SESSION WATCH
THE BILL ITSELF

HB 1531

Government-facilitated Purchases and Sales of Individual and Small Employer Health and Dental Plans

VERSION H 1531 Filed · BACK TO THE SUMMARY · OFFICIAL RECORD

underlined language is being added; struck language is being deleted. Line numbers are the Legislature's own — the same ones amendments cite.

1 A bill to be entitled
2 An act relating to government-facilitated purchases
3 and sales of individual and small employer health and
4 dental plans; creating s. 627.4463, F.S.; providing a
5 short title; providing purpose and legislative intent;
6 providing definitions; establishing the Florida Health
7 Insurance Exchange within the Office of Insurance
8 Regulation to facilitate purchase and sale of
9 qualified health plans; providing duties of the
10 exchange; authorizing the exchange to contract with an
11 eligible entity to perform the exchange's functions
12 under certain circumstances; authorizing the exchange
13 to enter into agreements with governmental agencies
14 and entities to carry out the exchange's
15 responsibilities under certain circumstances;
16 providing general requirements and prohibitions for
17 the exchange; providing certifications by the exchange
18 of health and dental benefit plans; authorizing the
19 Commissioner of Insurance Regulation and the office to
20 contract with a vendor to build and manage the
21 exchange; providing rulemaking authority; providing
22 construction; providing a contingent effective date.
24 Be It Enacted by the Legislature of the State of Florida:
26 Section 1. Section 627.4463, Florida Statutes, is created
27 to read:
28 627.4463 Florida Health Insurance Exchange; government-
29 facilitated purchases and sales of individual and small employer
30 health and dental plans.—
31 (1) SHORT TITLE.—This section may be cited as the "Florida
32 Health Insurance Exchange Act."
33 (2) PURPOSE AND INTENT.—The purpose of this section is to
34 provide for the establishment of the Florida Health Insurance
35 Exchange to facilitate the purchase and sale of qualified health
36 plans in the individual market in this state and to provide for
37 the establishment of a Small Business Health Options Program to
38 assist qualified small employers in this state in facilitating
39 the enrollment of their employees in qualified health plans
40 offered in the small group market. The intent of the Florida
41 Health Insurance Exchange is to reduce the number of uninsured
42 persons, provide a transparent marketplace and consumer
43 education, and assist persons with access to programs, premium
44 assistance tax credits, and cost-sharing reductions.
45 (3) DEFINITIONS.—As used in this section, the term:
46 (a) "Commissioner" means the Commissioner of Insurance
47 Regulation.
48 (b) "Educated health care consumer" means a person who is
49 knowledgeable about the health care system and has a background
50 or experience in making informed decisions regarding health,
51 medical, and scientific matters.
52 (c) "Exchange" means the Florida Health Insurance Exchange
53 established in this section.
54 (d)1. "Health benefit plan" means a policy, a contract, a
55 certificate, or an agreement offered or issued by a health
56 carrier to provide, deliver, arrange for, pay for, or reimburse
57 any of the costs of health care services.
58 2. The term does not include:
59 a. Coverage only for accident, disability income
60 insurance, or any combination thereof;
61 b. Coverage issued as a supplement to liability insurance;
62 c. Liability insurance, including general liability
63 insurance and motor vehicle liability insurance;
64 d. Workers' compensation or similar insurance;
65 e. Motor vehicle medical payment insurance;
66 f. Credit-only insurance;
67 g. Coverage for onsite medical clinics; or
68 h. Other similar insurance coverage, specified in federal
69 regulations issued under the Health Insurance Portability and
70 Accountability Act of 1996, Pub. L. No. 104-191, under which
71 benefits for health care services are secondary or incidental to
72 other insurance benefits.
