An act relating to health insurance; amending s. 112.363,
F.S.; specifying that coverage provided through the Cover
Florida Health Care Access Program is considered health
insurance coverage for the purposes of determining
eligibility for the state retiree health insurance
subsidy; amending s. 408.909, F.S.; revising eligibility
for enrollment in a health flex plan; revising the
expiration date of the health flex plan program; creating
s. 408.9091, F.S.; creating the Cover Florida Health Care
Access Program; providing a short title; providing
legislative intent; providing definitions; requiring the
Agency for Health Care Administration and the Office of
Insurance Regulation of the Financial Services Commission
within the Department of Financial Services to jointly
administer the program; providing program requirements;
requiring the development of guidelines to meet minimum
standards for quality care and access to care; requiring
the agency to ensure that the Cover Florida plans follow
standardized grievance procedures; requiring the Executive
Office of the Governor, the agency, and the office to
develop a public awareness program; authorizing public and
private entities to design or extend incentives for
participation in the Cover Florida Access Program;
requiring the agency and the office to announce an
invitation to negotiate for Cover Florida plan entities to
design a coverage proposal; requiring the agency and the
office to approve one plan entity; authorizing the agency
and the office to approve one regional network plan in
each existing Medicaid area; requiring the invitation to
negotiate to include certain guidelines; providing certain
conditions in which plans are disapproved or withdrawn;
authorizing the agency and the office to announce an
invitation to negotiate for companies that offer
supplemental insurance or discount medical plans;
providing that certain licensing requirements or ch. 641,
F.S., are not applicable to a Cover Florida plan;
providing that Cover Florida plans are considered
insurance under certain conditions; excluding Cover
Florida plans from the Florida Life and Health Insurance
Guaranty Association and the Health Maintenance
Organization Consumer Assistance Plan; providing
requirements for eligibility in a Cover Florida plan;
requiring each Cover Florida plan to maintain and provide
certain records; providing that coverage under a Cover
Florida plan is not an entitlement and does not give rise
to a cause of action; requiring the agency and the office
to evaluate the Cover Florida program and submit an annual
report to the Governor and the Legislature; requiring the
agency and the Financial Services Commission to adopt
rules; amending s. 624.91, F.S.; revising the duties of
the Florida Healthy Kids Corporation; amending s. 409.814,
F.S.; revising the eligibility requirements for
participation in the Medikids program or the Florida
Healthy Kids program; deleting certain limitations;
amending s. 627.6562, F.S.; requiring insurance policies
that provide dependent coverage to provide the
policyholder with the option of insuring a child until the
age of 30 under certain circumstances; amending s.
627.6699, F.S.; redefining the term "small employer" for
purposes of the Employee Health Care Access Act; providing
Be It Enacted by the Legislature of the State of Florida:
Section 1. Paragraph (d) of subsection (2) of section
112.363, Florida Statutes, is amended to read:
112.363 Retiree health insurance subsidy.--
(2) ELIGIBILITY FOR RETIREE HEALTH INSURANCE SUBSIDY.--
(d) Payment of the retiree health insurance subsidy shall
be made only after coverage for health insurance for the retiree
or beneficiary has been certified in writing to the Department of
Management Services. Participation in a former employer's group
health insurance program is not a requirement for eligibility
under this section. Coverage issued pursuant to s. 408.9091 is
considered health insurance for the purposes of this section.
Section 2. Subsections (5) and (10) of section 408.909,
Florida Statutes, are amended to read:
(5) ELIGIBILITY.--Eligibility to enroll in an approved
health flex plan is limited to residents of this state who:
(a) Are 64 years of age or younger;
(b) Have a family income equal to or less than 300 200
percent of the federal poverty level;
(c) Are eligible under a federally approved Medicaid
demonstration waiver and reside in Palm Beach County or Miami-
(c)(d) Are not covered by a private insurance policy and
are not eligible for coverage through a public health insurance
program, such as Medicare or Medicaid, unless specifically
authorized under paragraph (c), or another public health care
program, such as Kidcare, and have not been covered at any time
during the past 6 months; who are covered under an individual
contract issued by a health maintenance organization that is an
approved health flex plan on October 1, 2008, and are applying
for coverage in the same health flex plan without a lapse in
coverage and all other eligibility requirements under this
subsection are met; or who were covered under Medicaid or Kidcare
and lost eligibility for Medicaid or a Kidcare subsidy due to
income restrictions within 90 days before applying for health
care coverage through an approved health flex plan; and
(d)(e) Have applied for health care coverage through an
approved health flex plan and have agreed to make any payments
required for participation, including periodic payments or
payments due at the time health care services are provided.
