To implement the statutory requirement that enrollees share in savings through the benefit programs set forth in section 110.12303, F.S.

 

DEPARTMENT OF MANAGEMENT SERVICES

Division of State Employees’ Insurance

RULE NO.:RULE TITLE:

60P-6.011Shared Savings Program

PURPOSE AND EFFECT: To implement the statutory requirement that enrollees share in savings through the benefit programs set forth in section 110.12303, F.S.

SUMMARY: Description of the Shared Savings Program.

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.

The Agency has determined that the proposed rule is not expected to require legislative ratification based on the statement of estimated regulatory costs or if no SERC is required, the information expressly relied upon and described herein: the economic review conducted 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: 110.1055, 110.123(5), FS.

LAW IMPLEMENTED: 110.12303, 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 (IF NOT REQUESTED, THIS HEARING WILL NOT BE HELD):

DATE AND TIME: December 7, 2018, 2:00 p.m.

PLACE: Department of Management Services, Division of State Group Insurance, 4050 Esplanade Way, Suite 101, Tallahassee, Florida 32399

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: Martina Rogers, [e-mail] or [phone]. 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

 

THE FULL TEXT OF THE PROPOSED RULE IS:

 

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 receving 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 (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 (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 Section 110.12303, FS. History–New ______.

 

NAME OF PERSON ORIGINATING PROPOSED RULE: Tami Fillyaw, Director, Division of State Group Insurance

NAME OF AGENCY HEAD WHO APPROVED THE PROPOSED RULE: Erin Rock, Secretary

DATE PROPOSED RULE APPROVED BY AGENCY HEAD: November 13, 2018

DATE NOTICE OF PROPOSED RULE DEVELOPMENT PUBLISHED IN FAR: October 1, 2018