73 3. The term does not include the following benefits if the
74 benefits are provided under a separate policy, certificate, or
75 contract of insurance or are otherwise not an integral part of
76 the plan:
77 a. Limited scope dental or vision benefits;
78 b. Benefits for long-term care, nursing home care, home
79 health care, community-based care, or any combination thereof;
80 or
81 c. Other similar, limited benefits specified in federal
82 regulations issued under the Health Insurance Portability and
83 Accountability Act of 1996, Pub. L. No. 104-191.
84 4. The term does not include the following benefits if the
85 benefits are provided under a separate policy, certificate, or
86 contract of insurance, if there is no coordination between the
87 provision of the benefits and any exclusion of benefits under
88 any group health plan maintained by the same plan sponsor, and
89 if the benefits are paid with respect to an event without regard
90 to whether the benefits are provided with respect to such an
91 event under any group health plan maintained by the same plan
92 sponsor:
93 a. Coverage only for a specified disease or illness; or
94 b. Hospital indemnity or other fixed indemnity insurance.
95 5. The term does not include the following if offered as a
96 separate policy, certificate, or contract of insurance:
97 a. Medicare supplemental health insurance as defined in s.
98 1882(g)(1) of the Social Security Act;
99 b. Coverage supplemental to the coverage provided under
100 chapter 55 of Title 10, U.S.C., the Civilian Health and Medical
101 Program of the Uniformed Services; or
102 c. Similar supplemental coverage provided to coverage
103 under a group health plan.
104 (e) "Health carrier" or "carrier" means an entity subject
105 to the insurance laws and regulations of this state, or subject
106 to the jurisdiction of the commissioner, which contracts or
107 offers to contract to provide, deliver, arrange for, pay for, or
108 reimburse any of the costs of health care services, including an
109 accident and health insurance company, a health maintenance
110 organization, a nonprofit hospital and health service plan
111 corporation, or any other entity providing a plan of health
112 insurance, health benefits, or health services.
113 (f) "Qualified dental plan" means a limited scope dental
114 plan that has been certified in accordance with subsection (7).
115 (g) "Qualified employer" means a small employer that
116 elects to make its full-time employees and, at the option of the
117 employer, some or all of its part-time employees, eligible for
118 one or more qualified health plans offered through the SHOP
119 Exchange, provided that the employer:
120 1. Has its principal place of business in this state and
121 elects to provide coverage through the SHOP Exchange to all of
122 its eligible employees, wherever employed; or
123 2. Elects to provide coverage through the SHOP Exchange to
124 all of its eligible employees who are principally employed in
125 this state.
126 (h) "Qualified health plan" means a health benefit plan
127 that has in effect a certification that the plan meets the
128 criteria for certification described in s. 1311(c) of PPACA and
129 in subsection (7).
130 (i) "Qualified person" means a person, including a minor,
131 who meets all of the following conditions:
132 1. Is seeking to enroll in a qualified health plan offered
133 to persons through the exchange.
134 2. Resides in this state.
135 3. At the time of enrollment, is not incarcerated, other
136 than incarceration pending the disposition of charges.
137 4. Is, and is reasonably expected to be, for the entire
138 period for which enrollment is sought, a citizen or national of
139 the United States or an alien lawfully present in the United
140 States.
141 (j) "Secretary" means, except when the context clearly
142 indicates otherwise, the Secretary of the United States
143 Department of Health and Human Services.
144 (k) "SHOP Exchange" means the Small Business Health
145 Options Program established under subsection (6).
146 (l) "Small employer" has the same meaning as in s.
147 627.6699(3).
148 (4) ESTABLISHMENT OF THE FLORIDA HEALTH INSURANCE
149 EXCHANGE.—
150 (a) The Florida Health Insurance Exchange is established
151 as a governmental entity within the Office of Insurance
152 Regulation. To that end, the exchange shall strive to increase
153 the availability of affordable health insurance in this state,
154 while achieving efficiencies and economies and while providing
155 service to policyholders. It is the intent of the Legislature
156 that the exchange be an integral part of this state and that the
157 income of the exchange be exempt from federal income taxation.
158 The exchange shall operate pursuant to a plan of operation
159 approved by order of the commissioner. The plan is subject to
160 continuous review by the office. The office may, by order,
161 withdraw approval of all or part of a plan if the commissioner
162 determines that conditions have changed since approval was
163 granted and that the purposes of the plan require changes in the
164 plan.
