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-2.002:Eligibility and Enrollment

60P-2.003 Changes in Coverage

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.

SUMMARY: The department has established a proposed HMO Region map based on a referral pattern analysis of member claims and enrollment data. The proposed rule amendment changes HMO service area to HMO Region to align with the proposed rule amendment to Rule 60P-1.003.

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 SCHEDULED AND ANNOUNCED IN THE FAR.

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-2.002 Eligibility and Enrollment. 

(1) Eligibility to participate in the Health Program will be in accordance with Section 110.123, F.S. 

(2) Eligible dependents may only participate under a family coverage. 

(3) The surviving spouse may participate in the Health Program with family coverage if there are eligible children to be covered; otherwise, the surviving spouse may only participate under an individual coverage.  

(4) In order to participate in a HMO, the subscriber must reside in the HMO Region service area; if the subscriber is a state employee, he or she must either reside or work in the HMO Region service area. 

(5) An employee or state officer may apply for enrollment in the Health Program through the employing agency personnel office: 

(a) During the first sixty (60) calendar days of state employment or a new term of office; 

(b) During open enrollment; 

(c) Within thirty-one (31) days of a QSC of losing other group health coverage; 

(d) Within thirty-one (31) days of a QSC of an increase in the number of work hours for an employee; 

(e) Within thirty-one days prior to termination of employment and before the effective date of retirement. 

(6) The employing agency shall request an effective date of coverage for enrollment in the Health Program in accordance with Rule 60P-2.004, F.A.C., and indicate such date on the application along with the following required employee and agency information: 

(a) Employee’s name, social security number, birth date, sex, home mailing address, employment status, pay plan, employment date, SAMAS organizational code, I.D. code, and other insurance carriers; 

(b) Dependent’s name, social security number, birth date, sex, date dependent was acquired, relationship of dependent, documentation verifying dependent eligibility; 

(c) Employee’s requested plan type, type of coverage and Spouse Program eligibility; 

(d) Contains the signature and date of the employee and authorized signature and date of the employing agency certifying eligibility of the employee. 

(7) The employee acknowledges that eligibility and enrollment are governed by Section 110.123, F.S.; authorizes the State to reduce salary as often and in amount necessary to continue coverage; authorizes the State to deduct from salary any underpayment of employee contribution or overpayment of claims; acknowledges that premiums may change from time to time; authorizes any licensed physician or medical facility to release medical records of insureds to the health plan; certifies notification of COBRA rights and agrees to notify the Department at the time any dependent becomes ineligible for coverage; and agrees that all statements made on the application are complete and true. 

(8) After completion by the employee and employing agency, the employing agency shall enter applicable information into the state insurance computer data base and retain the application. 

(9) Upon learning of the death of an insured employee with family coverage, the agency personnel office, by certified mail, will notify the surviving spouse of his or her eligibility to continue coverage under the Health Program. A surviving spouse of a retiree shall be notified by the Department. Such notice shall advise the surviving spouse of the following: 

(a) That family coverage may be continued if there are eligible children to be covered; otherwise the spouse may continue participation only under individual coverage; 

(b) The amount of the applicable monthly total premium; 

(c) That in order to continue coverage the surviving spouse must complete an application in accordance with subsection 60P-2.002(2), F.A.C. The application must be submitted with one month’s total premium to the personnel office of the deceased employee’s agency and forwarded to the Department, or submitted to the Department for a retiree, either within thirty-one (31) calendar days after the end of the month in which the deceased employee died or within thirty-one (31) calendar days after receipt of the notice of eligibility to continue coverage, whichever is later. 

(10) In no case shall any subscriber or subscriber’s eligible dependent be covered simultaneously under two coverages within the Group Health Program. 

(11) An employee who applies for enrollment and is enrolled in the Health Program shall automatically be enrolled in the Pretax Premium Plan of the Flexible Benefits Program unless the employee submits a signed rejection which shall include the employee’s name, social security number, address, agency and a statement that this decision cannot be changed until the next open enrollment period. 

Rulemaking Authority 110.123(5) FS. Law Implemented 110.123 FS. History–New 10-8-78, Amended 5-22-79, 10-22-79, 4-15-80, 7-1-80, 9-13-82, 8-7-83, Formerly 22K-1.15, Amended 7-16-86, 9-25-86, Formerly 22K-1.202, Amended 8-22-96, Repromulgated 1-31-02, Amended 3-2-17, Amended ___________. 

 

60P-2.003 Changes in Coverage. 

(1) An employee enrolled in the Health Program may apply for a change to family coverage or individual coverage within thirty-one (31) calendar days of a QSC event if the change is consistent with the event or during the open enrollment period. 

(2) A retiree, surviving spouse or participant with continuation coverage enrolled with family coverage may apply to change to individual coverage at any time, however, those enrolled with individual coverage may apply for a change to family coverage within thirty-one (31) calendar days of the date of acquisition of or loss of other group coverage for any eligible dependent or during the open enrollment period. 

(3) A subscriber enrolled with individual coverage may apply for a change to family coverage prior to acquiring any eligible dependent. Since family coverage is effective the first day of any given month, a subscriber who will acquire the eligible dependent and is desirous of having immediate coverage of such dependent must: 

(a) Submit an application and pay a full month’s premium prior to the first day of the month in which the dependent will be acquired. Otherwise, coverage cannot be effective on the actual date of acquisition. 

(b) A subscriber applying for family coverage under paragraph (3)(a) above may also add any other eligible dependents. 

(4) If a subscriber enrolled with family coverage under an HMO plan is divorced, he or she may transfer such family coverage to the State Self Insurance Plan within thirty-one (31) calendar days after a covered dependent child is moved out of the HMO Region service area with the individual awarded custody of such child or during the open enrollment period. 

(5) An HMO subscriber who no longer resides in the HMO Region service area; if an employee, no longer resides or works; must change HMO plans or transfer to the State Self Insured Plan. 

(6) The employing agency shall request an effective date for the change in accordance with Rules 60P-2.004 and 60P-2.002, F.A.C., and indicate such date on the application. 

(7) All applications for coverage changes must be approved by the Department, subject to the following: 

(a) The Department shall approve a coverage change if the completed application is submitted to the employing agency within thirty-one (31) calendar days of and is consistent with the QSC event. 

(b) Documentation substantiating a QSC event is as follows: 

1. If changing to family coverage, proof of family status change or proof of loss of other group coverage is required. 

2. If changing to individual coverage, proof of family status change or proof of change of employment status is required. 

3. If adding an eligible dependent to family coverage, proof of family status change is required. 

4. If terminating coverage, proof of family status change or proof of employment change is required. 

Specific Authority 110.123(5) FS. Law Implemented 110.123 FS. History–New 10-8-78, Amended 10-22-79, 9-13-82, 8-7-83, Formerly 22K-1.16, Amended 7-16-86, 9-25-86, Formerly 22K-1.203, Amended 8-22-96, Repromulgated 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