The purpose of the rule amendment is to implement the statutory requirement in section 110.123(3)(h)2.d., Florida Statutes, to establish Health Maintenance Organization (HMO) Regions throughout the state within which an HMO is authorized by contract ...

 

DEPARTMENT OF MANAGEMENT SERVICES

Division of State Employees' Insurance

RULE NO.: RULE TITLE:

60P-1.003: Definitions

PURPOSE AND EFFECT: The purpose of the rule amendment is to implement the statutory requirement in section 110.123(3)(h)2.d., Florida Statutes, to establish Health Maintenance Organization (HMO) Regions throughout the state within which an HMO is authorized by contract to provide services to State Group Insurance Program enrollees. The proposed rule amendment changes the definition for HMO service area to a definition for HMO Region.

SUMMARY: The department has established a proposed HMO Region map based on a referral pattern analysis of member claims and enrollment data. The proposed HMO Region map is incorporated by reference in the rule with an effective date of January 1, 2023, to prevent conflict with current HMO service area contracts.

SUMMARY OF STATEMENT OF ESTIMATED REGULATORY COSTS AND LEGISLATIVE RATIFICATION:

The Agency has determined that this will not have an adverse impact on small business or likely increase directly or indirectly regulatory costs in excess of $200,000 in the aggregate within one year after the implementation of the rule. A SERC has not been prepared by the Agency.

Any person who wishes to provide information regarding a statement of estimated regulatory costs, or provide a proposal for a lower cost regulatory alternative must do so in writing within 21 days of this notice.

RULEMAKING AUTHORITY: 110.123, FS.

LAW IMPLEMENTED: 110.123, FS.

IF REQUESTED WITHIN 21 DAYS OF THE DATE OF THIS NOTICE, A HEARING WILL BE HELD AT THE DATE, TIME AND PLACE SHOWN BELOW:

DATE AND TIME: October 24, 2019, 3:00 p.m. Eastern time

PLACE: Department of Management Services, 4050 Esplanade Way, Suite 101, Tallahassee, Florida

Pursuant to the provisions of the Americans with Disabilities Act, any person requiring special accommodations to participate in this workshop/meeting is asked to advise the agency at least 7 days before the workshop/meeting by contacting: Lela Whitfield at [e-mail]. If you are hearing or speech impaired, please contact the agency using the Florida Relay Service, 1(800)955-8771 (TDD) or 1(800)955-8770 (Voice). If you are hearing or speech impaired, please contact the agency using the Florida Relay Service, 1(800)955-8771 (TDD) or 1(800)955-8770 (Voice).

THE PERSON TO BE CONTACTED REGARDING THE PROPOSED RULE IS: Debbie Shoup, Department of Management Services, Division of State Group Insurance, 4050 Esplanade Way, Suite 215, Tallahassee, Florida 32399 or [e-mail]

 

THE FULL TEXT OF THE PROPOSED RULE IS:

60P-1.003 Definitions. 

For the purpose of administering the State Group Insurance Program, the following words and terms shall have the meaning indicated: 

(1) “Administrator” means the Department of Management Services, hereinafter referred to as “Administrator” or “Department”. 

(2) “Appeal” means the filing of a petition pursuant to Rule 60P-1.004, F.A.C, and the proceeding that results from such filing. 

(3) “Cancellation” means the loss of coverage, with a right of reinstatement, caused by a failure to pay the required premiums for two consecutive months. 

(4) “Continuation coverage” means coverage that is identical to the coverage provided under the Health Program to active employees which must be offered to qualifying employees and dependents in accordance with the Consolidated Omnibus Budget Reconciliation Act (COBRA). 

(5) “Conversion plan” means a standard policy as is issued by the servicing agent to direct payment subscribers at applicable rates then in effect. An insured shall have the right to apply directly to the servicing agent in writing within thirty-one (31) days of the termination date of coverage under the Program. 

(6) “Coverage” means the provision of plan benefits to a subscriber and eligible dependents. 

(7) “Eligible children” shall mean the subscriber’s own children, legally adopted children or children placed in the subscriber’s home for the purpose of adoption in accordance with Chapter 63, Florida Statutes, stepchildren for whom the employee or retiree is financially responsible, or any other children for whom the subscriber has established legal guardianship in accordance with Chapter 744, Florida Statutes, foster children, or any other unmarried children for whom the subscriber has been granted court-ordered temporary or other custody. Such children are eligible for coverage as follows: 

(a) From their date of birth to the end of the month in which their nineteenth (19th) birthday occurs; 

(b) From their nineteenth (19th) birthday to the end of the calendar year in which their twenty-fifth (25th) birthday occurs, if they are dependent upon the subscriber for support and are either living with the subscriber or enrolled in any school, college or university which provides training or educational activities, and which is certified or licensed by a state or foreign country. 