165 (b) The exchange must:
166 1. Facilitate the purchase and sale of qualified health
167 plans.
168 2. Provide for the establishment of a SHOP Exchange to
169 assist qualified small employers in this state in facilitating
170 the enrollment of their employees in qualified health plans.
171 3. Meet the requirements of this section and any rules and
172 regulations implemented under this section.
173 (c) The exchange may contract with an eligible entity for
174 any of the exchange's functions described in this section. An
175 eligible entity includes, but is not limited to, an entity that
176 has experience in individual and small group health insurance
177 benefit administration or other experience relevant to the
178 responsibilities to be assumed by the entity, but a health
179 carrier or an affiliate of a health carrier is not an eligible
180 entity.
181 (d) The exchange may enter into information-sharing
182 agreements with federal and state agencies and exchanges in
183 other states to carry out its responsibilities under this
184 section, provided that such agreements include adequate
185 protections with respect to the confidentiality of the
186 information to be shared and comply with all state and federal
187 laws and regulations.
188 (5) GENERAL REQUIREMENTS.—
189 (a) The exchange must make qualified health plans
190 available to qualified persons and qualified employers beginning
191 January 1, 2028.
192 (b)1. The exchange may not make available any health
193 benefit plan that is not a qualified health plan.
194 2. The exchange must allow a health carrier to offer a
195 plan that provides limited scope dental benefits meeting the
196 requirements of s. 9832(c)(2)(A) of the Internal Revenue Code of
197 1986 through the exchange, either separately or in conjunction
198 with a qualified health plan, if the plan provides pediatric
199 dental benefits that meet the requirements of s. 1302(b)(1)(J)
200 of PPACA.
201 (c) Neither the exchange nor a carrier offering health
202 benefit plans through the exchange may charge a person a fee or
203 penalty for termination of coverage if the person enrolls in
204 another type of minimum essential coverage because the person
205 has become newly eligible for that coverage or because the
206 person's employer-sponsored coverage has become affordable under
207 the standards of s. 36B(c)(2)(C) of the Internal Revenue Code of
208 1986.
209 (6) DUTIES OF THE EXCHANGE.—The exchange must:
210 (a) Implement procedures for the certification,
211 recertification, and decertification, consistent with guidelines
212 developed by the Secretary under s. 1311(c) of PPACA and with
213 subsection (7), of health benefit plans as qualified health
214 plans.
215 (b) Provide for the operation of a toll-free telephone
216 hotline to respond to requests for assistance.
217 (c) Provide for enrollment periods, as provided under s.
218 1311(c)(6) of PPACA.
219 (d) Maintain an Internet website through which enrollees
220 and prospective enrollees of qualified health plans may obtain
221 standardized comparative information on such plans.
222 (e) Assign a rating to each qualified health plan offered
223 through the exchange in accordance with the criteria developed
224 by the Secretary under s. 1311(c)(3) of PPACA and determine each
225 qualified health plan's level of coverage in accordance with
226 regulations issued by the Secretary under s. 1302(d)(2)(A) of
227 PPACA.
228 (f) Use a standardized format for presenting health
229 benefit options in the exchange, including the use of the
230 uniform outline of coverage established under s. 2715 of the
231 Public Health Service Act.
232 (g) In accordance with s. 1413 of PPACA, inform persons of
233 eligibility requirements for the Medicaid program under Title
234 XIX of the Social Security Act, the Children's Health Insurance
235 Program under Title XXI of the Social Security Act, or any
236 applicable state or local public program and, if through
237 screening of the application by the exchange, the exchange
238 determines that any person is eligible for any such program,
239 enroll that person in that program.
240 (h) Establish and make available by electronic means a
241 calculator to determine the actual cost of coverage after
242 application of any premium tax credit under s. 36B of the
243 Internal Revenue Code of 1986 and any cost-sharing reduction
244 under s. 1402 of PPACA.
