SENATE AMENDMENT
Bill No. CS for SB 2020, 2nd Eng.
Amendment No. ___ Barcode 420016
CHAMBER ACTION
Senate House
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11 Senator Campbell moved the following amendment:
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13 Senate Amendment (with title amendment)
14 On page 5, between lines 18 and 29.
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16 insert:
17 Section 4. Subsections (2), (3), and (10) of section
18 408.909, Florida Statutes, are amended to read:
19 408.909 Health flex plans.--
20 (2) DEFINITIONS.--As used in this section, the term:
21 (a) "Agency" means the Agency for Health Care
22 Administration.
23 (b) "Department" means the Department of Insurance.
24 (c) "Enrollee" means an individual who has been
25 determined to be eligible for and is receiving health care
26 coverage under a health flex plan approved under this section.
27 (d) "Health care coverage" or "health flex plan
28 coverage" means health care services that are covered as
29 benefits under an approved health flex plan or that are
30 otherwise provided, either directly or through arrangements
31 with other persons, via a health flex plan on a prepaid per
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1 capita basis or on a prepaid aggregate fixed-sum basis.
2 (e) "Health flex plan" means a health plan approved
3 under subsection (3) which guarantees payment for specified
4 health care coverage provided to the enrollee who purchases
5 coverage directly from the plan or through a small business
6 purchasing arrangement sponsored by a local government.
7 (f) "Health flex plan entity" means a health insurer,
8 health maintenance organization,
9 health-care-provider-sponsored organization, local government,
10 health care district, or other public or private
11 community-based organization that develops and implements an
12 approved health flex plan and is responsible for administering
13 the health flex plan and paying all claims for health flex
14 plan coverage by enrollees of the health flex plan.
15 (3) PILOT PROGRAM.--The agency and the department
16 shall each approve or disapprove health flex plans that
17 provide health care coverage for eligible participants who
18 reside in the three areas of the state that have the highest
19 number of uninsured persons, as identified in the Florida
20 Health Insurance Study conducted by the agency and in Indian
21 River County. A health flex plan may limit or exclude benefits
22 otherwise required by law for insurers offering coverage in
23 this state, may cap the total amount of claims paid per year
24 per enrollee, may limit the number of enrollees or the term of
25 coverage, or may take any combination of those actions.
26 (a) The agency shall develop guidelines for the review
27 of applications for health flex plans and shall disapprove or
28 withdraw approval of plans that do not meet or no longer meet
29 minimum standards for quality of care and access to care.
30 (b) The department shall develop guidelines for the
31 review of health flex plan applications and shall disapprove
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1 or shall withdraw approval of plans that:
2 1. Contain any ambiguous, inconsistent, or misleading
3 provisions or any exceptions or conditions that deceptively
4 affect or limit the benefits purported to be assumed in the
5 general coverage provided by the health flex plan;
6 2. Provide benefits that are unreasonable in relation
7 to the premium charged or contain provisions that are unfair
8 or inequitable or contrary to the public policy of this state,
9 that encourage misrepresentation, or that result in unfair
10 discrimination in sales practices; or
11 3. Cannot demonstrate that the health flex plan is
12 financially sound and that the applicant is able to underwrite
13 or finance the health care coverage provided.
14 (c) The agency and the department may adopt rules as
15 needed to administer this section.
16 (10) EXPIRATION.--This section expires July 1, 2008
17 2004.
18 Section 5. Subsection (4) of section 624.406, Florida
19 Statutes, is amended to read:
20 624.406 Combinations of insuring powers, one
21 insurer.--An insurer which otherwise qualifies therefor may be
22 authorized to transact any one kind or combination of kinds of
23 insurance as defined in part V except:
24 (1) A life insurer may also grant annuities, but shall
25 not be authorized to transact any other kind of insurance
26 except health insurance, disability income insurance, excess
27 coverage for health maintenance organizations, or excess
28 insurance, specific and aggregate, for self-insurers of a plan
29 of health insurance and multiple-employer welfare
30 arrangements.
31 (2) A reciprocal insurer shall not transact life
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1 insurance.
2 (3) Except as to domestic business trust title
3 insurers as referred to in s. 624.404(6), so authorized prior
4 to the effective date of this code, a title insurer shall be a
5 stock insurer.
6 (4) A health insurer may also transact excess
7 insurance, specific and aggregate, for self-insurers of a plan
8 of health insurance and multiple-employer welfare arrangements
9 and reinsurance for the medical and lost-wages benefits
10 provided under a workers' compensation policy.
11 Section 6. Section 624.603, Florida Statutes, is
12 amended to read:
13 624.603 "Health insurance" defined.--"Health
14 insurance," also known as "disability insurance," is insurance
15 of human beings against bodily injury, disablement, or death
16 by accident or accidental means, or the expense thereof, or
17 against disablement or expense resulting from sickness, and
18 every insurance appertaining thereto. Health insurance does
19 not include workers' compensation coverages, except as
20 provided in s. 624.406.
21 Section 7. Section 627.6042, Florida Statutes, is
22 created to read:
23 627.6042 Dependent coverage.--
24 (1) If an insurer offers coverage that insures
25 dependent children of the policyholder or certificateholder,
26 the policy must insure a dependent child of the policyholder
27 or certificateholder at least until the end of the calendar
28 year in which the child reaches the age of 25, if the child
29 meets all of the following:
30 (a) The child is dependent upon the policyholder or
31 certificateholder for support.
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1 (b) The child is living in the household of the
2 policyholder or certificateholder or the child is a full-time
3 or part-time student.
4 (2) Nothing in this section affects or preempts an
5 insurer's right to medically underwrite or charge the
6 appropriate premium.
7 Section 8. Section 627.60425, Florida Statutes, is
8 created to read:
9 627.60425 Binding arbitration requirement
10 limitations.--Notwithstanding any other provision of law
11 except s. 624.155, an individual, blanket, or group life or
12 group health insurance policy, individual or group health
13 maintenance organization subscriber contract, prepaid limited
14 health organization subscriber contract, or any life or health
15 insurance policy or certificate delivered or issued for
16 delivery, including out of state group plans pursuant to s.
17 627.5515 or 627.6515 covering residents of this state, to any
18 resident of this state, shall not require the submission of
19 disputes between the parties to the policy, contract, or plan
20 to binding arbitration unless the applicant has indicated that
21 the same policy, contract, or plan was offered and rejected
22 without arbitration and that the binding arbitration provision
23 was fully explained to the applicant and willingly accepted.
24 Section 9. Section 627.6044, Florida Statutes, is
25 amended to read:
26 627.6044 Use of a specific methodology for payment of
27 claims.--
28 (1) Each insurance policy that provides for payment of
29 claims to non-network providers which is less than the payment
30 of the provider's billed charges to the insured, excluding
31 deductible, coinsurance, and copay amounts, shall:
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1 (a) Provide benefits, prior to deductible,
2 coinsurance, and copay amounts, for using a non-network
3 provider which are at least equal to the amount that would
4 have been allowed had the insured used a network provider, but
5 not in excess of the actual billed charges.
6 (b) Where there are multiple network providers in the
7 geographical area in which the services were provided, or if
8 none, the closest geographic area, the carrier may use an
9 averaging method of the contracted amounts, but not less than
10 the 80th percentile of all network contracted amounts in the
11 geographic area.
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13 For purposes of this subsection, the term "network providers"
14 means those providers for which an insured will not be
15 responsible for any balance payment for services provided by
16 such provider, excluding deductible, coinsurance, and copay
17 amounts. based on a specific methodology, including, but not
18 limited to, usual and customary charges, reasonable and
19 customary charges, or charges based upon the prevailing rate
20 in the community, shall specify the formula or criteria used
21 by the insurer in determining the amount to be paid.
22 (2) Each insurer issuing a policy that provides for
23 payment of claims based on a specific methodology shall
24 provide to an insured, upon her or his written request, an
25 estimate of the amount the insurer will pay for a particular
26 medical procedure or service. The estimate may be in the form
27 of a range of payments or an average payment and may specify
28 that the estimate is based on the assumption of a particular
29 service code. The insurer may require the insured to provide
30 detailed information regarding the procedure or service to be
31 performed, including the procedure or service code number
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1 provided by the health care provider and the health care
2 provider's estimated charge. An insurer that provides an
3 insured with a good faith estimate is not bound by the
4 estimate. However, a pattern of providing estimates that vary
5 significantly from the ultimate insurance payment constitutes
6 a violation of this code.
7 (3) The method used for determining the payment of
8 claims shall be included in filings made pursuant to s.
9 627.410(6), and may not be changed unless such change is filed
10 under s. 627.410(6).
