§ 627.6692 — Florida Health Insurance Coverage Continuation Act

Florida § 627.6692

• Jurisdiction: Florida
• Title: XXXVII
• Ch. 627: INSURANCE RATES AND CONTRACTS

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(1) SHORT TITLE. — This section may be cited as the “Florida Health Insurance Coverage Continuation Act.”

(2) PURPOSE AND INTENT. — The purpose and intent of this section is to ensure continued access to affordable health insurance coverage for employees of small employers and their dependents and other qualified beneficiaries not currently protected by the Consolidated Omnibus Budget Reconciliation Act of 1985.

(3) APPLICABILITY. — This section does not apply if continuation of coverage benefits are available to covered employees or other qualified beneficiaries pursuant to s. 4980B of the Internal Revenue Code, Chapter 18 of the Employee Retirement Income Security Act, 29 U.S.C. ss. 1161 et seq., or Chapter 6A of the Public Health Service Act, 42 U.S.C. ss. 300bb-1 et seq.

(4) DEFINITIONS. — As used in this section, the term: (a) “Applicable premium” means, with respect to any period of continuation of coverage for qualified beneficiaries, the premium charged by the group health plan for such period of coverage for beneficiaries with respect to whom a qualifying event has not occurred, regardless of whether such premium is paid by the employer or employee. (b) “Carrier” means a carrier, as defined in s. 627.6699 and subject to s. 627.6699, which issued the small employer’s group health plan. (c) “Continuation coverage” means coverage under the group health plan which meets the requirements of paragraph (5)(a). (d) “Covered employee” means an eligible employee, as defined in s. 627.6699 and subject to s. 627.6699, who is or was provided coverage under a group health plan by virtue of the individual’s employment or previous employment with a small employer. (e) “Group health plan” means any health benefit plan, as defined in s. 627.6699 and subject to s. 627.6699, maintained by a small employer, which health benefit plan provides health care benefit coverage for the employer’s employees or former employees, or for the dependents of such employees or former employees. (f) “Qualified beneficiary” means any individual who, on the day before the qualifying event for the covered employee, is a beneficiary under the group health plan by virtue of the individual being: 1. The covered employee, except if the employee is terminated for gross misconduct. The employer’s decision to terminate for gross misconduct is conclusive as to the carrier. 2. The spouse of the covered employee, as defined in s. 627.6699 as a dependent. 3. The dependent child of the covered employee, as defined in s. 627.6699 as a dependent. (g) “Qualifying event” means, with respect to any covered employee, any of the following events which, but for the election of continuation coverage, would result in a loss of coverage to a qualified beneficiary: 1. The death of the covered employee. 2. The termination or reduction of hours of the covered employee’s employment, except that termination of an employee for gross misconduct does not constitute a qualifying event. The employer’s decision to terminate for gross misconduct is conclusive as to the carrier. 3. The divorce or legal separation of the covered employee from the covered employee’s spouse. 4. A covered employee’s becoming entitled to benefits under either part A or part B of Title XVIII of the Social Security Act (Medicare). 5. A dependent child’s ceasing to be a dependent child under the generally applicable requirements of the group health plan. 6. A retiree or the spouse or child of a retiree losing coverage within 1 year before or after commencement of a bankruptcy proceeding under Title XI of the United States Code by the employer from whose employment the covered employee retired. (h) “Small employer” means any person who meets the definition of “small employer” as set forth in s. 627.6699 and subject to s. 627.6699, who for purposes of this section employs fewer than 20 employees.

