Florida Senate - 2015 CS for SB 968
By the Committee on Banking and Insurance; and Senator Detert
597-02740-15 2015968c1
1 A bill to be entitled
2 An act relating to employee health care plans;
3 amending s. 627.6699, F.S.; revising definitions;
4 removing provisions requiring certain insurance
5 carriers to provide semiannual reports to the Office
6 of Insurance Regulation; repealing requirements that
7 certain insurance carriers offer standard, basic, high
8 deductible, and limited health benefit plans; making
9 conforming changes; creating s. 627.66997, F.S.;
10 authorizing certain health benefit plans to use a
11 stop-loss insurance policy; defining the term “stop
12 loss insurance policy”; providing requirements for
13 such policies; amending ss. 627.642, 627.6475, and
14 627.657, F.S.; conforming cross-references; amending
15 ss. 627.6571, 627.6675, 641.31074, and 641.3922, F.S.;
16 conforming provisions to changes made by the act;
17 providing an effective date.
18
19 Be It Enacted by the Legislature of the State of Florida:
20
21 Section 1. Subsection (2) of section 627.6699, Florida
22 Statutes, is amended, present paragraphs (c) through (x) of
23 subsection (3) are redesignated as paragraphs (b) through (w),
24 respectively, and present paragraphs (b) and (o) of that
25 subsection, subsection (5), paragraph (b) of subsection (6),
26 paragraphs (g), (h), (j), and (l) through (o) of subsection
27 (11), subsections (12) through (14), paragraph (k) of subsection
28 (15), and subsections (16) through (18) of that section are
29 amended, to read:
30 627.6699 Employee Health Care Access Act.—
31 (2) PURPOSE AND INTENT.—The purpose and intent of this
32 section is to promote the availability of health insurance
33 coverage to small employers regardless of their claims
34 experience or their employees’ health status, to establish rules
35 regarding renewability of that coverage, to establish
36 limitations on the use of exclusions for preexisting conditions,
37 to provide for development of a standard health benefit plan and
38 a basic health benefit plan to be offered to all small
39 employers, to provide for establishment of a reinsurance program
40 for coverage of small employers, and to improve the overall
41 fairness and efficiency of the small group health insurance
42 market.
43 (3) DEFINITIONS.—As used in this section, the term:
44 (b) “Basic health benefit plan” and “standard health
45 benefit plan” mean low-cost health care plans developed pursuant
46 to subsection (12).
47 (n)(o) “Modified community rating” means a method used to
48 develop carrier premiums which spreads financial risk across a
49 large population; allows the use of separate rating factors for
50 age, gender, family composition, tobacco usage, and geographic
51 area as determined under paragraph (5)(f) (5)(j); and allows
52 adjustments for: claims experience, health status, or duration
53 of coverage as permitted under subparagraph (6)(b)5.; and
54 administrative and acquisition expenses as permitted under
55 subparagraph (6)(b)5.
56 (5) AVAILABILITY OF COVERAGE.—
57 (a) Beginning January 1, 1993, every small employer carrier
58 issuing new health benefit plans to small employers in this
59 state must, as a condition of transacting business in this
60 state, offer to eligible small employers a standard health
61 benefit plan and a basic health benefit plan. Such a small
62 employer carrier shall issue a standard health benefit plan or a
63 basic health benefit plan to every eligible small employer that
64 elects to be covered under such plan, agrees to make the
65 required premium payments under such plan, and to satisfy the
66 other provisions of the plan.
67 (a)(b) In the case of A small employer carrier that which
68 does not, on or after January 1, 1993, offer coverage but renews
69 or continues which does, on or after January 1, 1993, renew or
70 continue coverage in force must, such carrier shall be required
71 to provide coverage to newly eligible employees and dependents
72 on the same basis as small employer carriers that offer which
73 are offering coverage on or after January 1, 1993.
74 (b)(c) Every small employer carrier must, as a condition of
75 transacting business in this state,:
76 1. offer and issue all small employer health benefit plans
77 on a guaranteed-issue basis to every eligible small employer,
78 with 2 to 50 eligible employees, that elects to be covered under
79 such plan, agrees to make the required premium payments, and
80 satisfies the other provisions of the plan. A rider for
81 additional or increased benefits may be medically underwritten
82 and may only be added to the standard health benefit plan. The
83 increased rate charged for the additional or increased benefit
84 must be rated in accordance with this section.
85 2. In the absence of enrollment availability in the Florida
86 Health Insurance Plan, offer and issue basic and standard small
87 employer health benefit plans and a high-deductible plan that
88 meets the requirements of a health savings account plan or
89 health reimbursement account as defined by federal law, on a
90 guaranteed-issue basis, during a 31-day open enrollment period
91 of August 1 through August 31 of each year, to every eligible
92 small employer, with fewer than two eligible employees, which
93 small employer is not formed primarily for the purpose of buying
94 health insurance and which elects to be covered under such plan,
95 agrees to make the required premium payments, and satisfies the
96 other provisions of the plan. Coverage provided under this
97 subparagraph shall begin on October 1 of the same year as the
98 date of enrollment, unless the small employer carrier and the
99 small employer agree to a different date. A rider for additional
100 or increased benefits may be medically underwritten and may only
101 be added to the standard health benefit plan. The increased rate
102 charged for the additional or increased benefit must be rated in
103 accordance with this section. For purposes of this subparagraph,
104 a person, his or her spouse, and his or her dependent children
105 constitute a single eligible employee if that person and spouse
106 are employed by the same small employer and either that person
107 or his or her spouse has a normal work week of less than 25
108 hours. Any right to an open enrollment of health benefit
109 coverage for groups of fewer than two employees, pursuant to
110 this section, shall remain in full force and effect in the
111 absence of the availability of new enrollment into the Florida
112 Health Insurance Plan.
113 3. This paragraph does not limit a carrier’s ability to
114 offer other health benefit plans to small employers if the
115 standard and basic health benefit plans are offered and
116 rejected.
117 (d) A small employer carrier must file with the office, in
118 a format and manner prescribed by the committee, a standard
119 health care plan, a high deductible plan that meets the federal
120 requirements of a health savings account plan or a health
121 reimbursement arrangement, and a basic health care plan to be
122 used by the carrier. The provisions of this section requiring
123 the filing of a high deductible plan are effective September 1,
124 2004.
125 (e) The office at any time may, after providing notice and
126 an opportunity for a hearing, disapprove the continued use by
127 the small employer carrier of the standard or basic health
128 benefit plan on the grounds that such plan does not meet the
129 requirements of this section.
130 (c)(f) Except as provided in paragraph (d) (g), a health
131 benefit plan covering small employers must comply with
132 preexisting condition provisions specified in s. 627.6561 or,
133 for health maintenance contracts, in s. 641.31071.
134 (d)(g) A health benefit plan covering small employers,
135 issued or renewed on or after January 1, 1994, must comply with
136 the following conditions:
137 1. All health benefit plans must be offered and issued on a
138 guaranteed-issue basis, except that benefits purchased through
139 riders as provided in paragraph (c) may be medically
140 underwritten for the group, but may not be individually
141 underwritten as to the employees or the dependents of such
142 employees. Additional or increased benefits may only be offered
143 by riders.