(10) EXPIRATION.--This section expires July 1, 2013 2008.
Section 3. Section 408.9091, Florida Statutes, is created
408.9091 Cover Florida Health Care Access Act.--
(1) SHORT TITLE.--This section may be cited as the "Cover
Florida Health Access Program Act."
(2) INTENT.--The Legislature finds that a significant
proportion of state residents are unable to obtain affordable
health insurance coverage. The Legislature also finds that
existing "health flex" plan coverage has had limited
participation due in part to narrow eligibility restrictions as
well as minimal benefit options for catastrophic and emergency
care coverage. Therefore, it is the Legislature's intent to
expand the availability of health care options for uninsured
residents by developing an affordable health care product that
emphasizes coverage for basic and preventive health care
services; provides inpatient hospital, urgent, and emergency care
services; and is offered statewide by approved health insurers,
health maintenance organizations, health-care-provider-sponsored
organizations, or health care districts.
(3) DEFINITIONS.--As used in this section, the term:
(a) "Agency" means the Agency for Health Care
(b) "Office" means the Office of Insurance Regulation of
the Financial Services Commission.
(c) "Enrollee" means an individual who has been determined
to be eligible for and is receiving health insurance coverage
under a Cover Florida plan.
(d) "Cover Florida plan" means a consumer choice benefit
plan approved under this section which guarantees payment or
coverage for specified benefits provided to an enrollee.
(e) "Cover Florida plan coverage" means health care
services that are covered as benefits under a Cover Florida plan.
(f) "Cover Florida plan entity" means a health insurer,
health maintenance organization, health-care-provider-sponsored
organization, or health care district that develops and
implements a Cover Florida plan and is responsible for
administering the plan and paying all claims for Cover Florida
plan coverage by enrollees.
(g) "Cover Florida Plus" plan means a supplemental
insurance product, such as for additional catastrophic coverage
or dental, vision, or cancer coverage, approved under this
section and offered to all enrollees.
(4) PROGRAM.--The agency and the office shall jointly
establish and administer the Cover Florida Health Care Access
(a) General Cover Florida plan components must require
1. Plans are offered as guaranteed issue to enrollees,
subject to exclusions for preexisting conditions approved by the
office and the agency.
2. Plans are portable, such that the enrollee remains
covered regardless of employment status or the cost-sharing of
3. Plans may provide for cost containment through limits on
the number of services, caps on benefit payments, and copayments
4. A Cover Florida health plan entity makes all benefit
plan and marketing materials available in English and Spanish.
5. In order to provide for consumer choice, Cover Florida
health plan entities develop two alternative benefit option plans
having different cost and benefit levels, including at least one
plan that provides catastrophic coverage.
6. Plans without catastrophic coverage provide coverage
options for the following services, including, but not limited
a. Preventive health services, including preventive
screenings, annual health assessments, and well-care and well-
woman services, including mammograms, screenings for cervical
cancer, noninvasive colorectal or prostate screenings, and
b. Incentives for routine, preventive care.
c. Office visits for the diagnosis and treatment of illness
d. Office surgery, including anesthesia.
e. Services related to behavioral health services.
f. Durable medical equipment and prosthetics.
g. Diabetic supplies.
7. Plans providing catastrophic coverage, at a minimum,
provide coverage options for all of the services listed under
subparagraph 6., and in addition include, but are not limited to,
a. Inpatient hospital stays.
b. Hospital emergency care services.
c. Urgent care services.
d. Outpatient facility services, outpatient surgery, and
outpatient diagnostic services.
8. Plans offer prescription drug benefit coverage on all
plans, or use a prescription drug manager, such as the Florida
Discount Drug Card Program.
9. Plans provide, in enrollment materials, plain-language
information on policy benefit coverage, benefit limits, cost-
sharing requirements, and exclusions and a clear representation
of what is not covered in the plan.
10. Plans offered through a qualified employer meet the
requirements of s. 125 of the Internal Revenue Code.
(b) Guidelines shall be developed to ensure that Cover
Florida plans meet minimum standards for quality of care and
access to care. The agency shall ensure that the Cover Florida
plans follow standardized grievance procedures.
(c) Changes in Cover Florida plan benefits, premiums, and
policy forms are subject to regulatory oversight by the office
and agency as provided by rules adopted by the Financial Services
Commission and the agency.
(d) The agency, the office, and the Executive Office of the
Governor shall develop a public awareness program to be
implemented throughout the state for the promotion of the Cover
Florida Health Access Program.