(5) CONTINUATION OF COVERAGE UNDER GROUP HEALTH PLANS. — (a) A group health plan issued to a small employer must provide that each qualified beneficiary who would lose coverage under the group health plan because of a qualifying event is entitled, without evidence of insurability, to elect, within the election period provided in this section, continuation coverage under the employer’s group health plan. A qualified beneficiary who elects continuation coverage is subject to all the terms and conditions applicable under the group health plan. (b) Coverage under the group health plan must, at a minimum, extend for the period beginning on the date of the qualifying event and ending not earlier than the earliest of the following: 1. The date that is 18 months after the date on which the qualified beneficiary’s benefits under the group health plan would otherwise have ceased because of a qualifying event. 2. The date on which coverage ceases under the group health plan by reason of a failure to make timely payment of the applicable premium with respect to any qualified beneficiary. 3. The date a qualified beneficiary becomes covered under any other group health plan, if the qualified beneficiary will not be subject to any exclusion or limitation because of a preexisting condition of that beneficiary. 4. The date a qualified beneficiary is entitled to benefits under either part A or part B of Title XVIII of the Social Security Act (Medicare). 5. The date on which the employer terminates coverage under the group health plan for all employees. If the employer terminates coverage under the group health plan for all employees and if such group health plan is replaced by similar coverage under another group health plan, the qualified beneficiary shall have the right to become covered under the new group health plan for the balance of the period that she or he would have remained covered under the prior group health plan. A qualified beneficiary is to be treated in the same manner as an active beneficiary for whom a qualifying event has not taken place. (c) A qualified beneficiary who is determined, under Title II or Title XVI of the Social Security Act, to have been disabled at the time of a qualifying event, may be eligible to continue coverage for an additional 11 months (29 months total) if the qualified beneficiary provides the written determination of disability from the Social Security Administration to the insurance carrier within 60 days of the date of determination of disability by the Social Security Administration and prior to the end of the 18-month continuation period. The insurance carrier can charge up to 150 percent of the group rate during the 11-month disability extension. The qualified beneficiary must notify the insurance carrier within 30 days upon the determination that the qualified beneficiary is no longer disabled under Title II or Title XVI of the Social Security Act. (d)1. A qualified beneficiary must give written notice to the insurance carrier within 63 days after the occurrence of a qualifying event. Unless otherwise specified in the notice, a notice by any qualified beneficiary constitutes notice on behalf of all qualified beneficiaries. The written notice must inform the insurance carrier of the occurrence and type of the qualifying event giving rise to the potential election by a qualified beneficiary of continuation of coverage under the group health plan issued by that insurance carrier, except that in cases where the covered employee has been involuntarily discharged, the nature of such discharge need not be disclosed. The written notice must, at a minimum, identify the employer, the group health plan number, the name and address of all qualified beneficiaries, and such other information required by the insurance carrier under the terms of the group health plan or the commission by rule, to the extent that such information is known by the qualified beneficiary. 2. Within 14 days after the receipt of written notice under subparagraph 1., the insurance carrier shall send each qualified beneficiary by certified mail an election and premium notice form, approved by the office, which form must provide for the qualified beneficiary’s election or nonelection of continuation of coverage under the group health plan and the applicable premium amount due after the election to continue coverage. This subparagraph does not require separate mailing of notices to qualified beneficiaries residing in the same household, but requires a separate mailing for each separate household. (e)1. A covered employee or other qualified beneficiary who wishes continuation of coverage must pay the initial premium and elect such continuation in writing to the insurance carrier issuing the employer’s group health plan within 30 days after receiving notice from the insurance carrier under paragraph (d). Subsequent premiums are due by the grace period expiration date. The insurance carrier or the insurance carrier’s designee shall process all elections promptly and provide coverage retroactively to the date coverage would otherwise have terminated. The premium due shall be for the period beginning on the date coverage would have otherwise terminated due to the qualifying event. The first premium payment must include the coverage paid to the end of the month in which the first payment is made. After the election, the insurance carrier must bill the qualified beneficiary for premiums once each month, with a due date on the first of the month of coverage and allowing a 30-day grace period for payment. 2. Except as otherwise specified in an election, any election by a qualified beneficiary shall be deemed to include an election of continuation of coverage on behalf of any other qualified beneficiary residing in the same household who would lose coverage under the group health plan by reason of a qualifying event. This subparagraph does not preclude a qualified beneficiary from electing continuation of coverage on behalf of any other qualified beneficiary. (f) The premium paid for continuation of coverage may not exceed 115 percent of the applicable premium. (g) If an insurance carrier fails to comply with the notice requirements of subparagraph (d)2. and such noncompliance results in the failure of an eligible qualified beneficiary to elect continuation under the group health plan, the qualified beneficiary shall be deemed to have timely elected continuation of coverage within the election period and shall be covered under the group health plan at the expense of the noncomplying insurance carrier. The liability exposure of a noncomplying insurance carrier under this paragraph shall be limited to that period which includes the effective date of coverage pursuant to an affirmative election through the date on which the qualified beneficiary receives actual notice. This paragraph does not apply to the extent that the failure of the insurance carrier to comply with applicable notice requirements was due to noncompliance by the qualified beneficiary with notice requirements applicable to the qualified beneficiary. (h) If a covered employee is in the military reserve or National Guard and is called to active duty and the employee’s employment is terminated either after or during the active duty period, the termination is a separate qualifying event, distinct from the qualifying event that may have occurred when the employee was called to active duty, and the employee and other qualified beneficiaries are eligible for a new 18-month benefit period beginning on the later of the date active duty ends or the date of termination of employment. (i) If a covered employee is in the military reserve or National Guard and is called to active duty and: 1. The employee dies during the period of active duty, 2. There is a divorce or legal separation of the covered employee from the covered employee’s spouse, or 3. A dependent child ceases to be a dependent child under the requirements of the employer’s group health plan, such events are qualifying events distinct from the qualifying event that may have occurred when the employee was called to active duty. (j) Notwithstanding paragraph (b), if a qualified beneficiary in the military reserve or National Guard has elected to continue coverage and is thereafter called to active duty and the coverage under the group plan is terminated by the beneficiary or the carrier due to the qualified beneficiary becoming eligible for TRICARE (the health care program provided by the United States Defense Department), the 18-month period or such other applicable maximum time period for which the qualified beneficiary would otherwise be entitled to continue coverage is tolled during the time that he or she is covered under the TRICARE program. Within 63 days after the federal TRICARE coverage terminates, the qualified beneficiary may elect to continue coverage under the group health plan, retroactively to the date coverage terminated under TRICARE, for the remainder of the 18-month period or such other applicable time period, subject to termination of coverage at the earliest of the conditions specified in paragraph (b).