144 2. The provisions of Paragraph (c) applies (f) apply to
145 health benefit plans issued to a small employer who has two or
146 more eligible employees, and to health benefit plans that are
147 issued to a small employer who has fewer than two eligible
148 employees and that cover an employee who has had creditable
149 coverage continually to a date not more than 63 days before the
150 effective date of the new coverage.
151 3. For health benefit plans that are issued to a small
152 employer who has fewer than two employees and that cover an
153 employee who has not been continually covered by creditable
154 coverage within 63 days before the effective date of the new
155 coverage, preexisting condition provisions must not exclude
156 coverage for a period beyond 24 months following the employee’s
157 effective date of coverage and may relate only to:
158 a. Conditions that, during the 24-month period immediately
159 preceding the effective date of coverage, had manifested
160 themselves in such a manner as would cause an ordinarily prudent
161 person to seek medical advice, diagnosis, care, or treatment or
162 for which medical advice, diagnosis, care, or treatment was
163 recommended or received; or
164 b. A pregnancy existing on the effective date of coverage.
165 (e)(h) All health benefit plans issued under this section
166 must comply with the following conditions:
167 1. For employers who have fewer than two employees, a late
168 enrollee may be excluded from coverage for no longer than 24
169 months if he or she was not covered by creditable coverage
170 continually to a date not more than 63 days before the effective
171 date of his or her new coverage.
172 2. Any requirement used by a small employer carrier in
173 determining whether to provide coverage to a small employer
174 group, including requirements for minimum participation of
175 eligible employees and minimum employer contributions, must be
176 applied uniformly among all small employer groups having the
177 same number of eligible employees applying for coverage or
178 receiving coverage from the small employer carrier, except that
179 a small employer carrier that participates in, administers, or
180 issues health benefits pursuant to s. 381.0406 which do not
181 include a preexisting condition exclusion may require as a
182 condition of offering such benefits that the employer has had no
183 health insurance coverage for its employees for a period of at
184 least 6 months. A small employer carrier may vary application of
185 minimum participation requirements and minimum employer
186 contribution requirements only by the size of the small employer
187 group.
188 3. In applying minimum participation requirements with
189 respect to a small employer, a small employer carrier shall not
190 consider as an eligible employee employees or dependents who
191 have qualifying existing coverage in an employer-based group
192 insurance plan or an ERISA qualified self-insurance plan in
193 determining whether the applicable percentage of participation
194 is met. However, a small employer carrier may count eligible
195 employees and dependents who have coverage under another health
196 plan that is sponsored by that employer.
197 4. A small employer carrier shall not increase any
198 requirement for minimum employee participation or any
199 requirement for minimum employer contribution applicable to a
200 small employer at any time after the small employer has been
201 accepted for coverage, unless the employer size has changed, in
202 which case the small employer carrier may apply the requirements
203 that are applicable to the new group size.
204 5. If a small employer carrier offers coverage to a small
205 employer, it must offer coverage to all the small employer’s
206 eligible employees and their dependents. A small employer
207 carrier may not offer coverage limited to certain persons in a
208 group or to part of a group, except with respect to late
209 enrollees.
210 6. A small employer carrier may not modify any health
211 benefit plan issued to a small employer with respect to a small
212 employer or any eligible employee or dependent through riders,
213 endorsements, or otherwise to restrict or exclude coverage for
214 certain diseases or medical conditions otherwise covered by the
215 health benefit plan.
216 7. An initial enrollment period of at least 30 days must be
217 provided. An annual 30-day open enrollment period must be
218 offered to each small employer’s eligible employees and their
219 dependents. A small employer carrier must provide special
220 enrollment periods as required by s. 627.65615.
221 (i)1. A small employer carrier need not offer coverage or
222 accept applications pursuant to paragraph (a):
223 a. To a small employer if the small employer is not
224 physically located in an established geographic service area of
225 the small employer carrier, provided such geographic service
226 area shall not be less than a county;
227 b. To an employee if the employee does not work or reside
228 within an established geographic service area of the small
229 employer carrier; or
230 c. To a small employer group within an area in which the
231 small employer carrier reasonably anticipates, and demonstrates
232 to the satisfaction of the office, that it cannot, within its
233 network of providers, deliver service adequately to the members
234 of such groups because of obligations to existing group contract
235 holders and enrollees.
236 2. A small employer carrier that cannot offer coverage
237 pursuant to sub-subparagraph 1.c. may not offer coverage in the
238 applicable area to new cases of employer groups having more than
239 50 eligible employees or small employer groups until the later
240 of 180 days following each such refusal or the date on which the
241 carrier notifies the office that it has regained its ability to
242 deliver services to small employer groups.
243 3.a. A small employer carrier may deny health insurance
244 coverage in the small-group market if the carrier has
245 demonstrated to the office that:
246 (I) It does not have the financial reserves necessary to
247 underwrite additional coverage; and
248 (II) It is applying this sub-subparagraph uniformly to all
249 employers in the small-group market in this state consistent
250 with this section and without regard to the claims experience of
251 those employers and their employees and their dependents or any
252 health-status-related factor that relates to such employees and
253 dependents.
254 b. A small employer carrier, upon denying health insurance
255 coverage in connection with health benefit plans in accordance
256 with sub-subparagraph a., may not offer coverage in connection
257 with group health benefit plans in the small-group market in
258 this state for a period of 180 days after the date such coverage
259 is denied or until the insurer has demonstrated to the office
260 that the insurer has sufficient financial reserves to underwrite
261 additional coverage, whichever is later. The office may provide
262 for the application of this sub-subparagraph on a service-area
263 specific basis.
264 4. The commission shall, by rule, require each small
265 employer carrier to report, on or before March 1 of each year,
266 its gross annual premiums for all health benefit plans issued to
267 small employers during the previous calendar year, and also to
268 report its gross annual premiums for new, but not renewal,
269 standard and basic health benefit plans subject to this section
270 issued during the previous calendar year. No later than May 1 of
271 each year, the office shall calculate each carrier’s percentage
272 of all small employer group health premiums for the previous
273 calendar year and shall calculate the aggregate gross annual
274 premiums for new, but not renewal, standard and basic health
275 benefit plans for the previous calendar year.
276 (f)(j) The boundaries of geographic areas used by a small
277 employer carrier must coincide with county lines. A carrier may
278 not apply different geographic rating factors to the rates of
279 small employers located within the same county.
280 (6) RESTRICTIONS RELATING TO PREMIUM RATES.—
281 (b) For all small employer health benefit plans that are
282 subject to this section and issued by small employer carriers on
283 or after January 1, 1994, premium rates for health benefit plans
284 are subject to the following:
285 1. Small employer carriers must use a modified community
286 rating methodology in which the premium for each small employer
287 is determined solely on the basis of the eligible employee’s and
288 eligible dependent’s gender, age, family composition, tobacco
289 use, or geographic area as determined under paragraph (5)(f)
290 (5)(j) and in which the premium may be adjusted as permitted by
291 this paragraph. A small employer carrier is not required to use
292 gender as a rating factor for a nongrandfathered health plan.
293 2. Rating factors related to age, gender, family
294 composition, tobacco use, or geographic location may be
295 developed by each carrier to reflect the carrier’s experience.
296 The factors used by carriers are subject to office review and
297 approval.
