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

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A bill to be entitled 1
An act relating to government-facilitated purchases 2
and sales of individual and small employer health and 3
dental plans; creating s. 627.4463, F.S.; providing a 4
short title; providing purpose and legislative intent; 5
providing definitions; establishing the Florida Health 6
Insurance Exchange within the Office of Insurance 7
Regulation to facilitate purchase and sale of 8
qualified health plans; providing duties of the 9
exchange; authorizing the exchange to contract with an 10
eligible entity to perform the exchange's functions 11
under certain circumstances; authorizing the exchange 12
to enter into agreements with governmental agencies 13
and entities to carry out the exchange's 14
responsibilities under certain circumstances; 15
providing general requirements and prohibitions for 16
the exchange; providing certifications by the exchange 17
of health and dental benefit plans; authorizing the 18
Commissioner of Insurance Regulation and the office to 19
contract with a vendor to build and manage the 20
exchange; providing rulemaking authority; providing 21
construction; providing a contingent effective date. 22
23
Be It Enacted by the Legislature of the State of Florida: 24
25

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Section 1. Section 627.4463, Florida Statutes, is created 26
to read: 27
627.4463 Florida Health Insurance Exchange; government-28
facilitated purchases and sales of individual and small employer 29
health and dental plans.— 30
(1) SHORT TITLE.—This section may be cited as the "Florida 31
Health Insurance Exchange Act." 32
(2) PURPOSE AND INTENT.—The purpose of this section is to 33
provide for the establishment of the Florida Health Insurance 34
Exchange to facilitate the purchase and sale of qualified health 35
plans in the individual market in this state and to provide for 36
the establishment of a Small Business Health Options Program to 37
assist qualified small employers in this state in facilitating 38
the enrollment of their employees in qualified health plans 39
offered in the small group market. The intent of the Florida 40
Health Insurance Exchange is to reduce the number of uninsured 41
persons, provide a transparent marketplace and consumer 42
education, and assist persons with access to programs, premium 43
assistance tax credits, and cost-sharing reductions. 44
(3) DEFINITIONS.—As used in this section, the term: 45
(a) "Commissioner" means the Commissioner of Insurance 46
Regulation. 47
(b) "Educated health care consumer" means a person who is 48
knowledgeable about the health care system and has a background 49
or experience in making informed decisions regarding health, 50

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medical, and scientific matters. 51
(c) "Exchange" means the Florida Health Insurance Exchange 52
established in this section. 53
(d)1. "Health benefit plan" means a policy, a contract, a 54
certificate, or an agreement offered or issued by a health 55
carrier to provide, deliver, arrange for, pay for, or reimburse 56
any of the costs of health care services. 57
2. The term does not include: 58
a. Coverage only for accident, disability income 59
insurance, or any combination thereof; 60
b. Coverage issued as a supplement to liability insurance; 61
c. Liability insurance, including general liability 62
insurance and motor vehicle liability insurance; 63
d. Workers' compensation or similar insurance; 64
e. Motor vehicle medical payment insurance; 65
f. Credit-only insurance; 66
g. Coverage for onsite medical clinics; or 67
h. Other similar insurance coverage, specified in federal 68
regulations issued under the Health Insurance Portability and 69
Accountability Act of 1996, Pub. L. No. 104-191, under which 70
benefits for health care services are secondary or incidental to 71
other insurance benefits. 72
3. The term does not include the following benefits if the 73
benefits are provided under a separate policy, certificate, or 74
contract of insurance or are otherwise not an integral part of 75

