60P-6.011. Shared Savings Program

(1) The Shared Savings Program allows the enrollee of a state group health insurance plan or state-contracted health maintenance organization (HMO) to collect a Reward for receiving a healthcare service or bundled service provided through the online transparency platform established under section 110.12303(3), F.S., or receive a bundled surgery or other bundled medical procedure through the use of the Department’s contracted entity authorized under section 110.12303(2), F.S. A “Reward” is the amount that will be credited to an enrollee’s account or reimbursed to the enrollee for out-of-pocket healthcare expenses based on the date the enrollee or eligible dependent receives the healthcare service. An enrollee is limited to one Reward for receiving a healthcare service or bundled service.

(2) To earn a Reward by utilizing the online transparency platform, the enrollee or the enrollee’s eligible dependent must have:

(a) Complied with any prior approval or prior authorization required under the enrollee’s HMO or State group health insurance plan for the healthcare service;

(b) Received a covered healthcare service under the enrollee’s health insurance plan; and

(c) Shopped for the healthcare service through the online transparency portal within 12 months from the date of the healthcare service.

(3) A Reward for a healthcare service or bundled service received pursuant to section 110.12303(2), F.S., is available to a member enrolled in Medicare if the sum of the cost of the healthcare service or bundled service and the Reward is less than the Medicare reimbursement rate for a comparable bundled service.

(4) A Reward will be credited to the account(s) selected by the enrollee as of the date that the administrator receives notice that the Reward has been earned.

(a) A enrollee may designate the following accounts for the Reward to be credited to: a medical reimbursement account (healthcare flexible spending account or a limited purpose flexible spending account), a health savings account, a health reimbursement account, or a post-deductible health reimbursement account.

(b) If an enrollee fails to designate an account within thirty (30) days of availability of a Reward, the Reward will be credited as follows:

1. To a health reimbursement account for enrollees not enrolled in a high deductible health plan.

2. To a health savings account for enrollees enrolled in a high deductible health plan and receiving a state contribution to a health savings account.

3. To a post-deductible health reimbursement account for enrollees enrolled in a high deductible health plan and not receiving a state contribution to a health savings account.

(c) Once a Reward is credited to an account, funds cannot be credited to a different account, except as provided by these rules.

(5) Rewards credited to a health reimbursement account:

(a) Shall not be used to pay for insurance premiums; and

(b) Will roll over to the following Plan Year if not used.

(6) Rewards credited to a post-deductible health reimbursement account:

(a) Are available only after the enrollee satisfies the minimum federal deductible for high deductible health plans; and

(b) Are limited as set forth in paragraph (9)(a) of this rule.

(7) Rewards designated to be credited to a medical reimbursement account will be credited on January 1 of the following Plan Year. If the enrollee designates a Reward to be credited to a medical reimbursement account but fails to elect a medical reimbursement account for the following Plan Year, Rewards will be credited as set forth in paragraph (3)(b) of this rule.

(8) The annual maximum amount of Rewards that can be credited to a medical reimbursement account is $500.

(9) If any portion of a Reward remains after a Reward is designated to an account, the remaining portion will be credited to:

(a) A health reimbursement account for enrollees not enrolled in a high deductible health plan.

(b) A health savings account for enrollees enrolled in a high deductible health plan and receiving a state contribution to a health savings account.

(c) A post-deductible health reimbursement account for enrollees enrolled in a high deductible health plan and not receiving a state contribution to a health savings account.

(10) An enrollee may request the administrator of the health reimbursement account or post-deductible health reimbursement account to debit the account and provide the enrollee with a payment in an amount not to exceed the amount of the enrollee’s out-of-pocket medical expenses.

(11) Funds maintained within a health reimbursement account at the end of the Plan Year will be converted to a post-deductible health reimbursement account if the enrollee enrolls in a high deductible health plan. Funds maintained within a post-deductible health reimbursement account at the end of the Plan Year will be converted to a health reimbursement account if the enrollee is no longer enrolled in a high deductible health plan.

(12) Once an enrollee is no longer enrolled in a state group health insurance plan or HMO plan, all health reimbursement accounts and post-deductible health reimbursement accounts terminate and any funds contained therein are forfeited.

Rulemaking Authority 110.1055, 110.123(5) FS. Law Implemented 110.12303 FS. History–New 5-14-19.