298 3. Small employer carriers may not modify the rate for a
299 small employer for 12 months from the initial issue date or
300 renewal date, unless the composition of the group changes or
301 benefits are changed. However, a small employer carrier may
302 modify the rate one time within the 12 months after the initial
303 issue date for a small employer who enrolls under a previously
304 issued group policy that has a common anniversary date for all
305 employers covered under the policy if:
306 a. The carrier discloses to the employer in a clear and
307 conspicuous manner the date of the first renewal and the fact
308 that the premium may increase on or after that date.
309 b. The insurer demonstrates to the office that efficiencies
310 in administration are achieved and reflected in the rates
311 charged to small employers covered under the policy.
312 4. A carrier may issue a group health insurance policy to a
313 small employer health alliance or other group association with
314 rates that reflect a premium credit for expense savings
315 attributable to administrative activities being performed by the
316 alliance or group association if such expense savings are
317 specifically documented in the insurer’s rate filing and are
318 approved by the office. Any such credit may not be based on
319 different morbidity assumptions or on any other factor related
320 to the health status or claims experience of any person covered
321 under the policy. This subparagraph does not exempt an alliance
322 or group association from licensure for activities that require
323 licensure under the insurance code. A carrier issuing a group
324 health insurance policy to a small employer health alliance or
325 other group association shall allow any properly licensed and
326 appointed agent of that carrier to market and sell the small
327 employer health alliance or other group association policy. Such
328 agent shall be paid the usual and customary commission paid to
329 any agent selling the policy.
330 5. Any adjustments in rates for claims experience, health
331 status, or duration of coverage may not be charged to individual
332 employees or dependents. For a small employer’s policy, such
333 adjustments may not result in a rate for the small employer
334 which deviates more than 15 percent from the carrier’s approved
335 rate. Any such adjustment must be applied uniformly to the rates
336 charged for all employees and dependents of the small employer.
337 A small employer carrier may make an adjustment to a small
338 employer’s renewal premium, up to 10 percent annually, due to
339 the claims experience, health status, or duration of coverage of
340 the employees or dependents of the small employer. Semiannually,
341 small group carriers shall report information on forms adopted
342 by rule by the commission, to enable the office to monitor the
343 relationship of aggregate adjusted premiums actually charged
344 policyholders by each carrier to the premiums that would have
345 been charged by application of the carrier’s approved modified
346 community rates. If the aggregate resulting from the application
347 of such adjustment exceeds the premium that would have been
348 charged by application of the approved modified community rate
349 by 4 percent for the current policy term reporting period, the
350 carrier shall limit the application of such adjustments only to
351 minus adjustments beginning within 60 days after the report is
352 sent to the office. For any subsequent policy term reporting
353 period, if the total aggregate adjusted premium actually charged
354 does not exceed the premium that would have been charged by
355 application of the approved modified community rate by 4
356 percent, the carrier may apply both plus and minus adjustments.
357 A small employer carrier may provide a credit to a small
358 employer’s premium based on administrative and acquisition
359 expense differences resulting from the size of the group. Group
360 size administrative and acquisition expense factors may be
361 developed by each carrier to reflect the carrier’s experience
362 and are subject to office review and approval.
363 6. A small employer carrier rating methodology may include
364 separate rating categories for one dependent child, for two
365 dependent children, and for three or more dependent children for
366 family coverage of employees having a spouse and dependent
367 children or employees having dependent children only. A small
368 employer carrier may have fewer, but not greater, numbers of
369 categories for dependent children than those specified in this
370 subparagraph.
371 7. Small employer carriers may not use a composite rating
372 methodology to rate a small employer with fewer than 10
373 employees. For the purposes of this subparagraph, the term
374 “composite rating methodology” means a rating methodology that
375 averages the impact of the rating factors for age and gender in
376 the premiums charged to all of the employees of a small
377 employer.
378 8. A carrier may separate the experience of small employer
379 groups with fewer than 2 eligible employees from the experience
380 of small employer groups with 2-50 eligible employees for
381 purposes of determining an alternative modified community
382 rating.
383 a. If a carrier separates the experience of small employer
384 groups, the rate to be charged to small employer groups of fewer
385 than 2 eligible employees may not exceed 150 percent of the rate
386 determined for small employer groups of 2-50 eligible employees.
387 However, the carrier may charge excess losses of the experience
388 pool consisting of small employer groups with less than 2
389 eligible employees to the experience pool consisting of small
390 employer groups with 2-50 eligible employees so that all losses
391 are allocated and the 150-percent rate limit on the experience
392 pool consisting of small employer groups with less than 2
393 eligible employees is maintained.
394 b. Notwithstanding s. 627.411(1), the rate to be charged to
395 a small employer group of fewer than 2 eligible employees,
396 insured as of July 1, 2002, may be up to 125 percent of the rate
397 determined for small employer groups of 2-50 eligible employees
398 for the first annual renewal and 150 percent for subsequent
399 annual renewals.
400 9. A carrier shall separate the experience of grandfathered
401 health plans from nongrandfathered health plans for determining
402 rates.
403 (11) SMALL EMPLOYER HEALTH REINSURANCE PROGRAM.—
404 (g) A reinsuring carrier may reinsure with the program
405 coverage of an eligible employee of a small employer, or any
406 dependent of such an employee, subject to each of the following
407 provisions:
408 1. With respect to a standard and basic health care plan,
409 the program must reinsure the level of coverage provided; and,
410 with respect to any other plan, the program must reinsure the
411 coverage up to, but not exceeding, the level of coverage
412 provided under the standard and basic health care plan.
413 1.2. Except in the case of a late enrollee, a reinsuring
414 carrier may reinsure an eligible employee or dependent within 60
415 days after the commencement of the coverage of the small
416 employer. A newly employed eligible employee or dependent of a
417 small employer may be reinsured within 60 days after the
418 commencement of his or her coverage.
419 2.3. A small employer carrier may reinsure an entire
420 employer group within 60 days after the commencement of the
421 group’s coverage under the plan. The carrier may choose to
422 reinsure newly eligible employees and dependents of the
423 reinsured group pursuant to subparagraph 1.
424 3.4. The program may not reimburse a participating carrier
425 with respect to the claims of a reinsured employee or dependent
426 until the carrier has paid incurred claims of at least $5,000 in
427 a calendar year for benefits covered by the program. In
428 addition, the reinsuring carrier shall be responsible for 10
429 percent of the next $50,000 and 5 percent of the next $100,000
430 of incurred claims during a calendar year and the program shall
431 reinsure the remainder.
432 4.5. The board annually shall adjust the initial level of
433 claims and the maximum limit to be retained by the carrier to
434 reflect increases in costs and utilization within the standard
435 market for health benefit plans within the state. The adjustment
436 shall not be less than the annual change in the medical
437 component of the “Consumer Price Index for All Urban Consumers”
438 of the Bureau of Labor Statistics of the Department of Labor,
439 unless the board proposes and the office approves a lower
440 adjustment factor.
441 5.6. A small employer carrier may terminate reinsurance for
442 all reinsured employees or dependents on any plan anniversary.
443 6.7. The premium rate charged for reinsurance by the
444 program to a health maintenance organization that is approved by
445 the Secretary of Health and Human Services as a federally
446 qualified health maintenance organization pursuant to 42 U.S.C.
447 s. 300e(c)(2)(A) and that, as such, is subject to requirements
448 that limit the amount of risk that may be ceded to the program,
449 which requirements are more restrictive than subparagraph 3. 4.,
450 shall be reduced by an amount equal to that portion of the risk,
451 if any, which exceeds the amount set forth in subparagraph 3. 4.