11 (4) Any policy that provides that the insured is
12 responsible for the balance of a claim amount, excluding
13 deductible, coinsurance, and copay amounts, must disclose such
14 feature on the face of the policy or certificate and such
15 feature must be included in any outline of coverage provided
16 to the insured.
17 Section 10. Subsections (1) and (4) of section
18 627.6415, Florida Statutes, are amended to read:
19 627.6415 Coverage for natural-born, adopted, and
20 foster children; children in insured's custodial care.--
21 (1) A health insurance policy that provides coverage
22 for a member of the family of the insured shall, as to the
23 family member's coverage, provide that the health insurance
24 benefits applicable to children of the insured also apply to
25 an adopted child or a foster child of the insured placed in
26 compliance with chapter 63, prior to the child's 18th
27 birthday, from the moment of placement in the residence of the
28 insured. Except in the case of a foster child, the policy may
29 not exclude coverage for any preexisting condition of the
30 child. In the case of a newborn child, coverage begins at the
31 moment of birth if a written agreement to adopt the child has
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1 been entered into by the insured prior to the birth of the
2 child, whether or not the agreement is enforceable. This
3 section does not require coverage for an adopted child who is
4 not ultimately placed in the residence of the insured in
5 compliance with chapter 63.
6 (4) In order to increase access to postnatal, infant,
7 and pediatric health care for all children placed in
8 court-ordered custody, including foster children, all health
9 insurance policies that provide coverage for a member of the
10 family of the insured shall, as to such family member's
11 coverage, also provide that the health insurance benefits
12 applicable for children shall be payable with respect to a
13 foster child or other child in court-ordered temporary or
14 other custody of the insured, prior to the child's 18th
15 birthday.
16 Section 11. Paragraph (a) of subsection (5), paragraph
17 (c) of subsection (6), and paragraphs (b), (c), and (e) of
18 subsection (7) of section 627.6475, Florida Statutes, are
19 amended to read:
20 627.6475 Individual reinsurance pool.--
21 (5) ISSUER'S ELECTION TO BECOME A RISK-ASSUMING
22 CARRIER.--
23 (a) Each health insurance issuer that offers
24 individual health insurance must elect to become a
25 risk-assuming carrier or a reinsuring carrier for purposes of
26 this section. Each such issuer must make an initial election,
27 binding through December 31, 1999. The issuer's initial
28 election must be made no later than October 31, 1997. By
29 October 31, 1997, all issuers must file a final election,
30 which is binding for 2 years, from January 1, 1998, through
31 December 31, 1999, after which an election which shall be
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1 binding indefinitely or until modified or withdrawn for a
2 period of 5 years. The department may permit an issuer to
3 modify its election at any time for good cause shown, after a
4 hearing.
5 (6) ELECTION PROCESS TO BECOME A RISK-ASSUMING
6 CARRIER.--
7 (c) The department shall provide public notice of an
8 issuer's filing a designation of election under this
9 subsection to become a risk-assuming carrier and shall provide
10 at least a 21-day period for public comment upon receipt of
11 such filing prior to making a decision on the election. The
12 department shall hold a hearing on the election at the request
13 of the issuer.
14 (7) INDIVIDUAL HEALTH REINSURANCE PROGRAM.--
15 (b) A reinsuring carrier may reinsure with the program
16 coverage of an eligible individual, subject to each of the
17 following provisions:
18 1. A reinsuring carrier may reinsure an eligible
19 individual within 90 60 days after commencement of the
20 coverage of the eligible individual.
21 2. The program may not reimburse a participating
22 carrier with respect to the claims of a reinsured eligible
23 individual until the carrier has paid incurred claims of an
24 amount equal to the participating carrier's selected
25 deductible level at least $5,000 in a calendar year for
26 benefits covered by the program. In addition, the reinsuring
27 carrier is responsible for 10 percent of the next $50,000 and
28 5 percent of the next $100,000 of incurred claims during a
29 calendar year, and the program shall reinsure the remainder.
30 3. The board shall annually adjust the initial level
31 of claims and the maximum limit to be retained by the carrier
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1 to reflect increases in costs and utilization within the
2 standard market for health benefit plans within the state. The
3 adjustment may not be less than the annual change in the
4 medical component of the "Commerce Price Index for All Urban
5 Consumers" of the Bureau of Labor Statistics of the United
6 States Department of Labor, unless the board proposes and the
7 department approves a lower adjustment factor.
8 4. A reinsuring carrier may terminate reinsurance for
9 all reinsured eligible individuals on any plan anniversary.
10 5. The premium rate charged for reinsurance by the
11 program to a health maintenance organization that is approved
12 by the Secretary of Health and Human Services as a federally
13 qualified health maintenance organization pursuant to 42
14 U.S.C. s. 300e(c)(2)(A) and that, as such, is subject to
15 requirements that limit the amount of risk that may be ceded
16 to the program, which requirements are more restrictive than
17 subparagraph 2., shall be reduced by an amount equal to that
18 portion of the risk, if any, which exceeds the amount set
19 forth in subparagraph 2., which may not be ceded to the
20 program.
21 6. The board may consider adjustments to the premium
22 rates charged for reinsurance by the program or carriers that
23 use effective cost-containment measures, including high-cost
24 case management, as defined by the board.
25 7. A reinsuring carrier shall apply its
26 case-management and claims-handling techniques, including, but
27 not limited to, utilization review, individual case
28 management, preferred provider provisions, other managed-care
29 provisions, or methods of operation consistently with both
30 reinsured business and nonreinsured business.
31 (c)1. The board, as part of the plan of operation,
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1 shall establish a methodology for determining premium rates to
2 be charged by the program for reinsuring eligible individuals
3 pursuant to this section. The methodology must include a
4 system for classifying individuals which reflects the types of
5 case characteristics commonly used by carriers in this state.
6 The methodology must provide for the development of basic
7 reinsurance premium rates, which shall be multiplied by the
8 factors set for them in this paragraph to determine the
9 premium rates for the program. The basic reinsurance premium
10 rates shall be established by the board, subject to the
11 approval of the department, and shall be set at levels that
12 reasonably approximate gross premiums charged to eligible
13 individuals for individual health insurance by health
14 insurance issuers. The premium rates set by the board may vary
15 by geographical area, as determined under this section, to
16 reflect differences in cost. An eligible individual may be
17 reinsured for a rate that is five times the rate established
18 by the board.
19 2. The board shall periodically review the methodology
20 established, including the system of classification and any
21 rating factors, to ensure that it reasonably reflects the
22 claims experience of the program. The board may propose
23 changes to the rates that are subject to the approval of the
24 department.
25 (e)1. Before September March 1 of each calendar year,
26 the board shall determine and report to the department the
27 program net loss in the individual account for the previous
28 year, including administrative expenses for that year and the
29 incurred losses for that year, taking into account investment
30 income and other appropriate gains and losses.
31 2. Any net loss in the individual account for the year
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1 shall be recouped by assessing the carriers as follows:
2 a. The operating losses of the program shall be
3 assessed in the following order subject to the specified
4 limitations. The first tier of assessments shall be made
5 against reinsuring carriers in an amount that may not exceed 5
6 percent of each reinsuring carrier's premiums for individual
7 health insurance. If such assessments have been collected and
8 additional moneys are needed, the board shall make a second
9 tier of assessments in an amount that may not exceed 0.5
10 percent of each carrier' s health benefit plan premiums.
11 b. Except as provided in paragraph (f), risk-assuming
12 carriers are exempt from all assessments authorized pursuant
13 to this section. The amount paid by a reinsuring carrier for
14 the first tier of assessments shall be credited against any
15 additional assessments made.
16 c. The board shall equitably assess reinsuring
17 carriers for operating losses of the individual account based
18 on market share. The board shall annually assess each carrier
19 a portion of the operating losses of the individual account.
20 The first tier of assessments shall be determined by
21 multiplying the operating losses by a fraction, the numerator
22 of which equals the reinsuring carrier's earned premium
23 pertaining to direct writings of individual health insurance
24 in the state during the calendar year for which the assessment
25 is levied, and the denominator of which equals the total of
26 all such premiums earned by reinsuring carriers in the state
27 during that calendar year. The second tier of assessments
28 shall be based on the premiums that all carriers, except
29 risk-assuming carriers, earned on all health benefit plans
30 written in this state. The board may levy interim assessments
31 against reinsuring carriers to ensure the financial ability of
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1 the plan to cover claims expenses and administrative expenses
2 paid or estimated to be paid in the operation of the plan for
3 the calendar year prior to the association's anticipated
4 receipt of annual assessments for that calendar year. Any
5 interim assessment is due and payable within 30 days after
6 receipt by a carrier of the interim assessment notice. Interim
7 assessment payments shall be credited against the carrier's
8 annual assessment. Health benefit plan premiums and benefits
9 paid by a carrier that are less than an amount determined by
10 the board to justify the cost of collection may not be
11 considered for purposes of determining assessments.
