Florida Senate - 2017 SB 1612
By Senator Garcia
36-00646-17 20171612__
1 A bill to be entitled
2 An act relating to health care consumer protection;
3 amending s. 395.301, F.S.; revising the requirements
4 for a good faith itemized estimate provided to a
5 patient or prospective patient by a licensed facility
6 for nonemergency medical services; providing that a
7 facility and its contracted health care providers may
8 bill a patient for certain medical services only if
9 the patient consents in writing; providing a penalty
10 for violations; amending s. 456.0575, F.S.; requiring
11 written patient consent for certain health care
12 practitioners to bill a patient for services listed on
13 the itemized estimate which are not covered by the
14 patient’s health insurance; providing a penalty for
15 violations; amending s. 627.6385, F.S.; requiring
16 health insurers to provide certain information
17 available on their websites or by request, rather than
18 only on their websites; requiring a health insurer to
19 provide a certain response to the policyholder and
20 facility within a specified time after receiving an
21 itemized estimate; providing construction and
22 applicability; amending s. 627.64194, F.S.; providing
23 that an insurer is solely liable for payment of
24 certain fees for certain requested services under
25 certain circumstances; providing applicability;
26 conforming cross-references; amending s. 641.54, F.S.;
27 requiring a health maintenance organization to provide
28 a certain response to the subscriber and facility
29 within a specified time after receiving an itemized
30 estimate; providing applicability; providing an
31 effective date.
32
33 Be It Enacted by the Legislature of the State of Florida:
34
35 Section 1. Paragraph (b) of subsection (1) of section
36 395.301, Florida Statutes, is amended, present subsections (2)
37 through (6) of that section are redesignated as subsections (3)
38 through (7), respectively, and a new subsection (2) is added to
39 that section, to read:
40 395.301 Price transparency; itemized patient statement or
41 bill; patient admission status notification.—
42 (1) A facility licensed under this chapter shall provide
43 timely and accurate financial information and quality of service
44 measures to patients and prospective patients of the facility,
45 or to patients’ survivors or legal guardians, as appropriate.
46 Such information shall be provided in accordance with this
47 section and rules adopted by the agency pursuant to this chapter
48 and s. 408.05. Licensed facilities operating exclusively as
49 state facilities are exempt from this subsection.
50 (b)1. Upon request or preregistration, and before providing
51 any nonemergency medical services, each licensed facility shall
52 provide in writing or by electronic means an itemized a good
53 faith estimate of reasonably anticipated charges by the facility
54 for the treatment of the patient’s or prospective patient’s
55 specific condition, including services provided for such
56 treatment in the facility by other health care providers under
57 contract with the hospital who may bill the patient separately.
58 The facility must provide the estimate to the patient or
59 prospective patient and the patient’s health insurer within 7
60 business days after the receipt of the request and is not
61 required to adjust the estimate for any potential insurance
62 coverage. The estimate may be based on the descriptive service
63 bundles developed by the agency under s. 408.05(3)(c) unless the
64 patient or prospective patient requests a more personalized and
65 specific estimate that accounts for the specific condition and
66 characteristics of the patient or prospective patient. The
67 facility shall inform the patient or prospective patient that he
68 or she may contact his or her health insurer or health
69 maintenance organization for additional information concerning
70 cost-sharing responsibilities.
71 2. In the estimate, the facility shall provide to the
72 patient or prospective patient information on the facility’s
73 financial assistance policy, including the application process,
74 payment plans, and discounts and the facility’s charity care
75 policy and collection procedures.
76 3. The estimate shall clearly identify any facility fees
77 and, if applicable, include a statement notifying the patient or
78 prospective patient that a facility fee is included in the
79 estimate, the purpose of the fee, and that the patient may pay
80 less for the procedure or service at another facility or in
81 another health care setting.
82 4. Upon request, The facility shall notify the patient or
83 prospective patient of any revision to the estimate.