452 which may not be ceded to the program.
453 7.8. The board may consider adjustments to the premium
454 rates charged for reinsurance by the program for carriers that
455 use effective cost containment measures, including high-cost
456 case management, as defined by the board.
457 8.9. A reinsuring carrier shall apply its case-management
458 and claims-handling techniques, including, but not limited to,
459 utilization review, individual case management, preferred
460 provider provisions, other managed care provisions or methods of
461 operation, consistently with both reinsured business and
462 nonreinsured business.
463 (h)1. The board, as part of the plan of operation, shall
464 establish a methodology for determining premium rates to be
465 charged by the program for reinsuring small employers and
466 individuals pursuant to this section. The methodology shall
467 include a system for classification of small employers that
468 reflects the types of case characteristics commonly used by
469 small employer carriers in the state. The methodology shall
470 provide for the development of basic reinsurance premium rates,
471 which shall be multiplied by the factors set for them in this
472 paragraph to determine the premium rates for the program. The
473 basic reinsurance premium rates shall be established by the
474 board, subject to the approval of the office, and shall be set
475 at levels which reasonably approximate gross premiums charged to
476 small employers by small employer carriers for health benefit
477 plans with benefits similar to the standard and basic health
478 benefit plan. The premium rates set by the board may vary by
479 geographical area, as determined under this section, to reflect
480 differences in cost. The multiplying factors must be established
481 as follows:
482 a. The entire group may be reinsured for a rate that is 1.5
483 times the rate established by the board.
484 b. An eligible employee or dependent may be reinsured for a
485 rate that is 5 times the rate established by the board.
486 2. The board periodically shall review the methodology
487 established, including the system of classification and any
488 rating factors, to assure that it reasonably reflects the claims
489 experience of the program. The board may propose changes to the
490 rates which shall be subject to the approval of the office.
491 (j)1. Before July 1 of each calendar year, the board shall
492 determine and report to the office the program net loss for the
493 previous year, including administrative expenses for that year,
494 and the incurred losses for the year, taking into account
495 investment income and other appropriate gains and losses.
496 2. Any net loss for the year shall be recouped by
497 assessment of the carriers, as follows:
498 a. The operating losses of the program shall be assessed in
499 the following order subject to the specified limitations. The
500 first tier of assessments shall be made against reinsuring
501 carriers in an amount which shall not exceed 5 percent of each
502 reinsuring carrier’s premiums from health benefit plans covering
503 small employers. If such assessments have been collected and
504 additional moneys are needed, the board shall make a second tier
505 of assessments in an amount which shall not exceed 0.5 percent
506 of each carrier’s health benefit plan premiums. Except as
507 provided in paragraph (m) (n), risk-assuming carriers are exempt
508 from all assessments authorized pursuant to this section. The
509 amount paid by a reinsuring carrier for the first tier of
510 assessments shall be credited against any additional assessments
511 made.
512 b. The board shall equitably assess carriers for operating
513 losses of the plan based on market share. The board shall
514 annually assess each carrier a portion of the operating losses
515 of the plan. The first tier of assessments shall be determined
516 by multiplying the operating losses by a fraction, the numerator
517 of which equals the reinsuring carrier’s earned premium
518 pertaining to direct writings of small employer health benefit
519 plans in the state during the calendar year for which the
520 assessment is levied, and the denominator of which equals the
521 total of all such premiums earned by reinsuring carriers in the
522 state during that calendar year. The second tier of assessments
523 shall be based on the premiums that all carriers, except risk
524 assuming carriers, earned on all health benefit plans written in
525 this state. The board may levy interim assessments against
526 carriers to ensure the financial ability of the plan to cover
527 claims expenses and administrative expenses paid or estimated to
528 be paid in the operation of the plan for the calendar year prior
529 to the association’s anticipated receipt of annual assessments
530 for that calendar year. Any interim assessment is due and
531 payable within 30 days after receipt by a carrier of the interim
532 assessment notice. Interim assessment payments shall be credited
533 against the carrier’s annual assessment. Health benefit plan
534 premiums and benefits paid by a carrier that are less than an
535 amount determined by the board to justify the cost of collection
536 may not be considered for purposes of determining assessments.
537 c. Subject to the approval of the office, the board shall
538 make an adjustment to the assessment formula for reinsuring
539 carriers that are approved as federally qualified health
540 maintenance organizations by the Secretary of Health and Human
541 Services pursuant to 42 U.S.C. s. 300e(c)(2)(A) to the extent,
542 if any, that restrictions are placed on them that are not
543 imposed on other small employer carriers.
544 3. Before July 1 of each year, the board shall determine
545 and file with the office an estimate of the assessments needed
546 to fund the losses incurred by the program in the previous
547 calendar year.
548 4. If the board determines that the assessments needed to
549 fund the losses incurred by the program in the previous calendar
550 year will exceed the amount specified in subparagraph 2., the
551 board shall evaluate the operation of the program and report its
552 findings, including any recommendations for changes to the plan
553 of operation, to the office within 180 days following the end of
554 the calendar year in which the losses were incurred. The
555 evaluation shall include an estimate of future assessments, the
556 administrative costs of the program, the appropriateness of the
557 premiums charged and the level of carrier retention under the
558 program, and the costs of coverage for small employers. If the
559 board fails to file a report with the office within 180 days
560 following the end of the applicable calendar year, the office
561 may evaluate the operations of the program and implement such
562 amendments to the plan of operation the office deems necessary
563 to reduce future losses and assessments.
564 5. If assessments exceed the amount of the actual losses
565 and administrative expenses of the program, the excess shall be
566 held as interest and used by the board to offset future losses
567 or to reduce program premiums. As used in this paragraph, the
568 term “future losses” includes reserves for incurred but not
569 reported claims.
570 6. Each carrier’s proportion of the assessment shall be
571 determined annually by the board, based on annual statements and
572 other reports considered necessary by the board and filed by the
573 carriers with the board.
574 7. Provision shall be made in the plan of operation for the
575 imposition of an interest penalty for late payment of an
576 assessment.
577 8. A carrier may seek, from the office, a deferment, in
578 whole or in part, from any assessment made by the board. The
579 office may defer, in whole or in part, the assessment of a
580 carrier if, in the opinion of the office, the payment of the
581 assessment would place the carrier in a financially impaired
582 condition. If an assessment against a carrier is deferred, in
583 whole or in part, the amount by which the assessment is deferred
584 may be assessed against the other carriers in a manner
585 consistent with the basis for assessment set forth in this
586 section. The carrier receiving such deferment remains liable to
587 the program for the amount deferred and is prohibited from
588 reinsuring any individuals or groups in the program if it fails
589 to pay assessments.
590 (l) The board, as part of the plan of operation, shall
591 develop standards setting forth the manner and levels of
592 compensation to be paid to agents for the sale of basic and
593 standard health benefit plans. In establishing such standards,
594 the board shall take into consideration the need to assure the
595 broad availability of coverages, the objectives of the program,
596 the time and effort expended in placing the coverage, the need
597 to provide ongoing service to the small employer, the levels of
598 compensation currently used in the industry, and the overall
599 costs of coverage to small employers selecting these plans.