245 (i) Establish a SHOP Exchange through which a qualified
246 employer may access coverage for its employees, which must
247 enable any qualified employer to specify a level of coverage so
248 that any of its employees may enroll in any qualified health
249 plan offered through the SHOP Exchange at the specified level of
250 coverage.
251 (j) Subject to s. 1411 of PPACA, grant a certification
252 attesting that, for purposes of the individual responsibility
253 penalty under s. 5000A of the Internal Revenue Code of 1986, a
254 person is exempt from the individual responsibility requirement
255 or from the penalty imposed by that section because:
256 1. There is no affordable qualified health plan available
257 through the exchange, or the person's employer, covering the
258 person; or
259 2. The person meets the requirements for any other such
260 exemption from the individual responsibility requirement or
261 penalty.
262 (k) Transfer to the United States Secretary of the
263 Treasury the following:
264 1. A list of persons who are issued a certification under
265 paragraph (j), including the name and taxpayer identification
266 number of each person.
267 2. The name and taxpayer identification number of each
268 person who was an employee of an employer but who was determined
269 to be eligible for the premium tax credit under s. 36B of the
270 Internal Revenue Code of 1986 because:
271 a. The employer did not provide minimum essential
272 coverage; or
273 b. The employer provided the minimum essential coverage,
274 but the coverage was determined under s. 36B(c)(2)(C) of the
275 Internal Revenue Code to either be unaffordable to the employee
276 or not provide the required minimum actuarial value.
277 3. The name and taxpayer identification number of:
278 a. Each person who notifies the exchange under s.
279 1411(b)(4) of PPACA that he or she has changed employers.
280 b. Each person who ceases coverage under a qualified
281 health plan during a plan year and the effective date of that
282 cessation.
283 (l) Provide to each employer the name of each employee of
284 the employer described in subparagraph (k)2. who terminates
285 coverage under a qualified health plan during a plan year and
286 the effective date of the termination.
287 (m) Perform duties required of the exchange by the
288 Secretary or the United States Secretary of the Treasury related
289 to determining eligibility for premium tax credits, reduced
290 cost-sharing, or individual responsibility requirement
291 exemptions.
292 (n) Select entities qualified to serve as navigators in
293 accordance with s. 1311(i) of PPACA and standards developed by
294 the Secretary, and award grants to enable navigators to:
295 1. Conduct public education activities to raise awareness
296 of the availability of qualified health plans.
297 2. Distribute fair and impartial information concerning
298 enrollment in qualified health plans and the availability of
299 premium tax credits under s. 36B of the Internal Revenue Code of
300 1986 and cost-sharing reductions under s. 1402 of PPACA.
301 3. Facilitate enrollment in qualified health plans.
302 4. Provide referrals to any applicable office of health
303 insurance consumer assistance or health insurance ombudsman
304 established under s. 2793 of the Public Health Service Act, or
305 any other appropriate state agency, for any enrollee with a
306 grievance, complaint, or question regarding the enrollee's
307 health benefit plan or coverage or a determination under that
308 plan or coverage.
309 5. Provide information in a manner that is culturally and
310 linguistically appropriate to the needs of the populations being
311 served by the exchange.
312 (o) Review the rate of premium growth within the exchange
313 and outside the exchange and consider the information in
314 developing recommendations on whether to continue limiting
315 qualified employer status to small employers.
316 (p) Credit the amount of any free choice voucher to the
317 monthly premium of the plan in which a qualified employee is
318 enrolled, in accordance with s. 10108 of PPACA, and collect the
319 amount credited from the offering employer.
320 (q) Consult with stakeholders relevant to carrying out the
321 activities required under this section, including, but not
322 limited to:
323 1. Educated health care consumers who are enrollees in
324 qualified health plans.
325 2. Persons and entities with experience in facilitating
326 enrollment in qualified health plans.
327 3. Representatives of small businesses and self-employed
328 persons.
329 4. The Secretary of Health Care Administration.
330 5. Advocates for enrolling hard-to-reach populations.
