, are amended, and
517	subsections (40) and (41) are added to said section, to read:
518	641.31 Health maintenance contracts.--
519	(2) The rates charged by any health maintenance
520	organization to its subscribers shall not be excessive,
521	inadequate, or unfairly discriminatory or follow a rating
522	methodology that is inconsistent, indeterminate, or ambiguous or
523	encourages misrepresentation or misunderstanding. A law
524	restricting or limiting deductibles, coinsurance, copayments, or
525	annual or lifetime maximum payments shall not apply to any
526	health maintenance organization contract offered or delivered to
527	an individual or a group of 51 or more persons that provides
528	coverage as described in s. 641.31071(5)(a)2.The department, in
529	accordance with generally accepted actuarial practice as applied
530	to health maintenance organizations, may define by rule what
531	constitutes excessive, inadequate, or unfairly discriminatory
532	rates and may require whatever information it deems necessary to
533	determine that a rate or proposed rate meets the requirements of
534	this subsection.
535	(3)
536	(d) Any change in rates charged for the contract must be
537	filed with the department not less than 30 days in advance of
538	the effective date. At the expiration of such 30 days, the rate
539	filing shall be deemed approved unless prior to such time the
540	filing has been affirmatively approved or disapproved by order
541	of the department. The approval of the filing by the department
542	constitutes a waiver of any unexpired portion of such waiting
543	period. The department may extend by not more than an additional
544	15 days the period within which it may so affirmatively approve
545	or disapprove any such filing, by giving notice of such
546	extension before expiration of the initial 30-day period. At the
547	expiration of any such period as so extended, and in the absence
548	of such prior affirmative approval or disapproval, any such
549	filing shall be deemed approved. This paragraph does not apply
550	to group health contracts effectuated and delivered in this
551	state insuring groups of 51 or more persons, except for Medicare
552	supplement insurance, long-term care insurance, and any coverage
553	under which the increase in claims costs over the lifetime of
554	the contract due to advancing age or duration is refunded in the
555	premium.
556	(40) Health maintenance organizations shall make available
557	to the contract holder as part of the application for any such
558	contract, for an appropriate additional premium, the benefits or
559	level of benefits specified in the December 1999 Florida
560	Medicaid Therapy Services Handbook for genetic or congenital
561	disorders or conditions involving speech, language, swallowing,
562	and hearing and a hearing aid and earmolds benefit at the level
563	of benefits specified in the January 2001 Florida Medicaid
564	Hearing Services Handbook.
565	(a) Such optional coverage is not required to be offered
566	when substantially similar benefits are included in the contract
567	issued to the subscriber.
568	(b) This subsection does not require or prohibit the use
569	of a provider network.
570	(c) This subsection does not prohibit an organization from
571	requiring prior authorization for the benefits under this
572	subsection.
573	(d) This subsection does not apply to health maintenance
574	organizations issuing individual coverage to fewer than 50,000
575	members.
576	(e) This subsection shall take effect July 1, 2004.
577	(41) Every health maintenance organization shall make
578	available to its subscribers the estimated co-pay, co-insurance,
579	or deductible, whichever is applicable, for any covered service,
580	the status of the subscriber's maximum annual out-of-pocket
581	payments for a covered individual or family, and the status of
582	the subscriber's maximum lifetime benefit. Each health
583	maintenance organization shall, upon request of a subscriber,
584	provide an estimate of the amount the health maintenance
585	organization will pay for a particular medical procedure or
586	service. The estimate may be in the form of a range of payments
587	or an average payment. A health maintenance organization that
588	provides a subscriber with a good faith estimate is not bound by
589	the estimate.
590	Section 12. Section 641.31075, Florida Statutes, is
591	created to read:
592	641.31075 Requirements for replacing health coverage.--Any
593	health maintenance organization that is replacing any other
594	group health coverage with its group health maintenance coverage
595	shall comply with s. 627.666.
596	Section 13. Subsection (1) of section 641.3111, Florida
597	Statutes, is amended to read:
598	641.3111 Extension of benefits.--
599	(1) Every group health maintenance contract shall provide
600	that termination of the contract shall be without prejudice to
601	any continuous loss which commenced while the contract was in
602	force, but any extension of benefits beyond the period the
603	contract was in force may be predicated upon the continuous
604	total disability of the subscriber and may be limited to payment
605	for the treatment of a specific accident or illness incurred
606	while the subscriber was a member. The extension is required
607	regardless of whether the group contract holder or other entity
608	secures replacement coverage from a new insurer or health
609	maintenance organization or foregoes the provision of coverage.
610	The required provision must provide for continuation of contract
611	benefits in connection with the treatment of a specific accident
612	or illness incurred while the contract was in effect.Such
613	extension of benefits may be limited to the occurrence of the
614	earliest of the following events:
615	(a) The expiration of 12 months.
616	(b) Such time as the member is no longer totally disabled.
617	(c) A succeeding carrier elects to provide replacement
618	coverage without limitation as to the disability condition.
619	(d) The maximum benefits payable under the contract have
620	been paid.
621	Section 14. Subsection (6) is added to section 641.54,
622	Florida Statutes, to read:
623	641.54 Information disclosure.--
624	(6) Every health maintenance organization shall make
625	available to its subscribers the estimated co-pay, co-insurance,
626	or deductible, whichever is applicable, for any covered service,
627	the status of the subscriber’s maximum annual out-of-pocket
628	payments for a covered individual or family, and the status of
629	the subscriber’s maximum lifetime benefit. Each health
630	maintenance organization shall, upon request of a subscriber,
631	provide an estimate of the amount the health maintenance
632	organization will pay for a particular medical procedure or
633	service. The estimate may be in the form of a range of payments
634	or an average payment. A health maintenance organization that
635	provides a subscriber with a good faith estimate is not bound by
636	the estimate.
637	Section 15. Subsection (22) is added to section 641.19,
638	Florida Statutes, to read:
639	641.19 Definitions.--As used in this part, the term:
640	(22) "Specialty" or "specialist" shall not include the
641	services by a physician licensed under chapter 460.
642	Section 16. If any provision of this act or the
643	application thereof to any person or circumstance is held
644	invalid, the invalidity shall not affect other provisions or
645	applications of the act which can be given effect without the
646	invalid provision or application, and to this end the provisions
647	of this act are declared severable.
648	Section 17. Except as otherwise provided herein, this act
649	shall take effect upon becoming a law.
650