(e) Public or private entities may design programs to
encourage Floridians to participate in the Cover Florida Health
Access Program, or to encourage employers to cosponsor some share
of Cover Florida plan premiums for employees.
(5) PLAN PROPOSALS.--The agency and the office shall
announce, no later than July 1, 2008, an invitation to negotiate
for Cover Florida plan entities to design a Cover Florida plan
proposal in which benefits and premiums are specified.
(a) The invitation to negotiate shall include guidelines
for the review of Cover Florida plan applications, policy forms,
and all associated forms, and provide regulatory oversight of
Cover Florida plan advertisement and marketing procedures. A plan
shall be disapproved or withdrawn if the plan:
1. Contains any ambiguous, inconsistent, or misleading
provisions or any exceptions or conditions that deceptively
affect or limit the benefits purported to be assumed in the
general coverage provided by the plan;
2. Provides benefits that are unreasonable in relation to
the premium charged or contains provisions that are unfair or
inequitable, that are contrary to the public policy of this
state, that encourage misrepresentation, or that result in unfair
discrimination in sales practices;
3. Cannot demonstrate that the plan is financially sound
and that the applicant is able to underwrite or finance the
health care coverage provided;
4. Cannot demonstrate that the applicant and its management
are in compliance with the standards required under s.
5. Does not guarantee that enrollees may participate in the
Cover Florida plan entity's comprehensive network of providers,
as determined by the office, the agency, and the contract.
(b) The agency and the office may announce an invitation to
negotiate for the design of Cover Florida Plus products to
companies that offer supplemental insurance, discount medical
plan organizations licensed under part II of chapter 636, or
prepaid health clinics licensed under part II of chapter 641.
(c) The agency and office shall approve at least one Cover
Florida plan entity having an existing statewide network of
providers, and may approve at least one regional network plan in
each existing Medicaid area.
(6) LICENSE NOT REQUIRED.--
(a) The licensing requirements of the Florida Insurance
Code and chapter 641, relating to health maintenance
organizations, do not apply to a Cover Florida plan approved
under this section unless expressly made applicable. However, for
the purpose of prohibiting unfair trade practices, Cover Florida
plans are considered to be insurance subject to the applicable
provisions of part IX of chapter 626, except as otherwise
provided in this section.
(b) Cover Florida plans are not covered by the Florida Life
and Health Insurance Guaranty Association under part III of
chapter 631 or by the Health Maintenance Organization Consumer
Assistance Plan under part IV of chapter 631.
(7) ELIGIBILITY.--Eligibility to enroll in a Cover Florida
plan is limited to residents of this state who meet all of the
(a) Are 19 to 64 years of age.
(b) Are not covered by a private health insurance policy
and are not eligible for coverage through a public health
insurance program, such as Medicare, Medicaid, or Kidcare, unless
eligibility for coverage lapses due to no longer meeting income
or categorical requirements.
(c) Have not been covered by any health insurance program
at any time during the past 6 months, unless coverage under a
health insurance program was terminated within the previous 6
1. Loss of a job that provided an employer-sponsored health
2. Exhaustion of coverage that was continued under COBRA or
continuation-of-coverage requirements under s. 627.6692;
3. Reaching the limiting age under the policy; or
4. Death of, or divorce from, a spouse who was provided
employer-sponsored health benefit plan.
(d) Have applied for health care coverage through a Cover
Florida plan and have agreed to make any payments required for
participation, including periodic payments or payments due at the
time health care services are provided.
(8) RECORDS.--Each Cover Florida plan must maintain
enrollment data and provide network data and reasonable records
to enable the office and agency to monitor plans and to determine
the financial viability of the Cover Florida plan, as necessary.
(9) NONENTITLEMENT.--Coverage under a Cover Florida plan is
not an entitlement, and a cause of action does not arise against
the state, a local government entity, any other political
subdivision of this state, or the agency or office for failure to
make coverage available to eligible persons under this section.
(10) PROGRAM EVALUATION.--The agency and the office shall:
(a) Evaluate the Cover Florida program and its effect on
the entities that seek approval as Cover Florida plans, on the
number of enrollees, and on the scope of the health care coverage
offered under a Cover Florida plan;
(b) Provide an assessment of the Cover Florida plans and
their potential applicability in other settings;
(c) Use Cover Florida plans to gather more information to
evaluate low-income, consumer-driven benefit packages; and
(d) Jointly submit by March 1, 2009, and annually
thereafter, a report to the Governor, the President of the
Senate, and the Speaker of the House of Representatives providing
the information specified in paragraphs (a)-(c) and
recommendations relating to the successful implementation and
administration of the program.