12 d. Subject to the approval of the department, the
13 board shall adjust the assessment formula for reinsuring
14 carriers that are approved as federally qualified health
15 maintenance organizations by the Secretary of Health and Human
16 Services pursuant to 42 U.S.C. s. 300e(c)(2)(A) to the extent,
17 if any, that restrictions are placed on them which are not
18 imposed on other carriers.
19 3. Before September March 1 of each year, the board
20 shall determine and file with the department an estimate of
21 the assessments needed to fund the losses incurred by the
22 program in the individual account for the previous calendar
23 year.
24 4. If the board determines that the assessments needed
25 to fund the losses incurred by the program in the individual
26 account for the previous calendar year will exceed the amount
27 specified in subparagraph 2., the board shall evaluate the
28 operation of the program and report its findings and
29 recommendations to the department in the format established in
30 s. 627.6699(11) for the comparable report for the small
31 employer reinsurance program.
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1 Section 12. Subsection (4) of section 627.651, Florida
2 Statutes, is amended to read:
3 627.651 Group contracts and plans of self-insurance
4 must meet group requirements.--
5 (4) This section does not apply to any plan which is
6 established or maintained by an individual employer in
7 accordance with the Employee Retirement Income Security Act of
8 1974, Pub. L. No. 93-406, or to a multiple-employer welfare
9 arrangement as defined in s. 624.437(1), except that a
10 multiple-employer welfare arrangement shall comply with ss.
11 627.419, 627.657, 627.6575, 627.6578, 627.6579, 627.6612,
12 627.66121, 627.66122, 627.6615, 627.6616, and 627.662(8)(7).
13 This subsection does not allow an authorized insurer to issue
14 a group health insurance policy or certificate which does not
15 comply with this part.
16 Section 13. Section 627.662, Florida Statutes, is
17 amended to read:
18 627.662 Other provisions applicable.--The following
19 provisions apply to group health insurance, blanket health
20 insurance, and franchise health insurance:
21 (1) Section 627.569, relating to use of dividends,
22 refunds, rate reductions, commissions, and service fees.
23 (2) Section 627.602(1)(f) and (2), relating to
24 identification numbers and statement of deductible provisions.
25 (3) Section 627.6044, relating to the use of specific
26 methodology for payment of claims.
27 (4)(3) Section 627.635, relating to excess insurance.
28 (5)(4) Section 627.638, relating to direct payment for
29 hospital or medical services.
30 (6)(5) Section 627.640, relating to filing and
31 classification of rates.
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1 (7)(6) Section 627.613, relating to timely payment of
2 claims, or s. 627.6131, relating to payment of claims,
3 whichever is applicable.
4 (8)(7) Section 627.645(1), relating to denial of
5 claims.
6 (9)(8) Section 627.6471, relating to preferred
7 provider organizations.
8 (10)(9) Section 627.6472, relating to exclusive
9 provider organizations.
10 (11)(10) Section 627.6473, relating to combined
11 preferred provider and exclusive provider policies.
12 (12)(11) Section 627.6474, relating to provider
13 contracts.
14 Section 14. Subsection (6) of section 627.667, Florida
15 Statutes, is amended to read:
16 627.667 Extension of benefits.--
17 (6) This section also applies to holders of group
18 certificates which are renewed, delivered, or issued for
19 delivery to residents of this state under group policies
20 effectuated or delivered outside this state, unless a
21 succeeding carrier under a group policy has agreed to assume
22 liability for the benefits.
23 Section 15. Paragraph (e) of subsection (5) of section
24 627.6692, Florida Statutes, is amended to read:
25 627.6692 Florida Health Insurance Coverage
26 Continuation Act.--
27 (5) CONTINUATION OF COVERAGE UNDER GROUP HEALTH
28 PLANS.--
29 (e)1. A covered employee or other qualified
30 beneficiary who wishes continuation of coverage must pay the
31 initial premium and elect such continuation in writing to the
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1 insurance carrier issuing the employer's group health plan
2 within 63 30 days after receiving notice from the insurance
3 carrier under paragraph (d). Subsequent premiums are due by
4 the grace period expiration date. The insurance carrier or the
5 insurance carrier's designee shall process all elections
6 promptly and provide coverage retroactively to the date
7 coverage would otherwise have terminated. The premium due
8 shall be for the period beginning on the date coverage would
9 have otherwise terminated due to the qualifying event. The
10 first premium payment must include the coverage paid to the
11 end of the month in which the first payment is made. After the
12 election, the insurance carrier must bill the qualified
13 beneficiary for premiums once each month, with a due date on
14 the first of the month of coverage and allowing a 30-day grace
15 period for payment.
16 2. Except as otherwise specified in an election, any
17 election by a qualified beneficiary shall be deemed to include
18 an election of continuation of coverage on behalf of any other
19 qualified beneficiary residing in the same household who would
20 lose coverage under the group health plan by reason of a
21 qualifying event. This subparagraph does not preclude a
22 qualified beneficiary from electing continuation of coverage
23 on behalf of any other qualified beneficiary.
24 Section 16. Paragraphs (g), (h), (i), and (u) of
25 subsection (3), paragraph (c) of subsection (5), paragraph (a)
26 of subsection (9), paragraph (d) of subsection (10), and
27 paragraphs (f), (g), (h), and (j) of subsection (11) of
28 section 627.6699, Florida Statutes, are amended to read:
29 627.6699 Employee Health Care Access Act.--
30 (3) DEFINITIONS.--As used in this section, the term:
31 (g) "Dependent" means the spouse or child as described
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1 in s. 627.6512 of an eligible employee, subject to the
2 applicable terms of the health benefit plan covering that
3 employee.
4 (h) "Eligible employee" means an employee who works
5 full time, having a normal workweek of 25 or more hours, who
6 is paid wages or a salary at least equal to the federal
7 minimum hourly wage applicable to such employee, and who has
8 met any applicable waiting-period requirements or other
9 requirements of this act. The term includes a self-employed
10 individual, a sole proprietor, a partner of a partnership, or
11 an independent contractor, if the sole proprietor, partner, or
12 independent contractor is included as an employee under a
13 health benefit plan of a small employer, but does not include
14 a part-time, temporary, or substitute employee.
15 (i) "Established geographic area" means the county or
16 counties, or any portion of a county or counties, within which
17 the carrier provides or arranges for health care services to
18 be available to its insureds, members, or subscribers.
19 (u) "Self-employed individual" means an individual or
20 sole proprietor who derives his or her income from a trade or
21 business carried on by the individual or sole proprietor which
22 necessitates that the individual file with the Internal
23 Revenue Service for the most recent tax year federal income
24 tax forms with supporting schedules and accompanying income
25 reporting forms or federal income tax extensions of time to
26 file forms results in taxable income as indicated on IRS Form
27 1040, schedule C or F, and which generated taxable income in
28 one of the 2 previous years.
29 (5) AVAILABILITY OF COVERAGE.--
30 (c) Every small employer carrier must, as a condition
31 of transacting business in this state:
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1 1. Beginning July 1, 2000, offer and issue all small
2 employer health benefit plans on a guaranteed-issue basis to
3 every eligible small employer, with 2 to 50 eligible
4 employees, that elects to be covered under such plan, agrees
5 to make the required premium payments, and satisfies the other
6 provisions of the plan. A rider for additional or increased
7 benefits may be medically underwritten and may only be added
8 to the standard health benefit plan. The increased rate
9 charged for the additional or increased benefit must be rated
10 in accordance with this section.
11 2. Beginning July 1, 2000, and until July 31, 2001,
12 offer and issue basic and standard small employer health
13 benefit plans on a guaranteed-issue basis to every eligible
14 small employer which is eligible for guaranteed renewal, has
15 less than two eligible employees, is not formed primarily for
16 the purpose of buying health insurance, elects to be covered
17 under such plan, agrees to make the required premium payments,
18 and satisfies the other provisions of the plan. A rider for
19 additional or increased benefits may be medically underwritten
20 and may be added only to the standard benefit plan. The
21 increased rate charged for the additional or increased benefit
22 must be rated in accordance with this section. For purposes of
23 this subparagraph, a person, his or her spouse, and his or her
24 dependent children shall constitute a single eligible employee
25 if that person and spouse are employed by the same small
26 employer and either one has a normal work week of less than 25
27 hours.
28 3.a. Beginning August 1, 2001, offer and issue basic
29 and standard small employer health benefit plans on a
30 guaranteed-issue basis, during a 31-day open enrollment period
31 of August 1 through August 31 of each year, to every eligible
18
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Bill No. CS for SB 2020, 2nd Eng.