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the plan: 76
a. Limited scope dental or vision benefits; 77
b. Benefits for long-term care, nursing home care, home 78
health care, community-based care, or any combination thereof; 79
or 80
c. Other similar, limited benefits specified in federal 81
regulations issued under the Health Insurance Portability and 82
Accountability Act of 1996, Pub. L. No. 104-191. 83
4. The term does not include the following benefits if the 84
benefits are provided under a separate policy, certificate, or 85
contract of insurance, if there is no coordination between the 86
provision of the benefits and any exclusion of benefits under 87
any group health plan maintained by the same plan sponsor, and 88
if the benefits are paid with respect to an event without regard 89
to whether the benefits are provided with respect to such an 90
event under any group health plan maintained by the same plan 91
sponsor: 92
a. Coverage only for a specified disease or illness; or 93
b. Hospital indemnity or other fixed indemnity insurance. 94
5. The term does not include the following if offered as a 95
separate policy, certificate, or contract of insurance: 96
a. Medicare supplemental health insurance as defined in s. 97
1882(g)(1) of the Social Security Act; 98
b. Coverage supplemental to the coverage provided under 99
chapter 55 of Title 10, U.S.C., the Civilian Health and Medical 100

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Program of the Uniformed Services; or 101
c. Similar supplemental coverage provided to coverage 102
under a group health plan. 103
(e) "Health carrier" or "carrier" means an entity subject 104
to the insurance laws and regulations of this state, or subject 105
to the jurisdiction of the commissioner, which contracts or 106
offers to contract to provide, deliver, arrange for, pay for, or 107
reimburse any of the costs of health care services, including an 108
accident and health insurance company, a health maintenance 109
organization, a nonprofit hospital and health service plan 110
corporation, or any other entity providing a plan of health 111
insurance, health benefits, or health services. 112
(f) "Qualified dental plan" means a limited scope dental 113
plan that has been certified in accordance with subsection (7). 114
(g) "Qualified employer" means a small employer that 115
elects to make its full-time employees and, at the option of the 116
employer, some or all of its part-time employees, eligible for 117
one or more qualified health plans offered through the SHOP 118
Exchange, provided that the employer: 119
1. Has its principal place of business in this state and 120
elects to provide coverage through the SHOP Exchange to all of 121
its eligible employees, wherever employed; or 122
2. Elects to provide coverage through the SHOP Exchange to 123
all of its eligible employees who are principally employed in 124
this state. 125

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(h) "Qualified health plan" means a health benefit plan 126
that has in effect a certification that the plan meets the 127
criteria for certification described in s. 1311(c) of PPACA and 128
in subsection (7). 129
(i) "Qualified person" means a person, including a minor, 130
who meets all of the following conditions: 131
1. Is seeking to enroll in a qualified health plan offered 132
to persons through the exchange. 133
2. Resides in this state. 134
3. At the time of enrollment, is not incarcerated, other 135
than incarceration pending the disposition of charges. 136
4. Is, and is reasonably expected to be, for the entire 137
period for which enrollment is sought, a citizen or national of 138
the United States or an alien lawfully present in the United 139
States. 140
(j) "Secretary" means, except when the context clearly 141
indicates otherwise, the Secretary of the United States 142
Department of Health and Human Services. 143
(k) "SHOP Exchange" means the Small Business Health 144
Options Program established under subsection (6). 145
(l) "Small employer" has the same meaning as in s. 146
627.6699(3). 147
(4) ESTABLISHMENT OF THE FLORIDA HEALTH INSURANCE 148
EXCHANGE.— 149
(a) The Florida Health Insurance Exchange is established 150

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as a governmental entity within the Office of Insurance 151
Regulation. To that end, the exchange shall strive to increase 152
the availability of affordable health insurance in this state, 153
while achieving efficiencies and economies and while providing 154
service to policyholders. It is the intent of the Legislature 155
that the exchange be an integral part of this state and that the 156
income of the exchange be exempt from federal income taxation. 157
The exchange shall operate pursuant to a plan of operation 158
approved by order of the commissioner. The plan is subject to 159
continuous review by the office. The office may, by order, 160
withdraw approval of all or part of a plan if the commissioner 161
determines that conditions have changed since approval was 162
granted and that the purposes of the plan require changes in the 163
plan. 164
(b) The exchange must: 165
1. Facilitate the purchase and sale of qualified health 166
plans. 167
2. Provide for the establishment of a SHOP Exchange to 168
assist qualified small employers in this state in facilitating 169
the enrollment of their employees in qualified health plans. 170
3. Meet the requirements of this section and any rules and 171
regulations implemented under this section. 172
(c) The exchange may contract with an eligible entity for 173
any of the exchange's functions described in this section. An 174
eligible entity includes, but is not limited to, an entity that 175