(11) RULEMAKING AUTHORITY.--The agency and the Financial
Services Commission may adopt rules as needed to administer this
Section 4. Paragraph (b) of subsection (5) of section
624.91, Florida Statutes, is amended to read:
624.91 The Florida Healthy Kids Corporation Act.--
(5) CORPORATION AUTHORIZATION, DUTIES, POWERS.--
(b) The Florida Healthy Kids Corporation shall:
1. Arrange for the collection of any family, local
contributions, or employer payment or premium, in an amount to be
determined by the board of directors, to provide for payment of
premiums for comprehensive insurance coverage and for the actual
or estimated administrative expenses.
2. Arrange for the collection of any voluntary
contributions to provide for payment of premiums for children who
are not eligible for medical assistance under Title XXI of the
3. Subject to the provisions of s. 409.8134, accept
voluntary supplemental local match contributions that comply with
the requirements of Title XXI of the Social Security Act for the
purpose of providing additional coverage in contributing counties
4. Establish the administrative and accounting procedures
for the operation of the corporation.
5. Establish, with consultation from appropriate
professional organizations, standards for preventive health
services and providers and comprehensive insurance benefits
appropriate to children, provided that such standards for rural
areas shall not limit primary care providers to board-certified
6. Determine eligibility for children seeking to
participate in the Title XXI-funded components of the Florida
Kidcare program consistent with the requirements specified in s.
409.814, as well as the non-Title-XXI-eligible children as
provided in subsection (3).
7. Establish procedures under which providers of local
match to, applicants to and participants in the program may have
grievances reviewed by an impartial body and reported to the
board of directors of the corporation.
8. Establish participation criteria and, if appropriate,
contract with an authorized insurer, health maintenance
organization, or third-party administrator to provide
administrative services to the corporation.
9. Establish enrollment criteria which shall include
penalties or waiting periods of not fewer than 60 days for
reinstatement of coverage upon voluntary cancellation for
nonpayment of family premiums.
10. Contract with authorized insurers or any provider of
health care services, meeting standards established by the
corporation, for the provision of comprehensive insurance
coverage to participants. Such standards shall include criteria
under which the corporation may contract with more than one
provider of health care services in program sites. Health plans
shall be selected through a competitive bid process. The Florida
Healthy Kids Corporation shall purchase goods and services in the
most cost-effective manner consistent with the delivery of
quality medical care. The maximum administrative cost for a
Florida Healthy Kids Corporation contract shall be 15 percent.
For health care contracts, the minimum medical loss ratio for a
Florida Healthy Kids Corporation contract shall be 85 percent.
For dental contracts, the remaining compensation to be paid to
the authorized insurer or provider under a Florida Healthy Kids
Corporation contract shall be no less than an amount which is 85
percent of premium; to the extent any contract provision does not
provide for this minimum compensation, this section shall
prevail. The health plan selection criteria and scoring system,
and the scoring results, shall be available upon request for
inspection after the bids have been awarded.
11. Establish disenrollment criteria in the event local
matching funds are insufficient to cover enrollments.
12. Develop and implement a plan to publicize the Florida
Healthy Kids Corporation, the eligibility requirements of the
program, and the procedures for enrollment in the program and to
maintain public awareness of the corporation and the program.
13. Secure staff necessary to properly administer the
corporation. Staff costs shall be funded from state and local
matching funds and such other private or public funds as become
available. The board of directors shall determine the number of
staff members necessary to administer the corporation.
14. Provide a report annually to the Governor, Chief
Financial Officer, Commissioner of Education, Senate President,
Speaker of the House of Representatives, and Minority Leaders of
the Senate and the House of Representatives.
15. Provide information on a quarterly basis to the
Legislature and the Governor which compares the costs and
utilization of the full-pay enrolled population and the Title
XXI-subsidized enrolled population in the KidCare program. The
information, at a minimum, must include:
a. The monthly enrollment and expenditure for full-pay
enrollees in the Medikids and Florida Healthy Kids programs
compared to the Title XXI-subsidized enrolled population; and
b. The costs and utilization by service of the full-pay
enrollees in the Medikids and Florida Healthy Kids programs and
the Title XXI-subsidized enrolled population.
By February 1, 2009, the Florida Healthy Kids Corporation shall
provide a study to the Legislature and the Governor on premium
impacts to the subsidized portion of the program from the
inclusion of the full-pay program, which shall include
recommendations on how to eliminate or mitigate possible impacts
to the subsidized premiums.