84 5. In the estimate, the facility must notify the patient or
85 prospective patient that services may be provided in the health
86 care facility by the facility as well as by other health care
87 providers that may separately bill the patient, if applicable.
88 6. The facility shall take action to educate the public
89 that such estimates are available upon request.
90 7. Failure to timely provide the estimate pursuant to this
91 paragraph shall result in a daily fine of $1,000 until the
92 estimate is provided to the patient or prospective patient. The
93 total fine may not exceed $10,000.
94
95 The provision of an estimate does not preclude the actual
96 charges from exceeding the estimate.
97 (2) The facility and health care providers under contract
98 with the facility may bill the patient for a medical service
99 that is on the itemized estimate and that is not covered by the
100 patient’s health insurance only if the patient has provided
101 specific written consent for the service. A violation of this
102 subsection is punishable by a fine of $1,000 per occurrence.
103 Section 2. Subsection (2) of section 456.0575, Florida
104 Statutes, is amended to read:
105 456.0575 Duty to notify patients.—
106 (2) Upon request by a patient, before providing
107 nonemergency medical services in a facility licensed under
108 chapter 395, a health care practitioner shall provide, in
109 writing or by electronic means, a good faith estimate of
110 reasonably anticipated charges to treat the patient’s condition
111 at the facility. The health care practitioner shall provide the
112 estimate to the patient within 7 business days after receiving
113 the request and is not required to adjust the estimate for any
114 potential insurance coverage. The health care practitioner shall
115 inform the patient that the patient may contact his or her
116 health insurer or health maintenance organization for additional
117 information concerning cost-sharing responsibilities. The health
118 care practitioner shall provide information to uninsured
119 patients and insured patients for whom the practitioner is not a
120 network provider or preferred provider, which discloses the
121 practitioner’s financial assistance policy, including the
122 application process, payment plans, discounts, or other
123 available assistance, and the practitioner’s charity care policy
124 and collection procedures. Such estimate does not preclude the
125 actual charges from exceeding the estimate. Written patient
126 consent is required for a health care practitioner under
127 contract with a facility licensed under chapter 395 to bill the
128 patient for services on the itemized estimate under s. 395.301
129 which are not covered by the patient’s health insurance. The
130 billing of noncovered services without the patient’s consent
131 that is required in this subsection, or failure to provide the
132 estimate in accordance with this subsection, without good cause,
133 shall result in disciplinary action against the health care
134 practitioner and a fine of $500 per bill, or a daily fine of
135 $500 until the estimate is provided to the patient. The total
136 fine may not exceed $5,000.
137 Section 3. Subsection (1) of section 627.6385, Florida
138 Statutes, is amended, and subsection (4) is added to that
139 section, to read:
140 627.6385 Disclosures to policyholders; calculations of cost
141 sharing.—
142 (1) Each health insurer shall make available on its website
143 or by request:
144 (a) A method for policyholders to estimate their
145 copayments, deductibles, and other cost-sharing responsibilities
146 for health care services and procedures. Such method of making
147 an estimate shall be based on service bundles established
148 pursuant to s. 408.05(3)(c). Estimates do not preclude the
149 actual copayment, coinsurance percentage, or deductible,
150 whichever is applicable, from exceeding the estimate.
151 1. Estimates shall be calculated according to the policy
152 and known plan usage during the coverage period.
153 2. Estimates shall be made available based on providers
154 that are in-network and out-of-network.
155 3. A policyholder must be able to create estimates by any
156 combination of the service bundles established pursuant to s.
157 408.05(3)(c), a specified provider, or a comparison of
158 providers.
159 (b) A method for policyholders to estimate their
160 copayments, deductibles, and other cost-sharing responsibilities
161 based on a personalized estimate of charges received from a
162 facility pursuant to s. 395.301 or a practitioner pursuant to s.
163 456.0575.
