Fla. Admin. Code R. 69O-149.037
(c) 1. To avoid over insurance and to provide for coordination of benefits pursuant to Section 627.4235, F.S., a plan may include a provision to exclude claims for health benefits covered under the plan and paid by workers’ compensation insurance coverage of the employer.
2. To reflect the benefit differences provided by the plan, a carrier may file for approval a rating factor reflecting the additional benefits being provided by the health plan if the small employer does not have workers’ compensation insurance.
(4) Rate filing requirements:
(a) Modified Community Rating. Premium schedules for benefit plans offered to small employer groups shall be based solely on the following categories and factors applicable to eligible employees, without regard to the nature of the employer group.
(VIII) 65 & above years of age – Health Plan is Primary
b. Age Categories Effective On or After October 1, 2006.
(XI) 65 & above years of age – Health Plan is Primary
c. The rate for the age 65 & above – Medicare is Primary category shall be applicable when both employee and spouse are enrolled in Medicare. If one is enrolled and one is not, regardless of which spouse is the employee, the rate charged shall be adjusted to reflect the reduction of exposure due to the fact that one spouse is enrolled in Medicare. The rate shall be determined assuming that one individual is enrolled in Medicare. The rate for the individual enrolled in Medicare will be isolated, multiplied by the Medicare is Primary to the Health Plan is Primary ratio, and then added back to the portion of the rate that is not Medicare primary. Samples of illustrative calculations are as follows and other combinations should be calculated in a similar manner:
(II) For family coverage – The difference between the family rate and the employee + dependent rate shall be determined. This difference shall reflect the implied spouse rate. This implied spouse rate shall be multiplied by the ratio of the Medicare is Primary rate divided by the Health Plan is Primary rate. This resulting rate shall be added to the employee + dependent only rate.
2. Gender/Family Composition Factors.
a. Gender/Family Composition Categories.
(VI) Employee – Spouse – Dependent Children
b. For both the employee with spouse plus dependent children category and the employee with dependent children category, companies may include up to three optional dependent children categories.
c. At the option of the company, dependent only categories.
3. Area Factors by County.
4. Tobacco Usage Factor (>1, base rates are for non-tobacco user).
5. Effective Date and Trend Adjustment Factor. The premium schedule may be adjusted based on a medical trend table, approved pursuant to Part I of this rule chapter, reflecting the period of time from the date the rate schedule is effective to the anniversary date of the new or renewing group for medical trend adjustment.
1. Age Factors. Employee age shall be determined as of the date of issue and each subsequent renewal date thereafter as defined in the policy and certificate. If not explicitly defined in the contract, age shall be the attained age as of the date of issue or renewal of the certificate.
a. Age Categories Effective Prior to October 1, 2006.
(6) (a)1.a. A small employer carrier may make up to a 15 percent adjustment in rates from the modified community rate schedule for claims experience, health status, or duration of coverage for a particular employer group from that otherwise determined from the tabular rate schedule determined above pursuant to Section 627.6699(6)(b)5., F.S.
b. A small employer carrier may make an adjustment to a small employer’s renewal premium, not to exceed 10 percent annually due to claims experience, health status, or duration of coverage subject to a maximum 15 percent differential from the modified community rate pursuant to Section 627.6699(6)(b)5., F.S.
2. The objective criteria and standards for application of this rate adjustment shall be applicable to and used for all small employer groups on a non-discriminatory basis.
3. Such criteria and standards shall be filed for approval pursuant to part I of this rule chapter.
4. A small employer carrier may require completion of an application including health questions, but shall not decline to offer coverage if the employer is unwilling or unable to provide prior claims experience.
5. Such adjustment shall be uniformly applied to the entire premium schedule.
(8) Calculation of COBRA Rates. The premium paid for continuation of coverage may not exceed 115 percent of the group rate for groups that consist of fewer than 20 employees as permitted by Section 627.6692(5)(f), F.S., and 102 percent for groups with 20 or more employees as provided by Employee Retirement Income Security Act of 1974 (ERISA), 29 U.S.C.A. §1162 (2005). The additional rate indicated above, i.e., 15 percent and 2 percent shall be hereinafter referred to as the applicable load.
(a) Qualified beneficiaries, as defined in Section 627.6692(4)(f), F.S., electing continuation of coverage shall be charged the group rate applicable to the qualified beneficiary on the day before the qualifying event, as increased by the applicable load. Whenever the small employer group’s rates change, generally on the group’s anniversary, the rate subsequently charged to the qualified beneficiary for the continuation of coverage will be based on the small employer group’s rate which the qualified beneficiary would have been charged if the qualified beneficiary had remained within the group. If the qualified beneficiary electing continuation of coverage is a spouse or dependent of the covered employee, and the covered employee remains in the group, the rate charged to the covered employee shall be adjusted to reflect the reduction of risk exposure to the company, e.g., the group’s rate applicable after the demographic change. The rate charged for the spouse or dependent shall be isolated from the group’s rate and multiplied by a factor, not to exceed one plus the applicable load, to determine the COBRA rate. Samples of illustrative calculations are as follows and other combinations should be calculated in a similar manner:
1. For employee + dependent coverage when the dependent is electing continuation of coverage, the difference between the employee + dependent rate and the employee only rate shall be determined. This difference shall then be divided by the average number of dependents used by the carrier in developing the rate schedule. This value shall reflect the implied single dependent rate. To determine the COBRA rate, the implied dependent rate shall be multiplied by a factor that does not exceed one plus the applicable load. The employee shall be charged the group employee only rate.
2. For family coverage where the dependent is electing continuation of coverage, the difference between the family rate and the employee + spouse only rate shall be determined. This difference shall then be divided by the average number of dependents used by the carrier in developing the rate schedule. This value shall reflect the implied single dependent rate. To determine the COBRA rate, the implied single dependent rate shall be multiplied by a factor that does not exceed one plus the applicable load. The employee shall be charged the group rate applicable to the remaining covered lives in the group, e.g., if the remaining covered lives are the employee, spouse and another dependent, then the family rate would be charged. If the remaining covered lives are only the employee and spouse, then the employee + spouse rate would be charged.
3. If a small employer carrier uses optional dependent children categories as provided by sub-subparagraph (4)(a)2.b., above, the dependent rate shall be directly determined by calculating the difference between the two family tier rates, e.g., a rate with two dependents minus the rate with one dependent shall determine the single dependent rate.
Rulemaking Authority 624.308(1), 624.424(1)(c), 627.6699(17) FS. Law Implemented 627.410, 627.6692, 627.6699(3), (6), (12)(e), (13), (13)(i) FS. History–New 3-1-93, Amended 11-7-93, 5-11-94, 4-23-95, 8-4-02, 6-19-03, Formerly 4-149.037, Amended 7-6-06, 5-24-07.