600 (l)(m) The board shall monitor compliance with this
601 section, including the market conduct of small employer
602 carriers, and shall report to the office any unfair trade
603 practices and misleading or unfair conduct by a small employer
604 carrier that has been reported to the board by agents,
605 consumers, or any other person. The office shall investigate all
606 reports and, upon a finding of noncompliance with this section
607 or of unfair or misleading practices, shall take action against
608 the small employer carrier as permitted under the insurance code
609 or chapter 641. The board is not given investigatory or
610 regulatory powers, but must forward all reports of cases or
611 abuse or misrepresentation to the office.
612 (m)(n) Notwithstanding paragraph (j), the administrative
613 expenses of the program shall be recouped by assessment of risk
614 assuming carriers and reinsuring carriers and such amounts shall
615 not be considered part of the operating losses of the plan for
616 the purposes of this paragraph. Each carrier’s portion of such
617 administrative expenses shall be determined by multiplying the
618 total of such administrative expenses by a fraction, the
619 numerator of which equals the carrier’s earned premium
620 pertaining to direct writing of small employer health benefit
621 plans in the state during the calendar year for which the
622 assessment is levied, and the denominator of which equals the
623 total of such premiums earned by all carriers in the state
624 during such calendar year.
625 (n)(o) The board shall advise the office, the Agency for
626 Health Care Administration, the department, other executive
627 departments, and the Legislature on health insurance issues.
628 Specifically, the board shall:
629 1. Provide a forum for stakeholders, consisting of
630 insurers, employers, agents, consumers, and regulators, in the
631 private health insurance market in this state.
632 2. Review and recommend strategies to improve the
633 functioning of the health insurance markets in this state with a
634 specific focus on market stability, access, and pricing.
635 3. Make recommendations to the office for legislation
636 addressing health insurance market issues and provide comments
637 on health insurance legislation proposed by the office.
638 4. Meet at least three times each year. One meeting shall
639 be held to hear reports and to secure public comment on the
640 health insurance market, to develop any legislation needed to
641 address health insurance market issues, and to provide comments
642 on health insurance legislation proposed by the office.
643 5. Issue a report to the office on the state of the health
644 insurance market by September 1 each year. The report shall
645 include recommendations for changes in the health insurance
646 market, results from implementation of previous recommendations,
647 and information on health insurance markets.
648 (12) STANDARD, BASIC, HIGH DEDUCTIBLE, AND LIMITED HEALTH
649 BENEFIT PLANS.—
650 (a)1. The Chief Financial Officer shall appoint a health
651 benefit plan committee composed of four representatives of
652 carriers which shall include at least two representatives of
653 HMOs, at least one of which is a staff model HMO, two
654 representatives of agents, four representatives of small
655 employers, and one employee of a small employer. The carrier
656 members shall be selected from a list of individuals recommended
657 by the board. The Chief Financial Officer may require the board
658 to submit additional recommendations of individuals for
659 appointment.
660 2. The plans shall comply with all of the requirements of
661 this subsection.
662 3. The plans must be filed with and approved by the office
663 prior to issuance or delivery by any small employer carrier.
664 4. After approval of the revised health benefit plans, if
665 the office determines that modifications to a plan might be
666 appropriate, the Chief Financial Officer shall appoint a new
667 health benefit plan committee in the manner provided in
668 subparagraph 1. to submit recommended modifications to the
669 office for approval.
670 (b)1. Each small employer carrier issuing new health
671 benefit plans shall offer to any small employer, upon request, a
672 standard health benefit plan, a basic health benefit plan, and a
673 high deductible plan that meets the requirements of a health
674 savings account plan as defined by federal law or a health
675 reimbursement arrangement as authorized by the Internal Revenue
676 Service, that meet the criteria set forth in this section.
677 2. For purposes of this subsection, the terms “standard
678 health benefit plan,” “basic health benefit plan,” and “high
679 deductible plan” mean policies or contracts that a small
680 employer carrier offers to eligible small employers that
681 contain:
682 a. An exclusion for services that are not medically
683 necessary or that are not covered preventive health services;
684 and
685 b. A procedure for preauthorization by the small employer
686 carrier, or its designees.
687 3. A small employer carrier may include the following
688 managed care provisions in the policy or contract to control
689 costs:
690 a. A preferred provider arrangement or exclusive provider
691 organization or any combination thereof, in which a small
692 employer carrier enters into a written agreement with the
693 provider to provide services at specified levels of
694 reimbursement or to provide reimbursement to specified
695 providers. Any such written agreement between a provider and a
696 small employer carrier must contain a provision under which the
697 parties agree that the insured individual or covered member has
698 no obligation to make payment for any medical service rendered
699 by the provider which is determined not to be medically
700 necessary. A carrier may use preferred provider arrangements or
701 exclusive provider arrangements to the same extent as allowed in
702 group products that are not issued to small employers.
703 b. A procedure for utilization review by the small employer
704 carrier or its designees.
705
706 This subparagraph does not prohibit a small employer carrier
707 from including in its policy or contract additional managed care
708 and cost containment provisions, subject to the approval of the
709 office, which have potential for controlling costs in a manner
710 that does not result in inequitable treatment of insureds or
711 subscribers. The carrier may use such provisions to the same
712 extent as authorized for group products that are not issued to
713 small employers.
714 4. The standard health benefit plan shall include:
715 a. Coverage for inpatient hospitalization;
716 b. Coverage for outpatient services;
717 c. Coverage for newborn children pursuant to s. 627.6575;
718 d. Coverage for child care supervision services pursuant to
719 s. 627.6579;
720 e. Coverage for adopted children upon placement in the
721 residence pursuant to s. 627.6578;
722 f. Coverage for mammograms pursuant to s. 627.6613;
723 g. Coverage for handicapped children pursuant to s.
724 627.6615;
725 h. Emergency or urgent care out of the geographic service
726 area; and
727 i. Coverage for services provided by a hospice licensed
728 under s. 400.602 in cases where such coverage would be the most
729 appropriate and the most cost-effective method for treating a
730 covered illness.
731 5. The standard health benefit plan and the basic health
732 benefit plan may include a schedule of benefit limitations for
733 specified services and procedures. If the committee develops
734 such a schedule of benefits limitation for the standard health
735 benefit plan or the basic health benefit plan, a small employer
736 carrier offering the plan must offer the employer an option for
737 increasing the benefit schedule amounts by 4 percent annually.
738 6. The basic health benefit plan shall include all of the
739 benefits specified in subparagraph 4.; however, the basic health
740 benefit plan shall place additional restrictions on the benefits
741 and utilization and may also impose additional cost containment
742 measures.
743 7. Sections 627.419(2), (3), and (4), 627.6574, 627.6612,
744 627.66121, 627.66122, 627.6616, 627.6618, 627.668, and 627.66911
745 apply to the standard health benefit plan and to the basic
746 health benefit plan. However, notwithstanding said provisions,
747 the plans may specify limits on the number of authorized
748 treatments, if such limits are reasonable and do not
749 discriminate against any type of provider.
750 8. The high deductible plan associated with a health
751 savings account or a health reimbursement arrangement shall
752 include all the benefits specified in subparagraph 4.
753 9. Each small employer carrier that provides for inpatient
754 and outpatient services by allopathic hospitals may provide as
755 an option of the insured similar inpatient and outpatient
756 services by hospitals accredited by the American Osteopathic
757 Association when such services are available and the osteopathic
758 hospital agrees to provide the service.