164 (c) A hyperlink to the health information, including, but
165 not limited to, service bundles and quality of care information,
166 which is disseminated by the Agency for Health Care
167 Administration pursuant to s. 408.05(3).
168 (4) Upon receipt of an itemized estimate from a facility
169 pursuant to s. 395.301, the health insurer must provide a
170 response indicating the coverage status of each item to the
171 policyholder and the facility within 3 business days. Failure to
172 respond to the policyholder and the facility within such time
173 constitutes a waiver of the health insurer’s right to contest or
174 counter the facility’s itemized estimate. This subsection does
175 not apply to Medicaid health plans.
176 Section 4. Present subsections (4) through (6) of section
177 627.64194, Florida Statutes, are redesignated as subsections (5)
178 through (7), respectively, a new subsection (4) is added to that
179 section, and present subsections (5) and (6) are amended, to
180 read:
181 627.64194 Coverage requirements for services provided by
182 nonparticipating providers; payment collection limitations.—
183 (4) If an insurer denies, reduces, or terminates coverage
184 for an admission, availability of care, a continued stay, or a
185 health care service after determining that such requested
186 service, based upon the information provided, does not meet the
187 insurer’s requirements for medical necessity, appropriateness,
188 health care setting, level of care, or effectiveness, the
189 insurer is solely liable for any potential payment of fees and
190 the insured is not liable for payment of fees other than
191 applicable copayments, coinsurance, and deductibles to a
192 participating or nonparticipating provider if:
193 (a) The insurer’s determination conflicts with a
194 participating or nonparticipating provider’s determination that
195 the requirements for medical necessity, appropriateness, health
196 care setting, level of care, or effectiveness are met; and
197 (b) The insured did not receive both the itemized estimate
198 from a facility under s. 395.301 and the indication of the
199 coverage status of the item under s. 627.6385(4) or s.
200 641.54(6).
201
202 The provisions of s. 627.638 apply to this subsection. This
203 subsection does not apply to Medicaid health plans.
204 (6)(5) A nonparticipating provider of emergency services as
205 provided in subsection (2) or a nonparticipating provider of
206 nonemergency services as provided in subsection (3) may not be
207 reimbursed an amount greater than the amount provided in
208 subsection (5) (4) and may not collect or attempt to collect
209 from the insured, directly or indirectly, any excess amount,
210 other than copayments, coinsurance, and deductibles. This
211 section does not prohibit a nonparticipating provider from
212 collecting or attempting to collect from the insured an amount
213 due for the provision of noncovered services.
214 (7)(6) Any dispute with regard to the reimbursement to the
215 nonparticipating provider of emergency or nonemergency services
216 as provided in subsection (5) (4) shall be resolved in a court
217 of competent jurisdiction or through the voluntary dispute
218 resolution process in s. 408.7057.
219 Section 5. Subsection (6) of section 641.54, Florida
220 Statutes, is amended to read:
221 641.54 Information disclosure.—
222 (6) Each health maintenance organization shall make
223 available to its subscribers on its website or by request the
224 estimated copayment, coinsurance percentage, or deductible,
225 whichever is applicable, for any covered services as described
226 by the searchable bundles established on a consumer-friendly,
227 Internet-based platform pursuant to s. 408.05(3)(c) or as
228 described by a personalized estimate received from a facility
229 pursuant to s. 395.301 or a practitioner pursuant to s.
230 456.0575, the status of the subscriber’s maximum annual out-of
231 pocket payments for a covered individual or family, and the
232 status of the subscriber’s maximum lifetime benefit. Such
233 estimate does not preclude the actual copayment, coinsurance
234 percentage, or deductible, whichever is applicable, from
235 exceeding the estimate. Upon receipt of an itemized estimate
236 from a facility pursuant to s. 395.301, the health maintenance
237 organization must provide a response indicating the coverage
238 status of each item to the subscriber and the facility within 3
239 business days. This subsection does not apply to Medicaid health
240 plans.
241 Section 6. This act shall take effect July 1, 2017.