Florida Senate - 2021                                    SB 2506
       By the Committee on Appropriations
       576-03652-21                                          20212506__
    1                        A bill to be entitled                      
    2         An act relating to the state group insurance program;
    3         amending s. 110.123, F.S.; revising the definition of
    4         the term “full-time state employees” to conform to
    5         changes made by the act; authorizing persons eligible
    6         to participate in the program to elect membership with
    7         certain health maintenance organization plans;
    8         requiring that at least one health maintenance
    9         organization plan be made available to each enrollee
   10         residing in this state; deleting provisions providing
   11         for the establishment of health maintenance
   12         organization plan regions by Department of Management
   13         Services rule; deleting a requirement that health
   14         plans be offered in specified benefit levels;
   15         establishing regions for health maintenance
   16         organizations for specified purposes; providing
   17         construction; amending s. 110.12315, F.S.; removing a
   18         limitation on the annual maximum amount for coverage
   19         for medically necessary prescription and
   20         nonprescription enteral formulas and amino-acid-based
   21         elemental formulas for home use; requiring the
   22         department to ensure that the prescription drug
   23         program receives certain benefits; requiring the
   24         department to perform annual audits of such benefits;
   25         amending s. 110.131, F.S.; conforming a cross
   26         reference; providing an effective date.
   28  Be It Enacted by the Legislature of the State of Florida:
   30         Section 1. Paragraph (c) of subsection (2), paragraphs (h)
   31  and (j) of subsection (3), and paragraphs (c) and (d) of
   32  subsection (13) of section 110.123, Florida Statutes, are
   33  amended, and subsection (14) is added to that section, to read:
   34         110.123 State group insurance program.—
   35         (2) DEFINITIONS.—As used in ss. 110.123-110.1239, the term:
   36         (c) “Full-time state employees” means employees of all
   37  branches or agencies of state government holding salaried
   38  positions who are paid by state warrant or from agency funds and
   39  who work or are expected to work an average of at least 30 or
   40  more hours per week; employees paid from regular salary
   41  appropriations for 8 months’ employment, including university
   42  personnel on academic contracts; and employees paid from other
   43  personal-services (OPS) funds who are reasonably expected to
   44  work an average of at least 30 hours or more per week or have
   45  worked an average of at least 30 hours or more per week during
   46  the employee’s measurement period as described in subparagraphs
   47  1. and 2. The term includes all full-time employees of the state
   48  universities. The term does not include seasonal workers who are
   49  paid from OPS funds.
   50         1. For persons hired before April 1, 2013, the term
   51  includes any person paid from OPS funds who:
   52         a. Has worked an average of at least 30 hours or more per
   53  week during the initial measurement period from April 1, 2013,
   54  through September 30, 2013; or
   55         b. Has worked an average of at least 30 hours or more per
   56  week during a subsequent measurement period.
   57         2. For persons hired after April 1, 2013, the term includes
   58  any person paid from OPS funds who:
   59         a. Is reasonably expected to work an average of at least 30
   60  hours or more per week; or
   61         b. Has worked an average of at least 30 hours or more per
   62  week during the person’s measurement period.
   64         (h)1. A person eligible to participate in the state group
   65  insurance program may be authorized by rules adopted by the
   66  department, in lieu of participating in the state group health
   67  insurance plan, may to exercise an option to elect membership in
   68  a health maintenance organization plan which is under contract
   69  with the state in accordance with criteria established by this
   70  section and by said rules adopted by the department. The offer
   71  of optional membership in a health maintenance organization plan
   72  permitted by this paragraph may be limited or conditioned by
   73  rule as may be necessary to meet the requirements of state and
   74  federal laws.
   75         2. The department shall contract with health maintenance
   76  organizations seeking to participate in the state group
   77  insurance program through a request for proposal or other
   78  procurement process, as developed by the Department of
   79  Management Services and determined to be appropriate.
   80         a. The department shall establish a schedule of minimum
   81  benefits for health maintenance organization coverage, and that
   82  schedule shall include: physician services; inpatient and
   83  outpatient hospital services; emergency medical services,
   84  including out-of-area emergency coverage; diagnostic laboratory
   85  and diagnostic and therapeutic radiologic services; mental
   86  health, alcohol, and chemical dependency treatment services
   87  meeting the minimum requirements of state and federal law;
   88  skilled nursing facilities and services; prescription drugs;
   89  age-based and gender-based wellness benefits; and other benefits
   90  as may be required by the department. Additional services may be
   91  provided subject to the contract between the department and the
   92  HMO. As used in this paragraph, the term “age-based and gender
   93  based wellness benefits” includes aerobic exercise, education in
   94  alcohol and substance abuse prevention, blood cholesterol
   95  screening, health risk appraisals, blood pressure screening and
   96  education, nutrition education, program planning, safety belt
   97  education, smoking cessation, stress management, weight
   98  management, and women’s health education.