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has experience in individual and small group health insurance 176
benefit administration or other experience relevant to the 177
responsibilities to be assumed by the entity, but a health 178
carrier or an affiliate of a health carrier is not an eligible 179
entity. 180
(d) The exchange may enter into information-sharing 181
agreements with federal and state agencies and exchanges in 182
other states to carry out its responsibilities under this 183
section, provided that such agreements include adequate 184
protections with respect to the confidentiality of the 185
information to be shared and comply with all state and federal 186
laws and regulations. 187
(5) GENERAL REQUIREMENTS.— 188
(a) The exchange must make qualified health plans 189
available to qualified persons and qualified employers beginning 190
January 1, 2028. 191
(b)1. The exchange may not make available any health 192
benefit plan that is not a qualified health plan. 193
2. The exchange must allow a health carrier to offer a 194
plan that provides limited scope dental benefits meeting the 195
requirements of s. 9832(c)(2)(A) of the Internal Revenue Code of 196
1986 through the exchange, either separately or in conjunction 197
with a qualified health plan, if the plan provides pediatric 198
dental benefits that meet the requirements of s. 1302(b)(1)(J) 199
of PPACA. 200

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(c) Neither the exchange nor a carrier offering health 201
benefit plans through the exchange may charge a person a fee or 202
penalty for termination of coverage if the person enrolls in 203
another type of minimum essential coverage because the person 204
has become newly eligible for that coverage or because the 205
person's employer-sponsored coverage has become affordable under 206
the standards of s. 36B(c)(2)(C) of the Internal Revenue Code of 207
1986. 208
(6) DUTIES OF THE EXCHANGE.—The exchange must: 209
(a) Implement procedures for the certification, 210
recertification, and decertification, consistent with guidelines 211
developed by the Secretary under s. 1311(c) of PPACA and with 212
subsection (7), of health benefit plans as qualified health 213
plans. 214
(b) Provide for the operation of a toll-free telephone 215
hotline to respond to requests for assistance. 216
(c) Provide for enrollment periods, as provided under s. 217
1311(c)(6) of PPACA. 218
(d) Maintain an Internet website through which enrollees 219
and prospective enrollees of qualified health plans may obtain 220
standardized comparative information on such plans. 221
(e) Assign a rating to each qualified health plan offered 222
through the exchange in accordance with the criteria developed 223
by the Secretary under s. 1311(c)(3) of PPACA and determine each 224
qualified health plan's level of coverage in accordance with 225

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regulations issued by the Secretary under s. 1302(d)(2)(A) of 226
PPACA. 227
(f) Use a standardized format for presenting health 228
benefit options in the exchange, including the use of the 229
uniform outline of coverage established under s. 2715 of the 230
Public Health Service Act. 231
(g) In accordance with s. 1413 of PPACA, inform persons of 232
eligibility requirements for the Medicaid program under Title 233
XIX of the Social Security Act, the Children's Health Insurance 234
Program under Title XXI of the Social Security Act, or any 235
applicable state or local public program and, if through 236
screening of the application by the exchange, the exchange 237
determines that any person is eligible for any such program, 238
enroll that person in that program. 239
(h) Establish and make available by electronic means a 240
calculator to determine the actual cost of coverage after 241
application of any premium tax credit under s. 36B of the 242
Internal Revenue Code of 1986 and any cost-sharing reduction 243
under s. 1402 of PPACA. 244
(i) Establish a SHOP Exchange through which a qualified 245
employer may access coverage for its employees, which must 246
enable any qualified employer to specify a level of coverage so 247
that any of its employees may enroll in any qualified health 248
plan offered through the SHOP Exchange at the specified level of 249
coverage. 250