331 (r) Meet the following financial integrity requirements:
332 1. Keep an accurate accounting of all activities,
333 receipts, and expenditures and annually submit to the Secretary,
334 the Governor, the commissioner, and the Legislature a report
335 concerning such accountings.
336 2. Fully cooperate with any investigation conducted by the
337 Secretary pursuant to the Secretary's authority under PPACA and
338 allow the Secretary, in coordination with the Office of
339 Inspector General for the United States Department of Health and
340 Human Services, to:
341 a. Investigate the affairs of the exchange.
342 b. Examine the properties and records of the exchange.
343 c. Require periodic reports in relation to the activities
344 undertaken by the exchange.
345 3. In carrying out its activities under this section, not
346 use any funds intended for the administrative and operational
347 expenses of the exchange for staff retreats, promotional
348 giveaways, excessive executive compensation, or promotion of
349 federal or state legislative and regulatory modifications.
350 (7) HEALTH AND DENTAL BENEFIT PLAN CERTIFICATION.—
351 (a) The exchange may certify a health benefit plan as a
352 qualified health plan if all of the following conditions are
353 met:
354 1. The plan provides the essential health benefits package
355 described in s. 1302(a) of PPACA, except that the plan is not
356 required to provide essential benefits that duplicate the
357 minimum benefits of qualified dental plans, as provided in
358 paragraph (e), if all the following conditions are met:
359 a. The exchange has determined that at least one qualified
360 dental plan is available to supplement the plan's coverage.
361 b. The carrier makes prominent disclosure at the time the
362 plan is offered, in a form approved by the exchange, that the
363 plan does not provide the full range of essential pediatric
364 benefits, and that qualified dental plans providing those
365 benefits and other dental benefits not covered by the plan are
366 offered through the exchange.
367 2. The premium rates and contract language have been
368 approved by the office.
369 3. The plan provides at least a bronze level of coverage,
370 as determined pursuant to paragraph (6)(e) unless the plan is
371 certified as a qualified catastrophic plan, meets the
372 requirements of PPACA for catastrophic plans, and will only be
373 offered to persons eligible for catastrophic coverage.
374 4. The plan's cost-sharing requirements do not exceed the
375 limits established under s. 1302(c)(1) of PPACA, and, if the
376 plan is offered through the SHOP Exchange, the plan's deductible
377 does not exceed the limits established under s. 1302(c)(2) of
378 PPACA.
379 5. The health carrier offering the plan meets all of the
380 following requirements:
381 a. Is licensed and in good standing to offer health
382 insurance coverage in this state.
383 b. Offers at least one qualified health plan in the silver
384 level and at least one plan in the gold level through each
385 component of the exchange in which the carrier participates,
386 where the term "component" refers to the SHOP Exchange and the
387 exchange for individual coverage.
388 c. Charges the same premium rate for each qualified health
389 plan without regard to whether the plan is offered through the
390 exchange and without regard to whether the plan is offered
391 directly from the carrier or through an insurance producer.
392 d. Does not charge any cancellation fees or penalties in
393 violation of paragraph (5)(c).
394 e. Complies with the regulations developed by the
395 Secretary under s. 1311(d) of PPACA and such other requirements
396 as the exchange may establish.
397 6. The plan meets the requirements of certification as
398 adopted by regulation pursuant to subsection (9) and by the
399 Secretary under s. 1311(c) of PPACA, which include, but are not
400 limited to, minimum standards in the areas of marketing
401 practices, network adequacy, essential community providers in
402 underserved areas, accreditation, quality improvement, uniform
403 enrollment forms and descriptions of coverage, and information
404 on quality measures for health benefit plan performance.
405 7. The exchange determines that making the plan available
406 through the exchange is in the interest of qualified persons and
407 qualified employers in this state.
408 (b) The exchange may not exclude a health benefit plan:
409 1. On the basis that the plan is a fee-for-service plan;
410 2. Through the imposition of premium price controls by the
411 exchange; or
412 3. On the basis that the health benefit plan provides
413 treatments necessary to prevent patients' deaths in
414 circumstances the exchange determines are inappropriate or too
415 costly.