Amendment No. ___ Barcode 420016
1 small employer, with fewer than two eligible employees, which
2 small employer is not formed primarily for the purpose of
3 buying health insurance and which elects to be covered under
4 such plan, agrees to make the required premium payments, and
5 satisfies the other provisions of the plan. Coverage provided
6 under this sub-subparagraph subparagraph shall begin on
7 October 1 of the same year as the date of enrollment, unless
8 the small employer carrier and the small employer agree to a
9 different date. A rider for additional or increased benefits
10 may be medically underwritten and may only be added to the
11 standard health benefit plan. The increased rate charged for
12 the additional or increased benefit must be rated in
13 accordance with this section. For purposes of this
14 sub-subparagraph subparagraph, a person, his or her spouse,
15 and his or her dependent children constitute a single eligible
16 employee if that person and spouse are employed by the same
17 small employer and either that person or his or her spouse has
18 a normal work week of less than 25 hours.
19 b. Notwithstanding the restrictions set forth in
20 sub-subparagraph a., when a small employer group is losing
21 coverage because a carrier is exercising the provisions of s.
22 627.6571(3)(b) or s. 641.31074(3)(b), the eligible small
23 employer, as defined in sub-subparagraph a., shall be entitled
24 to enroll with another carrier offering small employer
25 coverage within 63 days after the notice of termination or the
26 termination date of the prior coverage, whichever is later.
27 Coverage provided under this sub-subparagraph shall begin
28 immediately upon enrollment unless the small employer carrier
29 and the small employer agree to a different date.
30 4. This paragraph does not limit a carrier's ability
31 to offer other health benefit plans to small employers if the
19
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Bill No. CS for SB 2020, 2nd Eng.
Amendment No. ___ Barcode 420016
1 standard and basic health benefit plans are offered and
2 rejected.
3 (9) SMALL EMPLOYER CARRIER'S ELECTION TO BECOME A
4 RISK-ASSUMING CARRIER OR A REINSURING CARRIER.--
5 (a) A small employer carrier must elect to become
6 either a risk-assuming carrier or a reinsuring carrier. Each
7 small employer carrier must make an initial election, binding
8 through January 1, 1994. The carrier's initial election must
9 be made no later than October 31, 1992. By October 31, 1993,
10 all small employer carriers must file a final election, which
11 is binding for 2 years, from January 1, 1994, through December
12 31, 1995, after which an election shall be binding for a
13 period of 5 years. Any carrier that is not a small employer
14 carrier on October 31, 1992, and intends to become a small
15 employer carrier after October 31, 1992, must file its
16 designation when it files the forms and rates it intends to
17 use for small employer group health insurance; such
18 designation shall be binding indefinitely or until modified or
19 withdrawn for 2 years after the date of approval of the forms
20 and rates, and any subsequent designation is binding for 5
21 years. The department may permit a carrier to modify its
22 election at any time for good cause shown, after a hearing.
23 (10) ELECTION PROCESS TO BECOME A RISK-ASSUMING
24 CARRIER.--
25 (d) The department shall provide public notice of a
26 small employer carrier's filing a designation of election
27 under subsection (9) to become a risk-assuming carrier and
28 shall provide at least a 21-day period for public comment upon
29 receipt of such filing prior to making a decision on the
30 election. The department shall hold a hearing on the election
31 at the request of the carrier.
20
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Bill No. CS for SB 2020, 2nd Eng.
Amendment No. ___ Barcode 420016
1 (11) SMALL EMPLOYER HEALTH REINSURANCE PROGRAM.--
2 (f) The program has the general powers and authority
3 granted under the laws of this state to insurance companies
4 and health maintenance organizations licensed to transact
5 business, except the power to issue health benefit plans
6 directly to groups or individuals. In addition thereto, the
7 program has specific authority to:
8 1. Enter into contracts as necessary or proper to
9 carry out the provisions and purposes of this act, including
10 the authority to enter into contracts with similar programs of
11 other states for the joint performance of common functions or
12 with persons or other organizations for the performance of
13 administrative functions.
14 2. Sue or be sued, including taking any legal action
15 necessary or proper for recovering any assessments and
16 penalties for, on behalf of, or against the program or any
17 carrier.
18 3. Take any legal action necessary to avoid the
19 payment of improper claims against the program.
20 4. Issue reinsurance policies, in accordance with the
21 requirements of this act.
22 5. Establish rules, conditions, and procedures for
23 reinsurance risks under the program participation.
24 6. Establish actuarial functions as appropriate for
25 the operation of the program.
26 7. Assess participating carriers in accordance with
27 paragraph (j), and make advance interim assessments as may be
28 reasonable and necessary for organizational and interim
29 operating expenses. Interim assessments shall be credited as
30 offsets against any regular assessments due following the
31 close of the calendar year.
21
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Bill No. CS for SB 2020, 2nd Eng.
Amendment No. ___ Barcode 420016
1 8. Appoint appropriate legal, actuarial, and other
2 committees as necessary to provide technical assistance in the
3 operation of the program, and in any other function within the
4 authority of the program.
5 9. Borrow money to effect the purposes of the program.
6 Any notes or other evidences of indebtedness of the program
7 which are not in default constitute legal investments for
8 carriers and may be carried as admitted assets.
9 10. To the extent necessary, increase the $5,000
10 deductible reinsurance requirement to adjust for the effects
11 of inflation. The program may evaluate the desirability of
12 establishing different levels of deductibles. If different
13 levels of deductibles are established, such levels and the
14 resulting premiums shall be approved by the office.
15 (g) A reinsuring carrier may reinsure with the program
16 coverage of an eligible employee of a small employer, or any
17 dependent of such an employee, subject to each of the
18 following provisions:
19 1. With respect to a standard and basic health care
20 plan, the program may must reinsure the level of coverage
21 provided; and, with respect to any other plan, the program may
22 must reinsure the coverage up to, but not exceeding, the level
23 of coverage provided under the standard and basic health care
24 plan. As an alternative to reinsuring the level of coverage
25 provided under the standard and basic health care plan, the
26 program may develop alternate levels of reinsurance designed
27 to coordinate with a reinsuring carrier's existing
28 reinsurance. The levels of reinsurance and resulting premiums
29 must be approved by the office.
30 2. Except in the case of a late enrollee, a reinsuring
31 carrier may reinsure an eligible employee or dependent within
22
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Bill No. CS for SB 2020, 2nd Eng.
Amendment No. ___ Barcode 420016
1 60 days after the commencement of the coverage of the small
2 employer. A newly employed eligible employee or dependent of a
3 small employer may be reinsured within 60 days after the
4 commencement of his or her coverage.
5 3. A small employer carrier may reinsure an entire
6 employer group within 60 days after the commencement of the
7 group's coverage under the plan. The carrier may choose to
8 reinsure newly eligible employees and dependents of the
9 reinsured group pursuant to subparagraph 1.
10 4. The program may evaluate the option of allowing a
11 small employer carrier to reinsure an entire employer group or
12 an eligible employee at the first or subsequent renewal date.
13 Any such option and the resulting premium must be approved by
14 the office.
15 5.4. The program may not reimburse a participating
16 carrier with respect to the claims of a reinsured employee or
17 dependent until the carrier has paid incurred claims of an
18 amount equal to the participating carrier's selected
19 deductible level at least $5,000 in a calendar year for
20 benefits covered by the program. In addition, the reinsuring
21 carrier shall be responsible for 10 percent of the next
22 $50,000 and 5 percent of the next $100,000 of incurred claims
23 during a calendar year and the program shall reinsure the
24 remainder.
25 6.5. The board annually shall adjust the initial level
26 of claims and the maximum limit to be retained by the carrier
27 to reflect increases in costs and utilization within the
28 standard market for health benefit plans within the state. The
29 adjustment shall not be less than the annual change in the
30 medical component of the "Consumer Price Index for All Urban
31 Consumers" of the Bureau of Labor Statistics of the Department
23
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Bill No. CS for SB 2020, 2nd Eng.
Amendment No. ___ Barcode 420016
1 of Labor, unless the board proposes and the department
2 approves a lower adjustment factor.
3 7.6. A small employer carrier may terminate
4 reinsurance for all reinsured employees or dependents on any
5 plan anniversary.
6 8.7. The premium rate charged for reinsurance by the
7 program to a health maintenance organization that is approved
8 by the Secretary of Health and Human Services as a federally
9 qualified health maintenance organization pursuant to 42
10 U.S.C. s. 300e(c)(2)(A) and that, as such, is subject to
11 requirements that limit the amount of risk that may be ceded
12 to the program, which requirements are more restrictive than
13 subparagraph 5. 4., shall be reduced by an amount equal to
14 that portion of the risk, if any, which exceeds the amount set
15 forth in subparagraph 5. 4. which may not be ceded to the
16 program.