759 (c) If a small employer rejects, in writing, the standard
760 health benefit plan, the basic health benefit plan, and the high
761 deductible health savings account plan or a health reimbursement
762 arrangement, the small employer carrier may offer the small
763 employer a limited benefit policy or contract.
764 (d)1. Upon offering coverage under a standard health
765 benefit plan, a basic health benefit plan, or a limited benefit
766 policy or contract for a small employer group, the small
767 employer carrier shall provide such employer group with a
768 written statement that contains, at a minimum:
769 a. An explanation of those mandated benefits and providers
770 that are not covered by the policy or contract;
771 b. An explanation of the managed care and cost control
772 features of the policy or contract, along with all appropriate
773 mailing addresses and telephone numbers to be used by insureds
774 in seeking information or authorization; and
775 c. An explanation of the primary and preventive care
776 features of the policy or contract.
777
778 Such disclosure statement must be presented in a clear and
779 understandable form and format and must be separate from the
780 policy or certificate or evidence of coverage provided to the
781 employer group.
782 2. Before a small employer carrier issues a standard health
783 benefit plan, a basic health benefit plan, or a limited benefit
784 policy or contract, the carrier must obtain from the prospective
785 policyholder a signed written statement in which the prospective
786 policyholder:
787 a. Certifies as to eligibility for coverage under the
788 standard health benefit plan, basic health benefit plan, or
789 limited benefit policy or contract;
790 b. Acknowledges the limited nature of the coverage and an
791 understanding of the managed care and cost control features of
792 the policy or contract;
793 c. Acknowledges that if misrepresentations are made
794 regarding eligibility for coverage under a standard health
795 benefit plan, a basic health benefit plan, or a limited benefit
796 policy or contract, the person making such misrepresentations
797 forfeits coverage provided by the policy or contract; and
798 d. If a limited plan is requested, acknowledges that the
799 prospective policyholder had been offered, at the time of
800 application for the insurance policy or contract, the
801 opportunity to purchase any health benefit plan offered by the
802 carrier and that the prospective policyholder rejected that
803 coverage.
804
805 A copy of such written statement must be provided to the
806 prospective policyholder by the time of delivery of the policy
807 or contract, and the original of such written statement must be
808 retained in the files of the small employer carrier for the
809 period of time that the policy or contract remains in effect or
810 for 5 years, whichever is longer.
811 3. Any material statement made by an applicant for coverage
812 under a health benefit plan which falsely certifies the
813 applicant’s eligibility for coverage serves as the basis for
814 terminating coverage under the policy or contract.
815 (e) A small employer carrier may not use any policy,
816 contract, form, or rate under this section, including
817 applications, enrollment forms, policies, contracts,
818 certificates, evidences of coverage, riders, amendments,
819 endorsements, and disclosure forms, until the insurer has filed
820 it with the office and the office has approved it under ss.
821 627.410 and 627.411 and this section.
822 (12)(13) STANDARDS TO ASSURE FAIR MARKETING.—
823 (a) Each small employer carrier shall actively market
824 health benefit plan coverage, including the basic and standard
825 health benefit plans, including any subsequent modifications or
826 additions to those plans, to eligible small employers in the
827 state. Before January 1, 1994, if a small employer carrier
828 denies coverage to a small employer on the basis of the health
829 status or claims experience of the small employer or its
830 employees or dependents, the small employer carrier shall offer
831 the small employer the opportunity to purchase a basic health
832 benefit plan and a standard health benefit plan. Beginning
833 January 1, 1994, Small employer carriers must offer and issue
834 all plans on a guaranteed-issue basis.
835 (b) A No small employer carrier or agent shall not,
836 directly or indirectly, engage in the following activities:
837 1. Encouraging or directing small employers to refrain from
838 filing an application for coverage with the small employer
839 carrier because of the health status, claims experience,
840 industry, occupation, or geographic location of the small
841 employer.
842 2. Encouraging or directing small employers to seek
843 coverage from another carrier because of the health status,
844 claims experience, industry, occupation, or geographic location
845 of the small employer.
846 (c) The provisions of Paragraph (a) does shall not apply
847 with respect to information provided by a small employer carrier
848 or agent to a small employer regarding the established
849 geographic service area or a restricted network provision of a
850 small employer carrier.
851 (d) A No small employer carrier shall not, directly or
852 indirectly, enter into any contract, agreement, or arrangement
853 with an agent that provides for or results in the compensation
854 paid to an agent for the sale of a health benefit plan to be
855 varied because of the health status, claims experience,
856 industry, occupation, or geographic location of the small
857 employer except if the compensation arrangement provides
858 compensation to an agent on the basis of percentage of premium,
859 provided that the percentage shall not vary because of the
860 health status, claims experience, industry, occupation, or
861 geographic area of the small employer.
862 (e) A small employer carrier shall provide reasonable
863 compensation, as provided under the plan of operation of the
864 program, to an agent, if any, for the sale of a basic or
865 standard health benefit plan.
866 (e)(f) A No small employer carrier shall not terminate,
867 fail to renew, or limit its contract or agreement of
868 representation with an agent for any reason related to the
869 health status, claims experience, occupation, or geographic
870 location of the small employers placed by the agent with the
871 small employer carrier unless the agent consistently engages in
872 practices that violate this section or s. 626.9541.
873 (f)(g) A No small employer carrier or agent shall not
874 induce or otherwise encourage a small employer to separate or
875 otherwise exclude an employee from health coverage or benefits
876 provided in connection with the employee’s employment.
877 (g)(h) Denial by a small employer carrier of an application
878 for coverage from a small employer shall be in writing and shall
879 state the reason or reasons for the denial.
880 (h)(i) The commission may establish regulations setting
881 forth additional standards to provide for the fair marketing and
882 broad availability of health benefit plans to small employers in
883 this state.
884 (i)(j) A violation of this section by a small employer
885 carrier or an agent is shall be an unfair trade practice under
886 s. 626.9541 or ss. 641.3903 and 641.3907.
887 (j)(k) If a small employer carrier enters into a contract,
888 agreement, or other arrangement with a third-party administrator
889 to provide administrative, marketing, or other services relating
890 to the offering of health benefit plans to small employers in
891 this state, the third-party administrator shall be subject to
892 this section.
893 (13)(14) DISCLOSURE OF INFORMATION.—
894 (a) In connection with the offering of a health benefit
895 plan to a small employer, a small employer carrier:
896 1. Shall make a reasonable disclosure to such employer, as
897 part of its solicitation and sales materials, of the
898 availability of information described in paragraph (b); and
899 2. Upon request of the small employer, provide such
900 information.
901 (b)1. Subject to subparagraph 3., with respect to a small
902 employer carrier that offers a health benefit plan to a small
903 employer, information described in this paragraph is information
904 that concerns:
905 a. The provisions of such coverage concerning an insurer’s
906 right to change premium rates and the factors that may affect
907 changes in premium rates;
908 b. The provisions of such coverage that relate to
909 renewability of coverage;
910 c. The provisions of such coverage that relate to any
911 preexisting condition exclusions; and
912 d. The benefits and premiums available under all health
913 insurance coverage for which the employer is qualified.
914 2. Information required under this subsection shall be
915 provided to small employers in a manner determined to be
916 understandable by the average small employer, and shall be
917 sufficient to reasonably inform small employers of their rights
918 and obligations under the health insurance coverage.