16.15. Establish benefit packages which conform to the
provisions of the Florida Kidcare program, as created in ss.
Section 5. Subsection (5) of section 409.814, Florida
Statutes, is amended to read:
409.814 Eligibility.--A child who has not reached 19 years
of age whose family income is equal to or below 200 percent of
the federal poverty level is eligible for the Florida Kidcare
program as provided in this section. For enrollment in the
Children's Medical Services Network, a complete application
includes the medical or behavioral health screening. If,
subsequently, an individual is determined to be ineligible for
coverage, he or she must immediately be disenrolled from the
respective Florida Kidcare program component.
(5) A child whose family income is above 200 percent of the
federal poverty level or a child who is excluded under the
provisions of subsection (4) may participate in the Medikids
program as provided in s. 409.8132 or, if the child is ineligible
for Medikids by reason of age, in the Florida Healthy Kids
program, subject to the following provisions:
(a) The family is not eligible for premium assistance
payments and must pay the full cost of the premium, including any
(b) The agency is authorized to place limits on enrollment
in Medikids by these children in order to avoid adverse
selection. The number of children participating in Medikids whose
family income exceeds 200 percent of the federal poverty level
must not exceed 10 percent of total enrollees in the Medikids
(b)(c) The board of directors of the Florida Healthy Kids
Corporation may is authorized to place limits on enrollment of
these children in order to avoid adverse selection. In addition,
the board is authorized to offer a reduced benefit package to
these children in order to limit program costs for such families.
The number of children participating in the Florida Healthy Kids
program whose family income exceeds 200 percent of the federal
poverty level must not exceed 10 percent of total enrollees in
the Florida Healthy Kids program.
Section 6. Effective upon this act becoming law and
applicable to policies issued or renewed on or after October 1,
2008, section 627.6562, Florida Statutes, is amended to read:
(1) If an insurer offers coverage that insures dependent
children of the policyholder or certificateholder, the policy
must insure a dependent child of the policyholder or
certificateholder at least until the end of the calendar year in
which the child reaches the age of 25, if the child meets all of
(a) The child is dependent upon the policyholder or
certificateholder for support.
(b) The child is living in the household of the
policyholder or certificateholder, or the child is a full-time or
(2) A policy that is subject to the requirements of
subsection (1) must also offer the policyholder or
certificateholder the option to insure a child of the
policyholder or certificateholder at least until the end of the
calendar year in which the child reaches the age of 30, if the
(a) Is unmarried and does not have a dependent of his or
(b) Is a resident of this state or a full-time or part-time
(c) Is not provided coverage as a named subscriber,
insured, enrollee, or covered person under any other group,
blanket, or franchise health insurance policy or individual
health benefits plan, or entitled to benefits under Title XVIII
of the Social Security Act.
(3) If, pursuant to subsection (2), a child is provided
coverage under the parent's policy after the end of the calendar
year in which the child reaches age 25, and coverage for the
child is subsequently terminated, the child is not eligible to be
covered under the parent's policy unless the child was
continuously covered by other creditable coverage without a gap
in coverage of more than 63 days. For the purposes of this
subsection, the term "creditable coverage" has the same meaning
(4)(2) Nothing in This section does not affect or preempt
affects or preempts an insurer's right to medically underwrite or
charge the appropriate premium.
Section 7. Effective upon this act becoming a law and
applicable to policies issued or renewed on or after that date,
paragraph (v) of subsection (3) of section 627.6699, Florida
Statutes, is amended to read:
627.6699 Employee Health Care Access Act.--
(3) DEFINITIONS.--As used in this section, the term:
(v) "Small employer" means, in connection with a health
benefit plan with respect to a calendar year and a plan year, any
person, sole proprietor, self-employed individual, independent
contractor, firm, corporation, partnership, or association that
is actively engaged in business, has its principal place of
business in this state, employed an average of at least 1 but not
more than 50 eligible employees on business days during the
preceding calendar year, the majority of whom were employed
within this state, and employs at least 1 employee on the first
day of the plan year, and is not formed primarily for the purpose
of purchasing health insurance. In determining the number of
eligible employees, companies that are an affiliated group as
defined in s. 1504(a) of the Internal Revenue Code shall be
considered one employer. For purposes of this section, a sole
proprietor, an independent contractor, or a self-employed
individual is considered a small employer only if all of the
conditions and criteria established in this section are met.
Section 8. This act shall take effect upon becoming a law.