HB 5

1	A bill to be entitled
2	An act relating to health insurance; creating s.
3	627.64195, F.S.; requiring individual accident or health
4	insurance policies to provide certain coverage for
5	orthoses and prostheses and orthotics and prosthetics;
6	providing requirements and limitations; specifying
7	deductible and copayment requirements; authorizing
8	insurers to specify certain benefits limitations;
9	providing for nonapplication to certain policy coverages;
10	creating s. 627.66915, F.S.; requiring group, blanket, or
11	franchise accident or health insurance policies to provide
12	coverage for orthoses and prostheses and orthotics and
13	prosthetics; providing requirements and limitations;
14	specifying deductible and copayment requirements;
15	authorizing insurers to specify certain benefits
16	limitations; providing for nonapplication to certain
17	policy coverages; amending s. 641.31, F.S.; requiring
18	health maintenance contracts to provide coverage for
19	orthoses and prostheses and orthotics and prosthetics;
20	providing requirements and limitations; specifying
21	deductible and copayment requirements; authorizing health
22	maintenance organizations to specify certain benefits
23	limitations; providing for nonapplication to certain
24	contract coverages; providing an effective date.
25
26	Be It Enacted by the Legislature of the State of Florida:
27
28	Section 1.  Section 627.64195, Florida Statutes, is created
29	to read:
30	627.64195  Coverage for orthoses and prostheses and
31	orthotics and prosthetics.-
32	(1)(a)  Each accident or health insurance policy issued,
33	amended, delivered, or renewed in this state on or after January
34	1, 2012, that provides medical coverage that includes coverage
35	for physician services in a physician's office and each accident
36	or health insurance policy that provides major medical or
37	similar comprehensive type coverage must provide coverage for
38	benefits for orthoses and prostheses as defined in s. 468.80 and
39	orthotics and prosthetics as defined in s. 468.80 that equal
40	those benefits provided for under federal laws for health
41	insurance for the aged and disabled pursuant to 42 U.S.C. ss.
42	1395k, 1395l, and 1395m and 42 C.F.R. ss. 414.202, 414.210,
43	414.228, and 410.100 as applicable to this section.
44	(b)1.  The coverage is subject to the deductible and
45	coinsurance provisions applicable to outpatient visits and is
46	also subject to all other terms and conditions applicable to
47	other benefits.
48	2.  Every insurer subject to the requirements of this
49	section shall make available to the policyholder as part of the
50	application, for an appropriate additional premium, the coverage
51	required in this section without such coverage being subject to
52	the deductible or coinsurance provisions of the policy.
53	(2)  An accident or health insurance policy may require
54	prior authorization for orthoses and prostheses and orthotics
55	and prosthetics in the same manner that prior authorization is
56	required for any other covered benefit.
57	(3)(a)  Covered benefits for orthoses or prostheses shall
58	be limited to the most appropriate model that adequately meets
59	the medical needs of the patient as determined by the insured's
60	treating physician.
61	(b)  The repair and replacement of orthoses or prostheses
62	also shall be covered subject to copayments and deductibles,
63	unless necessitated by misuse or loss.
64	(4)  An insurer may require, if coverage is provided
65	through a managed care plan, that benefits mandated pursuant to
66	this section be covered benefits only if the orthoses or
67	prostheses are provided by a vendor and orthotics or prosthetics
68	are rendered by an orthotist or prosthetist as defined in s.
69	468.80.
70	(5)  This section does not apply to insurance coverage
71	providing benefits for hospital confinement indemnity,
72	disability income, accident only, long-term care, Medicare
73	supplement, limited benefit health, specified disease indemnity,
74	sickness or bodily injury or death by accident or both, and
75	other limited benefit policies.
76	Section 2.  Section 627.66915, Florida Statutes, is created
77	to read:
78	627.66915  Coverage for orthoses and prostheses and
79	orthotics and prosthetics.-
80	(1)(a)  Each group, blanket, or franchise accident or
81	health insurance policy issued, amended, delivered, or renewed
82	in this state on or after January 1, 2012, that provides medical
83	coverage that includes coverage for physician services in a
84	physician's office and each such policy that provides major
85	medical or similar comprehensive type coverage must provide
86	coverage for benefits for orthoses and prostheses as defined in
87	s. 468.80 and orthotics and prosthetics as defined in s. 468.80
88	that equal those benefits provided for under federal laws for
89	health insurance for the aged and disabled pursuant to 42 U.S.C.