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(j) Subject to s. 1411 of PPACA, grant a certification 251
attesting that, for purposes of the individual responsibility 252
penalty under s. 5000A of the Internal Revenue Code of 1986, a 253
person is exempt from the individual responsibility requirement 254
or from the penalty imposed by that section because: 255
1. There is no affordable qualified health plan available 256
through the exchange, or the person's employer, covering the 257
person; or 258
2. The person meets the requirements for any other such 259
exemption from the individual responsibility requirement or 260
penalty. 261
(k) Transfer to the United States Secretary of the 262
Treasury the following: 263
1. A list of persons who are issued a certification under 264
paragraph (j), including the name and taxpayer identification 265
number of each person. 266
2. The name and taxpayer identification number of each 267
person who was an employee of an employer but who was determined 268
to be eligible for the premium tax credit under s. 36B of the 269
Internal Revenue Code of 1986 because: 270
a. The employer did not provide minimum essential 271
coverage; or 272
b. The employer provided the minimum essential coverage, 273
but the coverage was determined under s. 36B(c)(2)(C) of the 274
Internal Revenue Code to either be unaffordable to the employee 275

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or not provide the required minimum actuarial value. 276
3. The name and taxpayer identification number of: 277
a. Each person who notifies the exchange under s. 278
1411(b)(4) of PPACA that he or she has changed employers. 279
b. Each person who ceases coverage under a qualified 280
health plan during a plan year and the effective date of that 281
cessation. 282
(l) Provide to each employer the name of each employee of 283
the employer described in subparagraph (k)2. who terminates 284
coverage under a qualified health plan during a plan year and 285
the effective date of the termination. 286
(m) Perform duties required of the exchange by the 287
Secretary or the United States Secretary of the Treasury related 288
to determining eligibility for premium tax credits, reduced 289
cost-sharing, or individual responsibility requirement 290
exemptions. 291
(n) Select entities qualified to serve as navigators in 292
accordance with s. 1311(i) of PPACA and standards developed by 293
the Secretary, and award grants to enable navigators to: 294
1. Conduct public education activities to raise awareness 295
of the availability of qualified health plans. 296
2. Distribute fair and impartial information concerning 297
enrollment in qualified health plans and the availability of 298
premium tax credits under s. 36B of the Internal Revenue Code of 299
1986 and cost-sharing reductions under s. 1402 of PPACA. 300

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3. Facilitate enrollment in qualified health plans. 301
4. Provide referrals to any applicable office of health 302
insurance consumer assistance or health insurance ombudsman 303
established under s. 2793 of the Public Health Service Act, or 304
any other appropriate state agency, for any enrollee with a 305
grievance, complaint, or question regarding the enrollee's 306
health benefit plan or coverage or a determination under that 307
plan or coverage. 308
5. Provide information in a manner that is culturally and 309
linguistically appropriate to the needs of the populations being 310
served by the exchange. 311
(o) Review the rate of premium growth within the exchange 312
and outside the exchange and consider the information in 313
developing recommendations on whether to continue limiting 314
qualified employer status to small employers. 315
(p) Credit the amount of any free choice voucher to the 316
monthly premium of the plan in which a qualified employee is 317
enrolled, in accordance with s. 10108 of PPACA, and collect the 318
amount credited from the offering employer. 319
(q) Consult with stakeholders relevant to carrying out the 320
activities required under this section, including, but not 321
limited to: 322
1. Educated health care consumers who are enrollees in 323
qualified health plans. 324
2. Persons and entities with experience in facilitating 325