   99         b. The department may establish uniform deductibles,
  100  copayments, coverage tiers, or coinsurance schedules for all
  101  participating HMO plans.
  102         c. The department may require detailed information from
  103  each health maintenance organization participating in the
  104  procurement process, including information pertaining to
  105  organizational status, experience in providing prepaid health
  106  benefits, accessibility of services, financial stability of the
  107  plan, quality of management services, accreditation status,
  108  quality of medical services, network access and adequacy,
  109  performance measurement, ability to meet the department’s
  110  reporting requirements, and the actuarial basis of the proposed
  111  rates and other data determined by the director to be necessary
  112  for the evaluation and selection of health maintenance
  113  organization plans and negotiation of appropriate rates for
  114  these plans. Upon receipt of proposals by health maintenance
  115  organization plans and the evaluation of those proposals, the
  116  department may enter into negotiations with all of the plans or
  117  a subset of the plans, as the department determines appropriate.
  118  The department may negotiate regional or statewide contracts
  119  with health maintenance organization plans. Such plans must be
  120  cost-effective and must offer high value to enrollees.
  121         d. The department may limit the number of HMOs that it
  122  contracts with in each region based on the nature of the bids
  123  the department receives, the number of state employees in the
  124  region, or any unique characteristics of the region. At least
  125  one HMO plan must be available to each enrollee residing in this
  126  state The department shall establish the regions throughout the
  127  state by rule. The department must submit the rule to the
  128  President of the Senate and the Speaker of the House of
  129  Representatives for ratification no later than 30 days before
  130  the 2020 Regular Session of the Legislature. The rule may not
  131  take effect until it is ratified by the Legislature.
  132         e. All persons participating in the state group insurance
  133  program may be required to contribute towards a total state
  134  group health premium that may vary depending upon the plan,
  135  coverage level, and coverage tier selected by the enrollee and
  136  the level of state contribution authorized by the Legislature.
  137         3. The department is authorized to negotiate and to
  138  contract with specialty psychiatric hospitals for mental health
  139  benefits, on a regional basis, for alcohol, drug abuse, and
  140  mental and nervous disorders. The department may establish,
  141  subject to the approval of the Legislature pursuant to
  142  subsection (5), any such regional plan upon completion of an
  143  actuarial study to determine any impact on plan benefits and
  144  premiums.
  145         4. In addition to contracting pursuant to subparagraph 2.,
  146  the department may enter into contract with any HMO to
  147  participate in the state group insurance program which:
  148         a. Serves greater than 5,000 recipients on a prepaid basis
  149  under the Medicaid program;
  150         b. Does not currently meet the 25-percent non-Medicare/non
  151  Medicaid enrollment composition requirement established by the
  152  Department of Health excluding participants enrolled in the
  153  state group insurance program;
  154         c. Meets the minimum benefit package and copayments and
  155  deductibles contained in sub-subparagraphs 2.a. and b.;
  156         d. Is willing to participate in the state group insurance
  157  program at a cost of premiums that is not greater than 95
  158  percent of the cost of HMO premiums accepted by the department
  159  in each service area; and
  160         e. Meets the minimum surplus requirements of s. 641.225.
  162  The department is authorized to contract with HMOs that meet the
  163  requirements of sub-subparagraphs a.-d. before prior to the open
  164  enrollment period for state employees. The department is not
  165  required to renew the contract with the HMOs as set forth in
  166  this paragraph more than twice. Thereafter, the HMOs shall be
  167  eligible to participate in the state group insurance program
  168  only through the request for proposal or invitation to negotiate
  169  process described in subparagraph 2.
  170         5. All enrollees in a state group health insurance plan, a
  171  TRICARE supplemental insurance plan, or any health maintenance
  172  organization plan have the option of changing to any other
  173  health plan that is offered by the state within any open
  174  enrollment period designated by the department. Open enrollment
  175  shall be held at least once each calendar year.