90	ss. 1395k, 1395l, and 1395m and 42 C.F.R. ss. 414.202, 414.210,
91	414.228, and 410.100 as applicable to this section.
92	(b)1.  The coverage is subject to the deductible and
93	coinsurance provisions applicable to outpatient visits and is
94	also subject to all other terms and conditions applicable to
95	other benefits.
96	2.  Every insurer subject to the requirements of this
97	section shall make available to the policyholder as part of the
98	application, for an appropriate additional premium, the coverage
99	required in this section without such coverage being subject to
100	the deductible or coinsurance provisions of the policy.
101	(2)  A group, blanket, or franchise accident or health
102	insurance policy may require prior authorization for orthoses
103	and prostheses and orthotics and prosthetics in the same manner
104	that prior authorization is required for any other covered
105	benefit.
106	(3)(a)  Covered benefits for orthoses or prostheses shall
107	be limited to the most appropriate model that adequately meets
108	the medical needs of the patient as determined by the insured's
109	treating physician.
110	(b)  The repair and replacement of orthoses or prostheses
111	also shall be covered subject to copayments and deductibles,
112	unless necessitated by misuse or loss.
113	(4)  An insurer may require, if coverage is provided
114	through a managed care plan, that benefits mandated pursuant to
115	this section be covered benefits only if the orthoses or
116	prostheses are provided by a vendor and orthotics or prosthetics
117	are rendered by an orthotist or prosthetist as defined in s.
118	468.80.
119	(5)  This section does not apply to insurance coverage
120	providing benefits for hospital confinement indemnity,
121	disability income, accident only, long-term care, Medicare
122	supplement, limited benefit health, specified disease indemnity,
123	sickness or bodily injury or death by accident or both, and
124	other limited benefit policies.
125	Section 3.  Subsection (44) is added to section 641.31,
126	Florida Statutes, to read:
127	641.31  Health maintenance contracts.-
128	(44)(a)  Each health maintenance contract issued, amended,
129	delivered, or renewed in this state on or after January 1, 2012,
130	that provides medical coverage that includes coverage for
131	physician services in a physician's office and each contract,
132	plan, or policy that provides major medical or similar
133	comprehensive type coverage must provide coverage for benefits
134	for orthoses and prostheses as defined in s. 468.80 and
135	orthotics and prosthetics as defined in s. 468.80 that equal
136	those benefits provided for under federal laws for health
137	insurance for the aged and disabled pursuant to 42 U.S.C. ss.
138	1395k, 1395l, and 1395m and 42 C.F.R. ss. 414.202, 414.210,
139	414.228, and 410.100 as applicable to this subsection.
140	(b)1.  The coverage is subject to the deductible and
141	coinsurance provisions applicable to outpatient visits and is
142	also subject to all other terms and conditions applicable to
143	other benefits.
144	2.  Every health maintenance organization subject to the
145	requirements of this subsection shall make available to the
146	subscriber as part of the application, for an appropriate
147	additional premium, the coverage required in this subsection
148	without such coverage being subject to the deductible or
149	coinsurance provisions of the contract.
150	(c)  A health maintenance contract may require prior
151	authorization for orthoses and prostheses and orthotics and
152	prosthetics in the same manner that prior authorization is
153	required for any other covered benefit.
154	(d)1.  Covered benefits for orthoses or prostheses shall be
155	limited to the most appropriate model that adequately meets the
156	medical needs of the patient as determined by the insured's
157	treating physician.
158	2.  The repair and replacement of orthoses or prostheses
159	also shall be covered subject to copayments and deductibles,
160	unless necessitated by misuse or loss.
161	(e)  A health maintenance contract may require that
162	benefits mandated pursuant to this subsection be covered
163	benefits only if the orthoses or prostheses are provided by a
164	vendor and orthotics or prosthetics are rendered by a orthotist
165	or prosthetist as defined in s. 468.80.
166	(f)  This subsection does not apply to insurance coverage
167	providing benefits for hospital confinement indemnity,
168	disability income, accident only, long-term care, Medicare
169	supplement, limited benefit health, specified disease indemnity,
170	sickness or bodily injury or death by accident or both, and
171	other limited benefit policies.
172	Section 4.  This act shall take effect July 1, 2011.

CODING: Words stricken are deletions; words underlined are additions.