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enrollment in qualified health plans. 326
3. Representatives of small businesses and self-employed 327
persons. 328
4. The Secretary of Health Care Administration. 329
5. Advocates for enrolling hard-to-reach populations. 330
(r) Meet the following financial integrity requirements: 331
1. Keep an accurate accounting of all activities, 332
receipts, and expenditures and annually submit to the Secretary, 333
the Governor, the commissioner, and the Legislature a report 334
concerning such accountings. 335
2. Fully cooperate with any investigation conducted by the 336
Secretary pursuant to the Secretary's authority under PPACA and 337
allow the Secretary, in coordination with the Office of 338
Inspector General for the United States Department of Health and 339
Human Services, to: 340
a. Investigate the affairs of the exchange. 341
b. Examine the properties and records of the exchange. 342
c. Require periodic reports in relation to the activities 343
undertaken by the exchange. 344
3. In carrying out its activities under this section, not 345
use any funds intended for the administrative and operational 346
expenses of the exchange for staff retreats, promotional 347
giveaways, excessive executive compensation, or promotion of 348
federal or state legislative and regulatory modifications. 349
(7) HEALTH AND DENTAL BENEFIT PLAN CERTIFICATION.— 350

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(a) The exchange may certify a health benefit plan as a 351
qualified health plan if all of the following conditions are 352
met: 353
1. The plan provides the essential health benefits package 354
described in s. 1302(a) of PPACA, except that the plan is not 355
required to provide essential benefits that duplicate the 356
minimum benefits of qualified dental plans, as provided in 357
paragraph (e), if all the following conditions are met: 358
a. The exchange has determined that at least one qualified 359
dental plan is available to supplement the plan's coverage. 360
b. The carrier makes prominent disclosure at the time the 361
plan is offered, in a form approved by the exchange, that the 362
plan does not provide the full range of essential pediatric 363
benefits, and that qualified dental plans providing those 364
benefits and other dental benefits not covered by the plan are 365
offered through the exchange. 366
2. The premium rates and contract language have been 367
approved by the office. 368
3. The plan provides at least a bronze level of coverage, 369
as determined pursuant to paragraph (6)(e) unless the plan is 370
certified as a qualified catastrophic plan, meets the 371
requirements of PPACA for catastrophic plans, and will only be 372
offered to persons eligible for catastrophic coverage. 373
4. The plan's cost-sharing requirements do not exceed the 374
limits established under s. 1302(c)(1) of PPACA, and, if the 375

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plan is offered through the SHOP Exchange, the plan's deductible 376
does not exceed the limits established under s. 1302(c)(2) of 377
PPACA. 378
5. The health carrier offering the plan meets all of the 379
following requirements: 380
a. Is licensed and in good standing to offer health 381
insurance coverage in this state. 382
b. Offers at least one qualified health plan in the silver 383
level and at least one plan in the gold level through each 384
component of the exchange in which the carrier participates, 385
where the term "component" refers to the SHOP Exchange and the 386
exchange for individual coverage. 387
c. Charges the same premium rate for each qualified health 388
plan without regard to whether the plan is offered through the 389
exchange and without regard to whether the plan is offered 390
directly from the carrier or through an insurance producer. 391
d. Does not charge any cancellation fees or penalties in 392
violation of paragraph (5)(c). 393
e. Complies with the regulations developed by the 394
Secretary under s. 1311(d) of PPACA and such other requirements 395
as the exchange may establish. 396
6. The plan meets the requirements of certification as 397
adopted by regulation pursuant to subsection (9) and by the 398
Secretary under s. 1311(c) of PPACA, which include, but are not 399
limited to, minimum standards in the areas of marketing 400

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practices, network adequacy, essential community providers in 401
underserved areas, accreditation, quality improvement, uniform 402
enrollment forms and descriptions of coverage, and information 403
on quality measures for health benefit plan performance. 404
7. The exchange determines that making the plan available 405
through the exchange is in the interest of qualified persons and 406
qualified employers in this state. 407
(b) The exchange may not exclude a health benefit plan: 408
1. On the basis that the plan is a fee-for-service plan; 409
2. Through the imposition of premium price controls by the 410
exchange; or 411
3. On the basis that the health benefit plan provides 412
treatments necessary to prevent patients' deaths in 413
circumstances the exchange determines are inappropriate or too 414
costly. 415
(c) The exchange must require each health carrier seeking 416
certification of a plan as a qualified health plan to do all of 417
the following: 418
1. Submit a justification for any premium increase before 419
implementation of that increase. The carrier must prominently 420
post the information on its Internet website. The exchange must 421
take this information, along with the information and the 422
recommendations provided to the exchange by the commissioner 423
under s. 2794(b) of the Public Health Service Act, into 424
consideration when determining whether to allow the carrier to 425