  176         6. When a contract between a treating provider and the
  177  state-contracted health maintenance organization is terminated
  178  for any reason other than for cause, each party shall allow any
  179  enrollee for whom treatment was active to continue coverage and
  180  care when medically necessary, through completion of treatment
  181  of a condition for which the enrollee was receiving care at the
  182  time of the termination, until the enrollee selects another
  183  treating provider, or until the next open enrollment period
  184  offered, whichever is longer, but no longer than 6 months after
  185  termination of the contract. Each party to the terminated
  186  contract shall allow an enrollee who has initiated a course of
  187  prenatal care, regardless of the trimester in which care was
  188  initiated, to continue care and coverage until completion of
  189  postpartum care. This does not prevent a provider from refusing
  190  to continue to provide care to an enrollee who is abusive,
  191  noncompliant, or in arrears in payments for services provided.
  192  For care continued under this subparagraph, the program and the
  193  provider shall continue to be bound by the terms of the
  194  terminated contract. Changes made within 30 days before
  195  termination of a contract are effective only if agreed to by
  196  both parties.
  197         7. Any HMO participating in the state group insurance
  198  program shall submit health care utilization and cost data to
  199  the department, in such form and in such manner as the
  200  department shall require, as a condition of participating in the
  201  program. The department shall enter into negotiations with its
  202  contracting HMOs to determine the nature and scope of the data
  203  submission and the final requirements, format, penalties
  204  associated with noncompliance, and timetables for submission.
  205  These determinations shall be adopted by rule.
  206         8. The department may establish and direct, with respect to
  207  collective bargaining issues, a comprehensive package of
  208  insurance benefits that may include supplemental health and life
  209  coverage, dental care, long-term care, vision care, and other
  210  benefits it determines necessary to enable state employees to
  211  select from among benefit options that best suit their
  212  individual and family needs. Beginning with the 2018 plan year,
  213  the package of benefits may also include products and services
  214  described in s. 110.12303.
  215         a. Based upon a desired benefit package, the department
  216  shall issue a request for proposal or invitation to negotiate
  217  for providers interested in participating in the state group
  218  insurance program, and the department shall issue a request for
  219  proposal or invitation to negotiate for providers interested in
  220  participating in the non-health-related components of the state
  221  group insurance program. Upon receipt of all proposals, the
  222  department may enter into contract negotiations with providers
  223  submitting bids or negotiate a specially designed benefit
  224  package. Providers offering or providing supplemental coverage
  225  as of May 30, 1991, which qualify for pretax benefit treatment
  226  pursuant to s. 125 of the Internal Revenue Code of 1986, with
  227  5,500 or more state employees currently enrolled may be included
  228  by the department in the supplemental insurance benefit plan
  229  established by the department without participating in a request
  230  for proposal, submitting bids, negotiating contracts, or
  231  negotiating a specially designed benefit package. These
  232  contracts shall provide state employees with the most cost
  233  effective and comprehensive coverage available; however, except
  234  as provided in subparagraph (f)3., no state or agency funds
  235  shall be contributed toward the cost of any part of the premium
  236  of such supplemental benefit plans. With respect to dental
  237  coverage, the division shall include in any solicitation or
  238  contract for any state group dental program made after July 1,
  239  2001, a comprehensive indemnity dental plan option which offers
  240  enrollees a completely unrestricted choice of dentists. If a
  241  dental plan is endorsed, or in some manner recognized as the
  242  preferred product, such plan shall include a comprehensive
  243  indemnity dental plan option which provides enrollees with a
  244  completely unrestricted choice of dentists.
  245         b. Pursuant to the applicable provisions of s. 110.161, and
  246  s. 125 of the Internal Revenue Code of 1986, the department
  247  shall enroll in the pretax benefit program those state employees
  248  who voluntarily elect coverage in any of the supplemental
  249  insurance benefit plans as provided by sub-subparagraph a.
  250         c. Nothing herein contained shall be construed to prohibit
  251  insurance providers from continuing to provide or offer
  252  supplemental benefit coverage to state employees as provided
  253  under existing agency plans.
  254         (j) For the 2020 plan year and each plan year thereafter,
  255  health plans shall be offered in the following benefit levels:
  256         1. Platinum level, which shall have an actuarial value of
  257  at least 90 percent.
  258         2. Gold level, which shall have an actuarial value of at
  259  least 80 percent.