(6) ADMINISTRATOR CERTIFICATE OF AUTHORITY REQUIRED. — (a) An insurance carrier may contract with an administrator, as defined in s. 626.88, to meet the administrative requirements of this section. An administrator is required to have a certificate of authority pursuant to part VII of chapter 626. (b) An insurance carrier may contract with the covered employee’s employer, and the employer may contract with the employer’s designee, provided that the carrier consents to the designee for the employer or such designee, for the employer to perform the administrative requirements of this section, including collecting and forwarding premiums to the insurance carrier, in return for consideration from the insurance carrier. Such an agreement must be arranged in a separate addendum to the policy contract. Such agreement does not relieve the insurance carrier of its duties and responsibilities to qualified beneficiaries as required by this section. An insurance carrier may not, as a condition of providing coverage to a small employer, require the employer to perform duties related to this section. (c) An administrator certificate of authority is not required for a person who does not adjudicate or process claims and is not controlled by any licensed insurance company, prepaid hospital or medical plan, health maintenance organization, or multiple employer welfare arrangement, but who solely performs administrative services to provide the benefits required pursuant to this section; to the Consolidated Omnibus Budget Reconciliation Act (COBRA) as amended, 29 U.S.C. ss. 1161 et seq.; or to the Employee Retirement Income Security Act (ERISA), 29 U.S.C. ss. 1001 et seq., or Chapter 6A of the Public Health Service Act, 42 U.S.C. ss. 300bb-1 et seq.; or for an employer pursuant to a contract with the insurance carrier who meets the requirements of this section or the employer’s designee, provided that the carrier consents to the designee pursuant to a contract with the carrier that meets the requirements of this section or subject to this section.

(7) NOTICE REQUIRED IN POLICIES, CONTRACTS, CERTIFICATES, AND PLAN BOOKLETS. — The insurance carrier shall include at the time of the first renewal of the policy after February 1, 1997, a notification of the right to continue coverage as provided by this section and the procedures for requesting such continuation in each policy, contract, and certificate of coverage and in the plan booklet. The plan booklet must also contain all information necessary for a qualified beneficiary to comply with the notice requirements of subparagraph (5)(e)1., and must contain a form for such notice.

(8) NOTICE TO COVERED EMPLOYEES. — The insurance carrier shall mail an initial notice to each covered employee, covered spouse, and covered dependent describing their rights under this section. A mailing to one household constitutes a mailing to all covered persons residing in that household. A separate mailing is required for each separate household.

(9) RULES. — The commission shall adopt rules establishing standards for the initial notice of rights and as otherwise necessary to administer this section.

Legislative History

s. 1, ch. 96-319; s. 1734, ch. 97-102; s. 1, ch. 2001-353; s. 1169, ch. 2003-261; s. 7, ch. 2005-231.