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make plans available through the exchange. 426
2.a. Make available to the public, in plain language as 427
provided in subparagraph b., and submit to the exchange, the 428
Secretary, and the commissioner, accurate and timely disclosure 429
of the following: 430
(I) Claims payment policies and practices. 431
(II) Periodic financial disclosures. 432
(III) Data on enrollment. 433
(IV) Data on disenrollment. 434
(V) Data on the number of claims that are denied. 435
(VI) Data on rating practices. 436
(VII) Information on cost sharing and payments with 437
respect to any out-of-network coverage. 438
(VIII) Information on enrollee and participant rights 439
under Title I of PPACA. 440
(IX) Other information as determined appropriate by the 441
Secretary. 442
b. The information required in subparagraph a. must be 443
provided in plain language, as that term is defined in s. 444
1311(e)(3)(B) of PPACA. 445
3. Allow a person to learn, in a timely manner upon the 446
request of the person, the amount of cost sharing, including 447
deductibles, copayments, and coinsurance, under the person's 448
plan or coverage which the person would be responsible for 449
paying with respect to the furnishing of a specific item or 450

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service by a participating provider. At a minimum, this 451
information must be made available to the person through an 452
Internet website and through other means for persons without 453
access to the Internet. 454
(d) The exchange may not exempt any health carrier seeking 455
certification of a qualified health plan, regardless of the type 456
or size of the carrier, from state licensure or solvency 457
requirements and must apply the criteria of this section in a 458
manner that is equitable between or among health carriers 459
participating in the exchange. 460
(e)1. The provisions of this section that are applicable 461
to qualified health plans also apply to the extent relevant to 462
qualified dental plans, except as modified in accordance with 463
subparagraphs 2., 3., and 4. or by regulations adopted by the 464
exchange. 465
2. The carrier must be licensed to offer dental coverage 466
but need not be licensed to offer other health benefits. 467
3. The plan must be limited to dental and oral health 468
benefits, without substantially duplicating the benefits 469
typically offered by health benefit plans without dental 470
coverage, and must include, at a minimum, the essential 471
pediatric dental benefits prescribed by the Secretary pursuant 472
to s. 1302(b)(1)(J) of PPACA and such other dental benefits as 473
the exchange or the Secretary may specify by regulation. 474
4. Carriers may jointly offer a comprehensive plan through 475

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the exchange in which the dental benefits are provided by a 476
carrier through a qualified dental plan and the other benefits 477
are provided by a carrier through a qualified health plan, 478
provided that the plans are priced separately and are also made 479
available for purchase separately at the same price. 480
(8) VENDOR TO BUILD AND MANAGE EXCHANGE.—The commissioner 481
and the office shall contract with a vendor selected by a 482
competitive procurement to build and manage the exchange. 483
(9) RULEMAKING AUTHORITY.—The office may adopt rules and 484
regulations to implement this section. Rules and regulations 485
adopted under this section may not conflict with or prevent the 486
application of regulations adopted by the Secretary under PPACA. 487
(10) RELATION TO OTHER LAWS.—This section, and any action 488
taken by the exchange pursuant to this section, may not be 489
construed to preempt or supersede the authority of the 490
commission to regulate the business of insurance in this state. 491
Except as expressly provided to the contrary in this section, 492
all health carriers offering qualified health plans in this 493
state shall comply fully with all applicable health insurance 494
laws of this state and rules and regulations adopted and orders 495
issued by the commission. 496
Section 2. This act shall take effect July 1, 2026, but 497
only if HB 1533 or similar legislation is adopted in the same 498
legislative session or an extension thereof and becomes a law. 499