17 9.8. The board may consider adjustments to the premium
18 rates charged for reinsurance by the program for carriers that
19 use effective cost containment measures, including high-cost
20 case management, as defined by the board.
21 10.9. A reinsuring carrier shall apply its
22 case-management and claims-handling techniques, including, but
23 not limited to, utilization review, individual case
24 management, preferred provider provisions, other managed care
25 provisions or methods of operation, consistently with both
26 reinsured business and nonreinsured business.
27 (h)1. The board, as part of the plan of operation,
28 shall establish a methodology for determining premium rates to
29 be charged by the program for reinsuring small employers and
30 individuals pursuant to this section. The methodology shall
31 include a system for classification of small employers that
24
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SENATE AMENDMENT
Bill No. CS for SB 2020, 2nd Eng.
Amendment No. ___ Barcode 420016
1 reflects the types of case characteristics commonly used by
2 small employer carriers in the state. The methodology shall
3 provide for the development of basic reinsurance premium
4 rates, which shall be multiplied by the factors set for them
5 in this paragraph to determine the premium rates for the
6 program. The basic reinsurance premium rates shall be
7 established by the board, subject to the approval of the
8 department, and shall be set at levels which reasonably
9 approximate gross premiums charged to small employers by small
10 employer carriers for health benefit plans with benefits
11 similar to the standard and basic health benefit plan. The
12 premium rates set by the board may vary by geographical area,
13 as determined under this section, to reflect differences in
14 cost. The multiplying factors must be established as follows:
15 a. The entire group may be reinsured for a rate that
16 is 1.5 times the rate established by the board.
17 b. An eligible employee or dependent may be reinsured
18 for a rate that is 5 times the rate established by the board.
19 2. The board periodically shall review the methodology
20 established, including the system of classification and any
21 rating factors, to assure that it reasonably reflects the
22 claims experience of the program. The board may propose
23 changes to the rates which shall be subject to the approval of
24 the department.
25 (j)1. Before September March 1 of each calendar year,
26 the board shall determine and report to the department the
27 program net loss for the previous year, including
28 administrative expenses for that year, and the incurred losses
29 for the year, taking into account investment income and other
30 appropriate gains and losses.
31 2. Any net loss for the year shall be recouped by
25
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SENATE AMENDMENT
Bill No. CS for SB 2020, 2nd Eng.
Amendment No. ___ Barcode 420016
1 assessment of the carriers, as follows:
2 a. The operating losses of the program shall be
3 assessed in the following order subject to the specified
4 limitations. The first tier of assessments shall be made
5 against reinsuring carriers in an amount which shall not
6 exceed 5 percent of each reinsuring carrier's premiums from
7 health benefit plans covering small employers. If such
8 assessments have been collected and additional moneys are
9 needed, the board shall make a second tier of assessments in
10 an amount which shall not exceed 0.5 percent of each carrier's
11 health benefit plan premiums. Except as provided in paragraph
12 (n), risk-assuming carriers are exempt from all assessments
13 authorized pursuant to this section. The amount paid by a
14 reinsuring carrier for the first tier of assessments shall be
15 credited against any additional assessments made.
16 b. The board shall equitably assess carriers for
17 operating losses of the plan based on market share. The board
18 shall annually assess each carrier a portion of the operating
19 losses of the plan. The first tier of assessments shall be
20 determined by multiplying the operating losses by a fraction,
21 the numerator of which equals the reinsuring carrier's earned
22 premium pertaining to direct writings of small employer health
23 benefit plans in the state during the calendar year for which
24 the assessment is levied, and the denominator of which equals
25 the total of all such premiums earned by reinsuring carriers
26 in the state during that calendar year. The second tier of
27 assessments shall be based on the premiums that all carriers,
28 except risk-assuming carriers, earned on all health benefit
29 plans written in this state. The board may levy interim
30 assessments against carriers to ensure the financial ability
31 of the plan to cover claims expenses and administrative
26
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SENATE AMENDMENT
Bill No. CS for SB 2020, 2nd Eng.
Amendment No. ___ Barcode 420016
1 expenses paid or estimated to be paid in the operation of the
2 plan for the calendar year prior to the association' s
3 anticipated receipt of annual assessments for that calendar
4 year. Any interim assessment is due and payable within 30 days
5 after receipt by a carrier of the interim assessment notice.
6 Interim assessment payments shall be credited against the
7 carrier's annual assessment. Health benefit plan premiums and
8 benefits paid by a carrier that are less than an amount
9 determined by the board to justify the cost of collection may
10 not be considered for purposes of determining assessments.
11 c. Subject to the approval of the department, the
12 board shall make an adjustment to the assessment formula for
13 reinsuring carriers that are approved as federally qualified
14 health maintenance organizations by the Secretary of Health
15 and Human Services pursuant to 42 U.S.C. s. 300e(c)(2)(A) to
16 the extent, if any, that restrictions are placed on them that
17 are not imposed on other small employer carriers.
18 3. Before September March 1 of each year, the board
19 shall determine and file with the department an estimate of
20 the assessments needed to fund the losses incurred by the
21 program in the previous calendar year.
22 4. If the board determines that the assessments needed
23 to fund the losses incurred by the program in the previous
24 calendar year will exceed the amount specified in subparagraph
25 2., the board shall evaluate the operation of the program and
26 report its findings, including any recommendations for changes
27 to the plan of operation, to the department within 240 90 days
28 following the end of the calendar year in which the losses
29 were incurred. The evaluation shall include an estimate of
30 future assessments, the administrative costs of the program,
31 the appropriateness of the premiums charged and the level of
27
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SENATE AMENDMENT
Bill No. CS for SB 2020, 2nd Eng.
Amendment No. ___ Barcode 420016
1 carrier retention under the program, and the costs of coverage
2 for small employers. If the board fails to file a report with
3 the department within 240 90 days following the end of the
4 applicable calendar year, the department may evaluate the
5 operations of the program and implement such amendments to the
6 plan of operation the department deems necessary to reduce
7 future losses and assessments.
8 5. If assessments exceed the amount of the actual
9 losses and administrative expenses of the program, the excess
10 shall be held as interest and used by the board to offset
11 future losses or to reduce program premiums. As used in this
12 paragraph, the term "future losses" includes reserves for
13 incurred but not reported claims.
14 6. Each carrier's proportion of the assessment shall
15 be determined annually by the board, based on annual
16 statements and other reports considered necessary by the board
17 and filed by the carriers with the board.
18 7. Provision shall be made in the plan of operation
19 for the imposition of an interest penalty for late payment of
20 an assessment.
21 8. A carrier may seek, from the commissioner, a
22 deferment, in whole or in part, from any assessment made by
23 the board. The department may defer, in whole or in part, the
24 assessment of a carrier if, in the opinion of the department,
25 the payment of the assessment would place the carrier in a
26 financially impaired condition. If an assessment against a
27 carrier is deferred, in whole or in part, the amount by which
28 the assessment is deferred may be assessed against the other
29 carriers in a manner consistent with the basis for assessment
30 set forth in this section. The carrier receiving such
31 deferment remains liable to the program for the amount
28
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SENATE AMENDMENT
Bill No. CS for SB 2020, 2nd Eng.
Amendment No. ___ Barcode 420016
1 deferred and is prohibited from reinsuring any individuals or
2 groups in the program if it fails to pay assessments.
3 Section 17. Section 627.911, Florida Statutes, is
4 amended to read:
5 627.911 Scope of this part.--Any insurer or health
6 maintenance organization transacting insurance in this state
7 shall report information as required by this part.
8 Section 18. Section 627.9175, Florida Statutes, is
9 amended to read:
10 627.9175 Reports of information on health insurance.--
11 (1) Each authorized health insurer or health
12 maintenance organization shall submit annually to the office,
13 on or before March 1 of each year, information concerning
14 department as to policies of individual health insurance
15 coverage being issued or currently in force in this state. The
16 information shall include information related to premium,
17 number of policies, and covered lives for such policies and
18 other information necessary to analyze trends in enrollment,
19 premiums, and claim costs.:
20 (2) The required information shall be broken down by
21 market segment, to include:
22 (a) Health insurance issuer, company, or contact
23 person or agent.
24 (b) All health insurance products issued or in force,
25 including, but not limited to:
26 1. Direct premiums earned.
27 2. Direct losses incurred.
28 3. Direct premiums earned for new business issued
29 during the year.
30 4. Number of policies.
31 5. Number of certificates.