416 (c) The exchange must require each health carrier seeking
417 certification of a plan as a qualified health plan to do all of
418 the following:
419 1. Submit a justification for any premium increase before
420 implementation of that increase. The carrier must prominently
421 post the information on its Internet website. The exchange must
422 take this information, along with the information and the
423 recommendations provided to the exchange by the commissioner
424 under s. 2794(b) of the Public Health Service Act, into
425 consideration when determining whether to allow the carrier to
426 make plans available through the exchange.
427 2.a. Make available to the public, in plain language as
428 provided in subparagraph b., and submit to the exchange, the
429 Secretary, and the commissioner, accurate and timely disclosure
430 of the following:
431 (I) Claims payment policies and practices.
432 (II) Periodic financial disclosures.
433 (III) Data on enrollment.
434 (IV) Data on disenrollment.
435 (V) Data on the number of claims that are denied.
436 (VI) Data on rating practices.
437 (VII) Information on cost sharing and payments with
438 respect to any out-of-network coverage.
439 (VIII) Information on enrollee and participant rights
440 under Title I of PPACA.
441 (IX) Other information as determined appropriate by the
442 Secretary.
443 b. The information required in subparagraph a. must be
444 provided in plain language, as that term is defined in s.
445 1311(e)(3)(B) of PPACA.
446 3. Allow a person to learn, in a timely manner upon the
447 request of the person, the amount of cost sharing, including
448 deductibles, copayments, and coinsurance, under the person's
449 plan or coverage which the person would be responsible for
450 paying with respect to the furnishing of a specific item or
451 service by a participating provider. At a minimum, this
452 information must be made available to the person through an
453 Internet website and through other means for persons without
454 access to the Internet.
455 (d) The exchange may not exempt any health carrier seeking
456 certification of a qualified health plan, regardless of the type
457 or size of the carrier, from state licensure or solvency
458 requirements and must apply the criteria of this section in a
459 manner that is equitable between or among health carriers
460 participating in the exchange.
461 (e)1. The provisions of this section that are applicable
462 to qualified health plans also apply to the extent relevant to
463 qualified dental plans, except as modified in accordance with
464 subparagraphs 2., 3., and 4. or by regulations adopted by the
465 exchange.
466 2. The carrier must be licensed to offer dental coverage
467 but need not be licensed to offer other health benefits.
468 3. The plan must be limited to dental and oral health
469 benefits, without substantially duplicating the benefits
470 typically offered by health benefit plans without dental
471 coverage, and must include, at a minimum, the essential
472 pediatric dental benefits prescribed by the Secretary pursuant
473 to s. 1302(b)(1)(J) of PPACA and such other dental benefits as
474 the exchange or the Secretary may specify by regulation.
475 4. Carriers may jointly offer a comprehensive plan through
476 the exchange in which the dental benefits are provided by a
477 carrier through a qualified dental plan and the other benefits
478 are provided by a carrier through a qualified health plan,
479 provided that the plans are priced separately and are also made
480 available for purchase separately at the same price.
481 (8) VENDOR TO BUILD AND MANAGE EXCHANGE.—The commissioner
482 and the office shall contract with a vendor selected by a
483 competitive procurement to build and manage the exchange.
484 (9) RULEMAKING AUTHORITY.—The office may adopt rules and
485 regulations to implement this section. Rules and regulations
486 adopted under this section may not conflict with or prevent the
487 application of regulations adopted by the Secretary under PPACA.
488 (10) RELATION TO OTHER LAWS.—This section, and any action
489 taken by the exchange pursuant to this section, may not be
490 construed to preempt or supersede the authority of the
491 commission to regulate the business of insurance in this state.
492 Except as expressly provided to the contrary in this section,
493 all health carriers offering qualified health plans in this
494 state shall comply fully with all applicable health insurance
495 laws of this state and rules and regulations adopted and orders
496 issued by the commission.
497 Section 2. This act shall take effect July 1, 2026, but
498 only if HB 1533 or similar legislation is adopted in the same
499 legislative session or an extension thereof and becomes a law.