  260         3. Silver level, which shall have an actuarial value of at
  261  least 70 percent.
  262         4. Bronze level, which shall have an actuarial value of at
  263  least 60 percent.
  265         (c) The initial measurement period used to determine
  266  whether an employee hired before April 1, 2013, and paid from
  267  OPS funds is a full-time employee described in subparagraph
  268  (2)(c)1. is the 6-month period from April 1, 2013, through
  269  September 30, 2013.
  270         (d) All other measurement periods used to determine whether
  271  an employee paid from OPS funds is a full-time employee
  272  described in paragraph (2)(c) must be for 12 consecutive months.
  274         (a) The following regions are established for purposes of
  275  the department entering into contracts with HMOs to provide
  276  services on a regional basis on or after January 1, 2023,
  277  pursuant to paragraph (3)(h):
  278         1. Region 1 consists of Bay, Calhoun, Escambia, Gulf,
  279  Holmes, Jackson, Okaloosa, Santa Rosa, Walton, and Washington
  280  Counties.
  281         2. Region 2 consists of Franklin, Gadsden, Jefferson, Leon,
  282  Liberty, Madison, Taylor, and Wakulla Counties.
  283         3. Region 3 consists of Alachua, Bradford, Columbia, Dixie,
  284  Gilchrist, Hamilton, Lafayette, Levy, Marion, Suwannee, and
  285  Union Counties.
  286         4. Region 4 consists of Baker, Clay, Duval, Flagler,
  287  Nassau, Putnam, St. Johns, and Volusia Counties.
  288         5. Region 5 consists of Brevard, Indian River, Lake,
  289  Orange, Osceola, and Seminole Counties.
  290         6. Region 6 consists of Citrus, DeSoto, Hardee, Hernando,
  291  Highlands, Hillsborough, Manatee, Pasco, Pinellas, Polk,
  292  Sarasota, and Sumter Counties.
  293         7. Region 7 consists of Martin, Okeechobee, Palm Beach, and
  294  St. Lucie Counties.
  295         8. Region 8 consists of Charlotte, Collier, Glades, Hendry,
  296  and Lee Counties.
  297         9. Region 9 consists of Broward, Miami-Dade, and Monroe
  298  Counties.
  299         (b) The establishment of these regions does not limit the
  300  department’s authority to contract for HMO services on a
  301  statewide basis.
  302         Section 2. Subsection (10) of section 110.12315, Florida
  303  Statutes, is amended, and subsection (11) is added to that
  304  section, to read:
  305         110.12315 Prescription drug program.—The state employees’
  306  prescription drug program is established. This program shall be
  307  administered by the Department of Management Services, according
  308  to the terms and conditions of the plan as established by the
  309  relevant provisions of the annual General Appropriations Act and
  310  implementing legislation, subject to the following conditions:
  311         (10) In addition to the comprehensive package of health
  312  insurance and other benefits required or authorized to be
  313  included in the state group insurance program, the program must
  314  provide coverage for medically necessary prescription and
  315  nonprescription enteral formulas and amino-acid-based elemental
  316  formulas for home use, regardless of the method of delivery or
  317  intake, which are ordered or prescribed by a physician. As used
  318  in this subsection, the term “medically necessary” means the
  319  formula to be covered represents the only medically appropriate
  320  source of nutrition for a patient. Such coverage may not exceed
  321  an amount of $20,000 annually for any insured individual.
  322         (11) The department shall ensure that the prescription drug
  323  program receives the benefits of all discounts, rebates, and
  324  other fees associated with the prescription drugs and supplies
  325  provided through the program. The department shall annually
  326  audit such amounts received by the department or its pharmacy
  327  benefit manager for the prescription drugs and supplies provided
  328  through the program.
  329         Section 3. Subsection (5) of section 110.131, Florida
  330  Statutes, is amended to read:
  331         110.131 Other-personal-services employment.—
  332         (5) Beginning January 1, 2014, an other-personal-services
  333  (OPS) employee who has worked an average of at least 30 or more
  334  hours per week during the measurement period described in s.
  335  110.123(13)(c) s. 110.123(13)(c) or (d), or who is reasonably
  336  expected to work an average of at least 30 or more hours per
  337  week following his or her employment, is eligible to participate
  338  in the state group insurance program as provided under s.
  339  110.123.
  340         Section 4. This act shall take effect July 1, 2021.