29
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SENATE AMENDMENT
Bill No. CS for SB 2020, 2nd Eng.
Amendment No. ___ Barcode 420016
1 6. Number of total covered lives.
2 (3) The commission may adopt rules to administer this
3 section, including rules governing compliance and provisions
4 implementing electronic methodologies for use in furnishing
5 such records or documents. The commission may by rule specify
6 a uniform format for the submission of this information in
7 order to allow for meaningful comparisons.
8 (a) A summary of typical benefits, exclusions, and
9 limitations for each type of individual policy form currently
10 being issued in the state. The summary shall include, as
11 appropriate:
12 1. The deductible amount;
13 2. The coinsurance percentage;
14 3. The out-of-pocket maximum;
15 4. Outpatient benefits;
16 5. Inpatient benefits; and
17 6. Any exclusions for preexisting conditions.
18
19 The department shall determine other appropriate benefits,
20 exclusions, and limitations to be reported for inclusion in
21 the consumer's guide published pursuant to this section.
22 (b) A schedule of rates for each type of individual
23 policy form reflecting typical variations by age, sex, region
24 of the state, or any other applicable factor which is in use
25 and is determined to be appropriate for inclusion by the
26 department.
27
28 The department shall provide by rule a uniform format for the
29 submission of this information in order to allow for
30 meaningful comparisons of premiums charged for comparable
31 benefits. The department shall publish annually a consumer's
30
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SENATE AMENDMENT
Bill No. CS for SB 2020, 2nd Eng.
Amendment No. ___ Barcode 420016
1 guide which summarizes and compares the information required
2 to be reported under this subsection.
3 (2)(a) Every insurer transacting health insurance in
4 this state shall report annually to the department, not later
5 than April 1, information relating to any measure the insurer
6 has implemented or proposes to implement during the next
7 calendar year for the purpose of containing health insurance
8 costs or cost increases. The reports shall identify each
9 measure and the forms to which the measure is applied, shall
10 provide an explanation as to how the measure is used, and
11 shall provide an estimate of the cost effect of the measure.
12 (b) The department shall promulgate forms to be used
13 by insurers in reporting information pursuant to this
14 subsection and shall utilize such forms to analyze the effects
15 of health care cost containment programs used by health
16 insurers in this state.
17 (c) The department shall analyze the data reported
18 under this subsection and shall annually make available to the
19 public a summary of its findings as to the types of cost
20 containment measures reported and the estimated effect of
21 these measures.
22 Section 19. Section 627.9403, Florida Statutes, is
23 amended to read:
24 627.9403 Scope.--The provisions of this part shall
25 apply to long-term care insurance policies delivered or issued
26 for delivery in this state, and to policies delivered or
27 issued for delivery outside this state to the extent provided
28 in s. 627.9406, by an insurer, a fraternal benefit society as
29 defined in s. 632.601, a health maintenance organization as
30 defined in s. 641.19, a prepaid health clinic as defined in s.
31 641.402, or a multiple-employer welfare arrangement as defined
31
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SENATE AMENDMENT
Bill No. CS for SB 2020, 2nd Eng.
Amendment No. ___ Barcode 420016
1 in s. 624.437. A policy which is advertised, marketed, or
2 offered as a long-term care policy and as a Medicare
3 supplement policy shall meet the requirements of this part and
4 the requirements of ss. 627.671-627.675 and, to the extent of
5 a conflict, be subject to the requirement that is more
6 favorable to the policyholder or certificateholder. The
7 provisions of this part shall not apply to a continuing care
8 contract issued pursuant to chapter 651 and shall not apply to
9 guaranteed renewable policies issued prior to October 1, 1988.
10 Any limited benefit policy that limits coverage to care in a
11 nursing home or to one or more lower levels of care required
12 or authorized to be provided by this part or by department
13 rule must meet all requirements of this part that apply to
14 long-term care insurance policies, except ss. 627.9407(3)(c)
15 and (d), (9), (10)(f), and (12) and 627.94073(2). If the
16 limited benefit policy does not provide coverage for care in a
17 nursing home, but does provide coverage for one or more lower
18 levels of care, the policy shall also be exempt from the
19 requirements of s. 627.9407(3)(d).
20 Section 20. Paragraph (d) of subsection (3), and
21 subsections (9) through (17) of section 641.31, Florida
22 Statutes, are amended to read:
23 641.31 Health maintenance contracts.--
24 (3)
25 (d) Any change in rates charged for the contract must
26 be filed with the department not less than 30 days in advance
27 of the effective date. At the expiration of such 30 days, the
28 rate filing shall be deemed approved unless prior to such time
29 the filing has been affirmatively approved or disapproved by
30 order of the department. The approval of the filing by the
31 department constitutes a waiver of any unexpired portion of
32
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Bill No. CS for SB 2020, 2nd Eng.
Amendment No. ___ Barcode 420016
1 such waiting period. The department may extend by not more
2 than an additional 15 days the period within which it may so
3 affirmatively approve or disapprove any such filing, by giving
4 notice of such extension before expiration of the initial
5 30-day period. At the expiration of any such period as so
6 extended, and in the absence of such prior affirmative
7 approval or disapproval, any such filing shall be deemed
8 approved. This paragraph does not apply to group contracts
9 effectuated and delivered in this state insuring groups of 51
10 or more persons, except for Medicare supplement insurance,
11 long-term care insurance, and any coverage under which the
12 increase in claims costs over the lifetime of the contract due
13 to advancing age or duration is refunded in the premium.
14 (9)(a)1. If a health maintenance organization offers
15 coverage for dependent children of the subscriber, the
16 contract must cover a dependent child of the subscriber at
17 least until the end of the calendar year in which the child
18 reaches the age of 25, if the child meets all of the
19 following:
20 a. The child is dependent upon the subscriber for
21 support.
22 b. The child is living in the household of the
23 subscriber, or the child is a full-time or part-time student.
24 2. Nothing in this paragraph affects or preempts a
25 health maintenance organization's right to medically
26 underwrite or charge the appropriate premium.
27 (b)1. A contract that provides coverage for a family
28 member of the subscriber shall, as to such family member's
29 coverage, provide that benefits applicable to children of the
30 subscriber also apply to an adopted child or a foster child of
31 the subscriber placed in compliance with chapter 63 from the
33
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Bill No. CS for SB 2020, 2nd Eng.
Amendment No. ___ Barcode 420016
1 moment of placement in the residence of the subscriber. Except
2 in the case of a foster child, the contract may not exclude
3 coverage for any preexisting condition of the child. In the
4 case of a newborn child, coverage begins at the moment of
5 birth if a written agreement to adopt such child has been
6 entered into by the subscriber prior to the birth of the
7 child, whether or not the agreement is enforceable. This
8 section does not require coverage for an adopted child who is
9 not ultimately placed in the residence of the subscriber in
10 compliance with chapter 63.
11 2. A contract may require the subscriber to notify the
12 health maintenance organization of the birth or placement of
13 an adopted child within a specified time period of not less
14 than 30 days after the birth or placement in the residence of
15 a child adopted by the subscriber. If timely notice is given,
16 the health maintenance organization may not charge an
17 additional premium for coverage of the child for the duration
18 of the notice period. If timely notice is not given, the
19 health maintenance organization may charge an additional
20 premium from the date of birth or placement. If notice is
21 given within 60 days after the birth or placement of the
22 child, the health maintenance organization may not deny
23 coverage for the child due to the failure of the subscriber to
24 timely notify the health maintenance organization of the birth
25 or placement of the child.
26 3. If the contract does not require the subscriber to
27 notify the health maintenance organization of the birth or
28 placement of an adopted child within a specified time period,
29 the health maintenance organization may not deny coverage for
30 such child or retroactively charge the subscriber an
31 additional premium for such child. However, the health
34
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Bill No. CS for SB 2020, 2nd Eng.
Amendment No. ___ Barcode 420016
1 maintenance organization may prospectively charge the
2 subscriber an additional premium for the child if the health
3 maintenance organization provides at least 45 days' notice of
4 the additional premium required.
5 4. In order to increase access to postnatal, infant,
6 and pediatric health care for all children placed in
7 court-ordered custody, including foster children, all health
8 maintenance organization contracts that provide coverage for a
9 family member of the subscriber shall, as to such family
10 member's coverage, provide that benefits applicable for
11 children shall be payable with respect to a foster child or
12 other child in court-ordered temporary or other custody of the
13 subscriber.
14 (10) A contract that provides that coverage of a
15 dependent child shall terminate upon attainment of the
16 limiting age for dependent children specified in the contract
17 shall also provide in substance that attainment of the
18 limiting age does not terminate the coverage of the child
19 while the child continues to be:
20 (a) Incapable of self-sustaining employment by reason
21 of mental retardation or physical handicap.