919 3. An insurer is not required under this subsection to
920 disclose any information that is proprietary or a trade secret
921 under state law.
922 (14)(15) SMALL EMPLOYERS ACCESS PROGRAM.—
923 (k) Benefits.—The benefits provided by the plan shall be
924 the same as the coverage required for small employers under
925 subsection (12). Upon the approval of the office, the insurer
926 may also establish an optional mutually supported benefit plan
927 that which is an alternative plan developed within a defined
928 geographic region of this state or any other such alternative
929 plan that which will carry out the intent of this subsection.
930 Any small employer carrier issuing new health benefit plans may
931 offer a benefit plan with coverages similar to, but not less
932 than, any alternative coverage plan developed pursuant to this
933 subsection.
934 (15)(16) APPLICABILITY OF OTHER STATE LAWS.—
935 (a) Except as expressly provided in this section, a law
936 requiring coverage for a specific health care service or
937 benefit, or a law requiring reimbursement, utilization, or
938 consideration of a specific category of licensed health care
939 practitioner, does not apply to a standard or basic health
940 benefit plan policy or contract or a limited benefit policy or
941 contract offered or delivered to a small employer unless that
942 law is made expressly applicable to such policies or contracts.
943 A law restricting or limiting deductibles, coinsurance,
944 copayments, or annual or lifetime maximum payments does not
945 apply to any health plan policy, including a standard or basic
946 health benefit plan policy or contract, offered or delivered to
947 a small employer unless such law is made expressly applicable to
948 such policy or contract. However, every small employer carrier
949 must offer to eligible small employers the standard benefit plan
950 and the basic benefit plan, as required by subsection (5), as
951 such plans have been approved by the office pursuant to
952 subsection (12).
953 (b) Except as provided in this section, a standard or basic
954 health benefit plan policy or contract or limited benefit policy
955 or contract offered to a small employer is not subject to any
956 provision of this code which:
957 1. Inhibits a small employer carrier from contracting with
958 providers or groups of providers with respect to health care
959 services or benefits;
960 2. Imposes any restriction on a small employer carrier’s
961 ability to negotiate with providers regarding the level or
962 method of reimbursing care or services provided under a health
963 benefit plan; or
964 3. Requires a small employer carrier to either include a
965 specific provider or class of providers when contracting for
966 health care services or benefits or to exclude any class of
967 providers that is generally authorized by statute to provide
968 such care.
969 (b)(c) Any second tier assessment paid by a carrier
970 pursuant to paragraph (11)(j) may be credited against
971 assessments levied against the carrier pursuant to s. 627.6494.
972 (c)(d) Notwithstanding chapter 641, a health maintenance
973 organization may is authorized to issue contracts providing
974 benefits equal to the standard health benefit plan, the basic
975 health benefit plan, and the limited benefit policy authorized
976 by this section.
977 (16)(17) RESTRICTIONS ON COVERAGE.—
978 (a) A plan under which coverage is purchased in whole or in
979 part with any state or federal funds through an exchange created
980 pursuant to the federal Patient Protection and Affordable Care
981 Act, Pub. L. No. 111-148, may not provide coverage for an
982 abortion, as defined in s. 390.011(1), except if the pregnancy
983 is the result of an act of rape or incest, or in the case where
984 a woman suffers from a physical disorder, physical injury, or
985 physical illness, including a life-endangering physical
986 condition caused by or arising from the pregnancy itself, which
987 would, as certified by a physician, place the woman in danger of
988 death unless an abortion is performed. Coverage is deemed to be
989 purchased with state or federal funds if any tax credit or cost
990 sharing credit is applied toward the plan.
991 (b) This subsection does not prohibit a plan from providing
992 any person or entity with separate coverage for an abortion if
993 such coverage is not purchased in whole or in part with state or
994 federal funds.
995 (c) As used in this section, the term “state” means this
996 state or any political subdivision of the state.
997 (17)(18) RULEMAKING AUTHORITY.—The commission may adopt
998 rules to administer this section, including rules governing
999 compliance by small employer carriers and small employers.
1000 Section 2. Section 627.66997, Florida Statutes, is created
1001 to read:
1002 627.66997 Stop-loss insurance.—
1003 (1) A self-insured health benefit plan established or
1004 maintained by a small employer, as defined in s. 627.6699(3)(v),
1005 is exempt from s. 627.6699 and may use a stop-loss insurance
1006 policy issued to the employer. For purposes of this subsection,
1007 the term “stop-loss insurance policy” means an insurance policy
1008 issued to a small employer which covers the small employer’s
1009 obligation for the excess cost of medical care on an equivalent
1010 basis per employee provided under a self-insured health benefit
1011 plan.
1012 (a) A small employer stop-loss insurance policy is
1013 considered a health insurance policy and is subject to s.
1014 627.6699 if the policy has an aggregate attachment point that is
1015 lower than the greatest of:
1016 1. Two thousand dollars multiplied by the number of
1017 employees;
1018 2. One hundred twenty percent of expected claims, as
1019 determined by the stop-loss insurer in accordance with actuarial
1020 standards of practice; or
1021 3. Twenty thousand dollars.
1022 (b) Once claims under the small employer health benefit
1023 plan reach the aggregate attachment point set forth in paragraph
1024 (a), the stop-loss insurance policy authorized under this
1025 section must cover 100 percent of all claims that exceed the
1026 aggregate attachment point.
1027 (2) A self-insured health benefit plan established or
1028 maintained by an employer with 51 or more covered employees is
1029 considered health insurance if the plan’s stop-loss coverage, as
1030 defined in s. 627.6482(14), has an aggregate attachment point
1031 that is lower than the greater of:
1032 (a) One hundred ten percent of expected claims, as
1033 determined by the stop-loss insurer in accordance with actuarial
1034 standards of practice; or
1035 (b) Twenty thousand dollars.
1036 (3) Stop-loss insurance carriers shall use a consistent
1037 basis for determining the number of an employer’s covered
1038 employees. Such basis may include, but is not limited to, the
1039 average number of employees employed annually or at a uniform
1040 time.
1041 Section 3. Subsection (3) of section 627.642, Florida
1042 Statutes, is amended to read:
1043 627.642 Outline of coverage.—
1044 (3) In addition to the outline of coverage, a policy as
1045 specified in s. 627.6699(3)(k) 627.6699(3)(l) must be
1046 accompanied by an identification card that contains, at a
1047 minimum:
1048 (a) The name of the organization issuing the policy or the
1049 name of the organization administering the policy, whichever
1050 applies.
1051 (b) The name of the contract holder.
1052 (c) The type of plan only if the plan is filed in the
1053 state, an indication that the plan is self-funded, or the name
1054 of the network.
1055 (d) The member identification number, contract number, and
1056 policy or group number, if applicable.
1057 (e) A contact phone number or electronic address for
1058 authorizations and admission certifications.
1059 (f) A phone number or electronic address whereby the
1060 covered person or hospital, physician, or other person rendering
1061 services covered by the policy may obtain benefits verification
1062 and information in order to estimate patient financial
1063 responsibility, in compliance with privacy rules under the
1064 Health Insurance Portability and Accountability Act.
1065 (g) The national plan identifier, in accordance with the
1066 compliance date set forth by the federal Department of Health
1067 and Human Services.