(c) Such children who are mentally or physically disabled shall be eligible to continue coverage after attainment of the above age limits and while the subscriber’s family coverage is in effect provided such children are incapable of self-sustaining employment by reason of such mental or physical disability and chiefly dependent upon the subscriber for support and maintenance. 

(d) Such children who are over the above age limits at the time of the subscriber’s enrollment in the Program, and who are mentally or physically disabled, shall be eligible for coverage if they are incapable of self-sustaining employment by reason of such mental or physical disability and chiefly dependent upon the employee or retiree for support and maintenance. 

(8) “Eligible dependents” shall mean the following: 

(a) The wife or husband of the employee or retiree and any eligible children. 

(b) The eligible children of a surviving spouse. 

(c) The newborn child of an eligible child from the date of birth until the end of the month the child attains eighteen (18) months of age. 

(d) Children of law enforcement, probation, or correctional officers who were killed in the line of duty and who are attending a college or university beyond their eighteenth (18th) birthday. 

(9) “Employee contribution” means that portion of the total premium required by the subscriber to keep the insurance in force. 

(10) “Family coverage” means the provision of Plan benefits under a single plan for a subscriber and one or more of his or her eligible dependents. 

(11) “Financially responsible” shall mean the degree of financial support sufficient to claim the eligible dependent as an exemption on the subscriber’s Federal income tax return. 

(12) “Health maintenance organization (HMO) Region” is the designated geographical area composed of a county or contiguous counties, within which an HMO is authorized by contract with the Department to provide covered services to Subscribers. The Department has established regions effective January 1, 2023, as set forth in the HMO Region map incorporated by reference and is available on the Department’s website at www.mybenefits.myflorida.com/health or at https://www.flrules.org/Gateway/reference.asp?No=Ref-_or by writing to the Division of State Group Insurance, Post Office Box 5450, Tallahassee, Florida 32314-5450. “Health maintenance organization (HMO) service area” means the geographic area composed of a county or contiguous counties for which the HMO has received a Certificate of Authority issued by the Florida Department of Insurance to provide or arrange for comprehensive health services and for which the HMO has received approval to offer such services to state employees residing in the area

(13) “Health Program” means the insurance plans offered to eligible subscribers. 

(14) “Individual coverage” means the provision of plan benefits for the subscriber only. 

(15) “Initial eligibility period” means the sixty (60) day period beginning on the date a person first becomes employed by the state. 

(16) “Open enrollment period” means a period designated by the Department during which time eligible persons may enroll or make changes in the Health Program. 

(17) “Qualifying status change (QSC) event” or “QSC event” means the change in employment status, for subscriber or spouse, family status or significant change in health coverage of the employee or spouse attributable to the spouse’s employment. 

(18) “Servicing agent” means an insurance carrier or professional administrator selected by competitive bid, or request for proposal process and contracted by the Department to process and pay health insurance claims for subscribers and eligible dependents insured under the Health Program and to provide other specific services required by the Department. 

(19) “State contribution” means that portion of the total premium appropriated by law. 

(20) “Subscriber” means the employee, retiree, surviving spouse, terminated employee or individual with continuation coverage participating in the State Group Insurance Program. 

(21) “Suspension” means the temporary loss of coverage caused by a failure to pay the required premiums for one month. 

(22) “Termination” means the loss of coverage, without a right for reinstatement, caused by a failure to pay the required premiums for three or more consecutive months. 

(23) “Total disability” means disability of an employee resulting from disease or injury which completely and continuously prevents the employee from engaging in any and every occupation or business and from performing any and all work for compensation or profit. 

(24) “Total premium or full premium” means the total amount equal to the State contribution plus an amount equal to the employee contribution as determined by the Legislature in the General Appropriations Act. 

Specific Authority 110.123(5) FS. Law Implemented 110.123 FS. History–New 11-2-76, Amended 2-3-77, 6-30-77, 7-1-80, Formerly 22K-1.03, Amended 7-16-86, 9-25-86, 4-11-88, Formerly 22K-1.103, Amended 8-22-96, Repromulgated as Amended 1-31-02, Amended ___________. 

 

NAME OF PERSON ORIGINATING PROPOSED RULE: Jennifer Lloyd, Director, Division of State Group Insurance

NAME OF AGENCY HEAD WHO APPROVED THE PROPOSED RULE: Jonathan R. Satter, Secretary

DATE PROPOSED RULE APPROVED BY AGENCY HEAD: September 18, 2019

DATE NOTICE OF PROPOSED RULE DEVELOPMENT PUBLISHED IN FAR: July 10, 2019