22 (b) Chiefly dependent upon the subscriber for support
23 and maintenance.
24
25 If a claim is denied under a contract for the stated reason
26 that the child has attained the limiting age for dependent
27 children specified in the contract, the notice of denial must
28 state that the subscriber has the burden of establishing that
29 the child continues to meet the criteria specified in
30 paragraphs (a) and (b). All health maintenance contracts that
31 provide coverage, benefits, or services for a member of the
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SENATE AMENDMENT
Bill No. CS for SB 2020, 2nd Eng.
Amendment No. ___ Barcode 420016
1 family of the subscriber must, as to such family member's
2 coverage, benefits, or services, provide also that the
3 coverage, benefits, or services applicable for children must
4 be provided with respect to a newborn child of the subscriber,
5 or covered family member of the subscriber, from the moment of
6 birth. However, with respect to a newborn child of a covered
7 family member other than the spouse of the insured or
8 subscriber, the coverage for the newborn child terminates 18
9 months after the birth of the newborn child. The coverage,
10 benefits, or services for newborn children must consist of
11 coverage for injury or sickness, including the necessary care
12 or treatment of medically diagnosed congenital defects, birth
13 abnormalities, or prematurity, and transportation costs of the
14 newborn to and from the nearest appropriate facility
15 appropriately staffed and equipped to treat the newborn's
16 condition, when such transportation is certified by the
17 attending physician as medically necessary to protect the
18 health and safety of the newborn child.
19 (a) A contract may require the subscriber to notify
20 the plan of the birth of a child within a time period, as
21 specified in the contract, of not less than 30 days after the
22 birth, or a contract may require the preenrollment of a
23 newborn prior to birth. However, if timely notice is given, a
24 plan may not charge an additional premium for additional
25 coverage of the newborn child for not less than 30 days after
26 the birth of the child. If timely notice is not given, the
27 plan may charge an additional premium from the date of birth.
28 If notice is given within 60 days of the birth of the child,
29 the contract may not deny coverage of the child due to failure
30 of the subscriber to timely notify the plan of the birth of
31 the child or to preenroll the child.
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SENATE AMENDMENT
Bill No. CS for SB 2020, 2nd Eng.
Amendment No. ___ Barcode 420016
1 (b) If the contract does not require the subscriber to
2 notify the plan of the birth of a child within a specified
3 time period, the plan may not deny coverage of the child nor
4 may it retroactively charge the subscriber an additional
5 premium for the child; however, the contract may prospectively
6 charge the member an additional premium for the child if the
7 plan provides at least 45 days' notice of the additional
8 charge.
9 (11)(10) No alteration of any written application for
10 any health maintenance contract shall be made by any person
11 other than the applicant without his or her written consent,
12 except that insertions may be made by the health maintenance
13 organization, for administrative purposes only, in such manner
14 as to indicate clearly that such insertions are not to be
15 ascribed to the applicant.
16 (12)(11) No contract shall contain any waiver of
17 rights or benefits provided to or available to subscribers
18 under the provisions of any law or rule applicable to health
19 maintenance organizations.
20 (13)(12) Each health maintenance contract,
21 certificate, or member handbook shall state that emergency
22 services and care shall be provided to subscribers in
23 emergency situations not permitting treatment through the
24 health maintenance organization's providers, without prior
25 notification to and approval of the organization. Not less
26 than 75 percent of the reasonable charges for covered services
27 and supplies shall be paid by the organization, up to the
28 subscriber contract benefit limits. Payment also may be
29 subject to additional applicable copayment provisions, not to
30 exceed $100 per claim. The health maintenance contract,
31 certificate, or member handbook shall contain the definitions
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SENATE AMENDMENT
Bill No. CS for SB 2020, 2nd Eng.
Amendment No. ___ Barcode 420016
1 of "emergency services and care" and "emergency medical
2 condition" as specified in s. 641.19(7) and (8), shall
3 describe procedures for determination by the health
4 maintenance organization of whether the services qualify for
5 reimbursement as emergency services and care, and shall
6 contain specific examples of what does constitute an
7 emergency. In providing for emergency services and care as a
8 covered service, a health maintenance organization shall be
9 governed by s. 641.513.
10 (14)(13) In addition to the requirements of this
11 section, with respect to a person who is entitled to have
12 payments for health care costs made under Medicare, Title
13 XVIII of the Social Security Act ("Medicare"), parts A and/or
14 B:
15 (a) The health maintenance organization shall mail or
16 deliver notification to the Medicare beneficiary of the date
17 of enrollment in the health maintenance organization within 10
18 days after receiving notification of enrollment approval from
19 the United States Department of Health and Human Services,
20 Health Care Financing Administration. When a Medicare
21 beneficiary who is a subscriber of the health maintenance
22 organization requests disenrollment from the organization, the
23 organization shall mail or deliver to the beneficiary notice
24 of the effective date of the disenrollment within 10 days
25 after receipt of the written disenrollment request. The health
26 maintenance organization shall forward the disenrollment
27 request to the United States Department of Health and Human
28 Services, Health Care Financing Administration, in a timely
29 manner so as to effectuate the next available disenrollment
30 date, as prescribed by such federal agency.
31 (b) The health maintenance contract, certificate, or
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SENATE AMENDMENT
Bill No. CS for SB 2020, 2nd Eng.
Amendment No. ___ Barcode 420016
1 member handbook shall be delivered to the subscriber no later
2 than the earlier of 10 working days after the health
3 maintenance organization and the Health Care Financing
4 Administration of the United States Department of Health and
5 Human Services approve the subscriber's enrollment application
6 or the effective date of coverage of the subscriber under the
7 health maintenance contract. However, if notice from the
8 Health Care Financing Administration of its approval of the
9 subscriber's enrollment application is received by the health
10 maintenance organization after the effective coverage date
11 prescribed by the Health Care Financing Administration, the
12 health maintenance organization shall deliver the contract,
13 certificate, or member handbook to the subscriber within 10
14 days after receiving such notice. When a Medicare recipient is
15 enrolled in a health maintenance organization program, the
16 contract, certificate, or member handbook shall be accompanied
17 by a health maintenance organization identification sticker
18 with instruction to the Medicare beneficiary to place the
19 sticker on the Medicare identification card.
20 (15)(14) Whenever a subscriber of a health maintenance
21 organization is also a Medicaid recipient, the health
22 maintenance organization's coverage shall be primary to the
23 recipient's Medicaid benefits and the organization shall be a
24 third party subject to the provisions of s. 409.910(4).
25 (16)(15)(a) All health maintenance contracts,
26 certificates, and member handbooks shall contain the following
27 provision:
28
29 "Grace Period: This contract has a (insert a number not
30 less than 10) day grace period. This provision means that if
31 any required premium is not paid on or before the date it is
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SENATE AMENDMENT
Bill No. CS for SB 2020, 2nd Eng.
Amendment No. ___ Barcode 420016
1 due, it may be paid during the following grace period. During
2 the grace period, the contract will stay in force."
3
4 (b) The required provision of paragraph (a) shall not
5 apply to certificates or member handbooks delivered to
6 individual subscribers under a group health maintenance
7 contract when the employer or other person who will hold the
8 contract on behalf of the subscriber group pays the entire
9 premium for the individual subscribers. However, such required
10 provision shall apply to the group health maintenance
11 contract.
12 (17)(16) The contracts must clearly disclose the
13 intent of the health maintenance organization as to the
14 applicability or nonapplicability of coverage to preexisting
15 conditions. If coverage of the contract is not to be
16 applicable to preexisting conditions, the contract shall
17 specify, in substance, that coverage pertains solely to
18 accidental bodily injuries resulting from accidents occurring
19 after the effective date of coverage and that sicknesses are
20 limited to those which first manifest themselves subsequent to
21 the effective date of coverage.
22 (17) All health maintenance contracts that provide
23 coverage for a member of the family of the subscriber, shall,
24 as to such family member's coverage, provide that coverage,
25 benefits, or services applicable for children shall be
26 provided with respect to an adopted child of the subscriber,
27 which child is placed in compliance with chapter 63, from the
28 moment of placement in the residence of the subscriber. Such
29 contracts may not exclude coverage for any preexisting
30 condition of the child. In the case of a newborn child,
31 coverage shall begin from the moment of birth if a written
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SENATE AMENDMENT
Bill No. CS for SB 2020, 2nd Eng.
Amendment No. ___ Barcode 420016
1 agreement to adopt such child has been entered into by the
2 subscriber prior to the birth of the child, whether or not
3 such agreement is enforceable. However, coverage for such
4 child shall not be required in the event that the child is not
5 ultimately placed in the residence of the subscriber in
6 compliance with chapter 63.