1068
1069 The identification card must present the information in a
1070 readily identifiable manner or, alternatively, the information
1071 may be embedded on the card and available through magnetic
1072 stripe or smart card. The information may also be provided
1073 through other electronic technology.
1074 Section 4. Paragraph (g) of subsection (7) and paragraph
1075 (a) of subsection (8) of section 627.6475, Florida Statutes, are
1076 amended to read:
1077 627.6475 Individual reinsurance pool.—
1078 (7) INDIVIDUAL HEALTH REINSURANCE PROGRAM.—
1079 (g) Except as otherwise provided in this section, the board
1080 and the office shall have all powers, duties, and
1081 responsibilities with respect to carriers that issue and
1082 reinsure individual health insurance, as specified for the board
1083 and the office in s. 627.6699(11) with respect to small employer
1084 carriers, including, but not limited to, the provisions of s.
1085 627.6699(11) relating to:
1086 1. Use of assessments that exceed the amount of actual
1087 losses and expenses.
1088 2. The annual determination of each carrier’s proportion of
1089 the assessment.
1090 3. Interest for late payment of assessments.
1091 4. Authority for the office to approve deferment of an
1092 assessment against a carrier.
1093 5. Limited immunity from legal actions or carriers.
1094 6. Development of standards for compensation to be paid to
1095 agents. Such standards shall be limited to those specifically
1096 enumerated in s. 627.6699(12)(d) 627.6699(13)(d).
1097 7. Monitoring compliance by carriers with this section.
1098 (8) STANDARDS TO ASSURE FAIR MARKETING.—
1099 (a) Each health insurance issuer that offers individual
1100 health insurance shall actively market coverage to eligible
1101 individuals in the state. The provisions of s. 627.6699(12)
1102 627.6699(13) that apply to small employer carriers that market
1103 policies to small employers shall also apply to health insurance
1104 issuers that offer individual health insurance with respect to
1105 marketing policies to individuals.
1106 Section 5. Subsection (2) of section 627.657, Florida
1107 Statutes, is amended to read:
1108 627.657 Provisions of group health insurance policies.—
1109 (2) The medical policy as specified in s. 627.6699(3)(k)
1110 627.6699(3)(l) must be accompanied by an identification card
1111 that contains, at a minimum:
1112 (a) The name of the organization issuing the policy or name
1113 of the organization administering the policy, whichever applies.
1114 (b) The name of the certificateholder.
1115 (c) The type of plan only if the plan is filed in the
1116 state, an indication that the plan is self-funded, or the name
1117 of the network.
1118 (d) The member identification number, contract number, and
1119 policy or group number, if applicable.
1120 (e) A contact phone number or electronic address for
1121 authorizations and admission certifications.
1122 (f) A phone number or electronic address whereby the
1123 covered person or hospital, physician, or other person rendering
1124 services covered by the policy may obtain benefits verification
1125 and information in order to estimate patient financial
1126 responsibility, in compliance with privacy rules under the
1127 Health Insurance Portability and Accountability Act.
1128 (g) The national plan identifier, in accordance with the
1129 compliance date set forth by the federal Department of Health
1130 and Human Services.
1131
1132 The identification card must present the information in a
1133 readily identifiable manner or, alternatively, the information
1134 may be embedded on the card and available through magnetic
1135 stripe or smart card. The information may also be provided
1136 through other electronic technology.
1137 Section 6. Paragraph (e) of subsection (2) of section
1138 627.6571, Florida Statutes, is amended to read:
1139 627.6571 Guaranteed renewability of coverage.—
1140 (2) An insurer may nonrenew or discontinue a group health
1141 insurance policy based only on one or more of the following
1142 conditions:
1143 (e) In the case of an insurer that offers health insurance
1144 coverage through a network plan, there is no longer any enrollee
1145 in connection with such plan who lives, resides, or works in the
1146 service area of the insurer or in the area in which the insurer
1147 is authorized to do business and, in the case of the small-group
1148 market, the insurer would deny enrollment with respect to such
1149 plan under s. 627.6699(5)(i).
1150 Section 7. Subsection (11) of section 627.6675, Florida
1151 Statutes, is amended to read:
1152 627.6675 Conversion on termination of eligibility.—Subject
1153 to all of the provisions of this section, a group policy
1154 delivered or issued for delivery in this state by an insurer or
1155 nonprofit health care services plan that provides, on an
1156 expense-incurred basis, hospital, surgical, or major medical
1157 expense insurance, or any combination of these coverages, shall
1158 provide that an employee or member whose insurance under the
1159 group policy has been terminated for any reason, including
1160 discontinuance of the group policy in its entirety or with
1161 respect to an insured class, and who has been continuously
1162 insured under the group policy, and under any group policy
1163 providing similar benefits that the terminated group policy
1164 replaced, for at least 3 months immediately prior to
1165 termination, shall be entitled to have issued to him or her by
1166 the insurer a policy or certificate of health insurance,
1167 referred to in this section as a “converted policy.” A group
1168 insurer may meet the requirements of this section by contracting
1169 with another insurer, authorized in this state, to issue an
1170 individual converted policy, which policy has been approved by
1171 the office under s. 627.410. An employee or member shall not be
1172 entitled to a converted policy if termination of his or her
1173 insurance under the group policy occurred because he or she
1174 failed to pay any required contribution, or because any
1175 discontinued group coverage was replaced by similar group
1176 coverage within 31 days after discontinuance.
1177 (11) ALTERNATIVE PLANS.—The insurer shall, in addition to
1178 the option required by subsection (10), offer the standard
1179 health benefit plan, as established pursuant to s. 627.6699(12).
1180 The insurer may, at its option, also offer alternative plans for
1181 group health conversion in addition to the plans required by
1182 this section.
1183 Section 8. Paragraph (e) of subsection (2) of section
1184 641.31074, Florida Statutes, is amended to read:
1185 641.31074 Guaranteed renewability of coverage.—
1186 (2) A health maintenance organization may nonrenew or
1187 discontinue a contract based only on one or more of the
1188 following conditions:
1189 (e) There is no longer any enrollee in connection with such
1190 plan who lives, resides, or works in the service area of the
1191 health maintenance organization or in the area in which the
1192 health maintenance organization is authorized to do business
1193 and, in the case of the small group market, the organization
1194 would deny enrollment with respect to such plan under s.
1195 627.6699(5)(i).
1196 Section 9. Subsection (10) of section 641.3922, Florida
1197 Statutes, is amended to read:
1198 641.3922 Conversion contracts; conditions.—Issuance of a
1199 converted contract shall be subject to the following conditions:
1200 (10) ALTERNATE PLANS.—The health maintenance organization
1201 shall offer a standard health benefit plan as established
1202 pursuant to s. 627.6699(12). The health maintenance organization
1203 may, at its option, also offer alternative plans for group
1204 health conversion in addition to those required by this section,
1205 provided any alternative plan is approved by the office or is a
1206 converted policy, approved under s. 627.6675 and issued by an
1207 insurance company authorized to transact insurance in this
1208 state. Approval by the office of an alternative plan shall be
1209 based on compliance by the alternative plan with the provisions
1210 of this part and the rules promulgated thereunder, applicable
1211 provisions of the Florida Insurance Code and rules promulgated
1212 thereunder, and any other applicable law.
1213 Section 10. This act shall take effect July 1, 2015.