7 Section 21. Section 641.31025, Florida Statutes, is
8 created to read:
9 641.31025 Specific reasons for denial of
10 coverage.--The denial of an application for a health
11 maintenance organization contract must be accompanied by the
12 specific reasons for the denial, including, but not limited
13 to, the specific underwriting reasons, if applicable.
14 Section 22. Section 641.31075, Florida Statutes, is
15 created to read:
16 641.31075 Replacement.--Any health maintenance
17 organization that is replacing any other group health coverage
18 with its group health maintenance coverage shall comply with
19 s. 627.666.
20 Section 23. Subsections (1) and (3) of section
21 641.3111, Florida Statutes, are amended to read:
22 641.3111 Extension of benefits.--
23 (1) Every group health maintenance contract shall
24 provide that termination of the contract shall be without
25 prejudice to any continuous loss which commenced while the
26 contract was in force, but any extension of benefits beyond
27 the period the contract was in force may be predicated upon
28 the continuous total disability of the subscriber and may be
29 limited to payment for the treatment of a specific accident or
30 illness incurred while the subscriber was a member. The
31 extension is required regardless of whether the group contract
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SENATE AMENDMENT
Bill No. CS for SB 2020, 2nd Eng.
Amendment No. ___ Barcode 420016
1 holder or other entity secures replacement coverage from a new
2 insurer or health maintenance organization or foregoes the
3 provision of coverage. The required provision must provide for
4 continuation of contract benefits in connection with the
5 treatment of a specific accident or illness incurred while the
6 contract was in effect. Such extension of benefits may be
7 limited to the occurrence of the earliest of the following
8 events:
9 (a) The expiration of 12 months.
10 (b) Such time as the member is no longer totally
11 disabled.
12 (c) A succeeding carrier elects to provide replacement
13 coverage without limitation as to the disability condition.
14 (c)(d) The maximum benefits payable under the contract
15 have been paid.
16 (3) In the case of maternity coverage, when not
17 covered by the succeeding carrier, a reasonable extension of
18 benefits or accrued liability provision is required, which
19 provision provides for continuation of the contract benefits
20 in connection with maternity expenses for a pregnancy that
21 commenced while the policy was in effect. The extension shall
22 be for the period of that pregnancy and shall not be based
23 upon total disability.
24 Section 24. Subsection (1) of section 641.2018,
25 Florida Statutes, is amended to read:
26 641.2018 Limited coverage for home health care
27 authorized.--
28 (1) Notwithstanding other provisions of this chapter,
29 a health maintenance organization may issue a contract that
30 limits coverage to home health care services only. The
31 organization and the contract shall be subject to all of the
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SENATE AMENDMENT
Bill No. CS for SB 2020, 2nd Eng.
Amendment No. ___ Barcode 420016
1 requirements of this part that do not require or otherwise
2 apply to specific benefits other than home care services. To
3 this extent, all of the requirements of this part apply to any
4 organization or contract that limits coverage to home care
5 services, except the requirements for providing comprehensive
6 health care services as provided in ss. 641.19(4), (12), and
7 (13), and 641.31(1), except ss. 641.31(9), (13)(12), (17),
8 (18), (19), (20), (21), and (24) and 641.31095.
9 Section 25. Section 641.3107, Florida Statutes, is
10 amended to read:
11 641.3107 Delivery of contract.--Unless delivered upon
12 execution or issuance, a health maintenance contract,
13 certificate of coverage, or member handbook shall be mailed or
14 delivered to the subscriber or, in the case of a group health
15 maintenance contract, to the employer or other person who will
16 hold the contract on behalf of the subscriber group within 10
17 working days from approval of the enrollment form by the
18 health maintenance organization or by the effective date of
19 coverage, whichever occurs first. However, if the employer or
20 other person who will hold the contract on behalf of the
21 subscriber group requires retroactive enrollment of a
22 subscriber, the organization shall deliver the contract,
23 certificate, or member handbook to the subscriber within 10
24 days after receiving notice from the employer of the
25 retroactive enrollment. This section does not apply to the
26 delivery of those contracts specified in s. 641.31(14)(13).
27
28 (Redesignate subsequent sections.)
29
30
31
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Bill No. CS for SB 2020, 2nd Eng.
Amendment No. ___ Barcode 420016
1 ================ T I T L E A M E N D M E N T ===============
2 And the title is amended as follows:
3 Delete everything before the enacting clause
4
5 and insert:
6 An act relating to health insurance; amending
7 s. 408.909, F.S.; revising the definition of
8 the term "health flex plans"; authorizing plans
9 to limit the term of coverage; extending the
10 required period without coverage before one is
11 eligible to participate; extending the
12 expiration date for the program; amending s.
13 409.904, F.S.; postponing the effective date of
14 changes to standards for eligibility for
15 certain optional medical assistance, including
16 coverage under the medically needy program;
17 providing appropriations; providing for
18 retroactive application; amending s. 408.909,
19 F.S.; revising the definition of the term
20 "health flex plans"; authorizing plans to limit
21 the term of coverage; extending the expiration
22 date for the program; amending s. 624.406,
23 F.S.; providing for reinsurance under a
24 workers' compensation insurance policy;
25 amending s. 624.603, F.S.; providing an
26 exception in which health insurance includes
27 workers' compensation coverages; creating s.
28 627.6042, F.S.; requiring policies of insurers
29 offering coverage of dependent children to
30 maintain such coverage until the child reaches
31 age 25, under certain circumstances; providing
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SENATE AMENDMENT
Bill No. CS for SB 2020, 2nd Eng.
Amendment No. ___ Barcode 420016
1 application; creating s. 627.60425, F.S.;
2 providing for limitations to the requirement
3 for binding arbitration; amending s. 627.6044,
4 F.S.; providing for the payment of claims to
5 non-network providers under specified
6 conditions; requiring that the method used for
7 determining payment of claims be included in
8 filings; providing for disclosure; amending s.
9 627.6415, F.S.; deleting an age limitation on
10 application of certain dependent coverage
11 requirements; amending s. 627.6475, F.S.;
12 revising risk-assuming carrier election
13 requirements and procedures; revising certain
14 criteria and limitations under the individual
15 health reinsurance program; amending s.
16 627.651, F.S., relating to group contracts and
17 plans; conforming a cross-reference to changes
18 made by the act; amending s. 627.662, F.S.;
19 revising a list of provisions applicable to
20 group, blanket, or franchise health insurance
21 to include use of specific methodology for
22 payment of claims provisions; amending s.
23 627.667, F.S.; deleting a limitation on
24 application of certain extension of benefits
25 provisions; amending s. 627.6692, F.S.;
26 increasing a time period for payment of premium
27 to continue coverage under a group health plan;
28 amending s. 627.6699, F.S.; revising certain
29 definitions; revising certain coverage
30 enrollment eligibility criteria for small
31 employers; revising small employer carrier
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SENATE AMENDMENT
Bill No. CS for SB 2020, 2nd Eng.
Amendment No. ___ Barcode 420016
1 election requirements and procedures; revising
2 certain criteria and limitations under the
3 small employer health reinsurance program;
4 providing a limitation; revising certain rate
5 adjustment criteria; amending ss. 627.911 and
6 627.9175, F.S.; applying certain information
7 reporting requirements to health maintenance
8 organizations; revising health insurance
9 information requirements and criteria;
10 authorizing the Financial Services Commission
11 to adopt rules; deleting an annual report
12 requirement; amending s. 627.9403, F.S.;
13 exempting limited benefit policies relating to
14 nursing home care from certain requirements for
15 long-term care insurance; amending s. 641.31,
16 F.S.; requiring prepaid limited health service
17 organizations and health maintenance
18 organizations offering coverage of dependent
19 children to maintain such coverage until the
20 child reaches age 25, under certain
21 circumstances; providing application; providing
22 requirements for contract termination and
23 denial of a claim related to limiting age
24 attainment; creating s. 641.31025, F.S.;
25 requiring that specific reasons for denial of
26 coverage be provided; creating s. 641.31075,
27 F.S.; imposing compliance requirements upon
28 health maintenance organization replacements of
29 other group health coverage with organization
30 coverage; amending s. 641.3111, F.S.; deleting
31 limitations on certain extension of benefits
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SENATE AMENDMENT
Bill No. CS for SB 2020, 2nd Eng.
Amendment No. ___ Barcode 420016
1 provisions upon group health maintenance
2 contract termination; imposing additional
3 extension of benefits requirements upon such
4 termination; amending ss. 641.2018 and
5 641.3107, F.S., relating to home health care
6 coverage and contracts; conforming
7 cross-references to changes made by the act;
8 providing an effective date.
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10
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