Senate Bill 0228c1
CODING: Words stricken are deletions; words underlined are additions.
Florida Senate - 1998 CS for SB 228
By the Committee on Health Care and Senators Gutman,
Holzendorf, Kurth, Myers, Forman, Cowin, Grant, Bronson,
Latvala, Kirkpatrick, Sullivan, Horne, Casas, Brown-Waite,
Lee, Dudley, Klein, Harris, Jones, Geller, Laurent, Turner,
Campbell, Crist, Dyer and Meadows
317-1667A-98
1 A bill to be entitled
2 An act relating to cleft-lip and cleft-palate
3 treatment; creating s. 627.64193, F.S.;
4 requiring certain health insurance policies to
5 provide coverage for cleft-lip and cleft-palate
6 treatment for children; amending s. 627.6515,
7 F.S.; applying certain requirements for group
8 coverage to out-of-state groups; creating s.
9 627.66911, F.S.; requiring certain health
10 insurance policies to provide coverage for
11 cleft-lip and cleft-palate treatment for
12 children; amending s. 627.6699, F.S.; applying
13 certain requirements for group coverage to
14 coverage for small employers; amending s.
15 641.31, F.S.; providing for cleft-lip and
16 cleft-palate treatment for children by health
17 maintenance organizations; providing a
18 legislative determination of an important state
19 interest; providing applicability; providing an
20 effective date.
21
22 Be It Enacted by the Legislature of the State of Florida:
23
24 Section 1. Section 627.64193, Florida Statutes, is
25 created to read:
26 627.64193 Required coverage for cleft lip and cleft
27 palate.--A health insurance policy that covers a child under
28 the age of 18 must provide coverage for treatment of cleft lip
29 and cleft palate for the child. The coverage must include
30 medical, dental, speech therapy, audiology, and nutrition
31 services only if such services are prescribed by the treating
1
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Florida Senate - 1998 CS for SB 228
317-1667A-98
1 physician or surgeon and such physician or surgeon certifies
2 that such services are medically necessary and consequent to
3 treatment of the cleft lip or cleft palate. The coverage
4 required by this section is subject to terms and conditions
5 applicable to other benefits. This section does not apply to
6 specified-accident, specified-disease, hospital indemnity,
7 limited benefit disability income, or long-term-care insurance
8 policies.
9 Section 2. Paragraph (c) of subsection (2) of section
10 627.6515, Florida Statutes, is amended to read:
11 627.6515 Out-of-state groups.--
12 (2) This part does not apply to a group health
13 insurance policy issued or delivered outside this state under
14 which a resident of this state is provided coverage if:
15 (c) The policy provides the benefits specified in ss.
16 627.419, 627.6574, 627.6575, 627.6579, 627.6612, 627.66121,
17 627.66122, 627.6613, 627.667, 627.6675, and 627.6691, and
18 627.66911.
19 Section 3. Section 627.66911, Florida Statutes, is
20 created to read:
21 627.66911 Required coverage for cleft lip and cleft
22 palate.--A health insurance policy that covers a child under
23 the age of 18 must provide coverage for treatment of cleft lip
24 and cleft palate for the child. The coverage must include
25 medical, dental, speech therapy, audiology, and nutrition
26 services only if such services are prescribed by the treating
27 physician or surgeon and such physician or surgeon certifies
28 that such services are medically necessary and consequent to
29 treatment of the cleft lip or cleft palate. The coverage
30 required by this section is subject to terms and conditions
31 applicable to other benefits. This section does not apply to
2
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Florida Senate - 1998 CS for SB 228
317-1667A-98
1 specified-accident, specified-disease, hospital indemnity,
2 limited benefit disability income, or long-term-care insurance
3 policies.
4 Section 4. Paragraph (b) of subsection (12) of section
5 627.6699, Florida Statutes, is amended to read:
6 627.6699 Employee Health Care Access Act.--
7 (12) STANDARD, BASIC, AND LIMITED HEALTH BENEFIT
8 PLANS.--
9 (b)1. Each small employer carrier issuing new health
10 benefit plans shall offer to any small employer, upon request,
11 a standard health benefit plan and a basic health benefit plan
12 that meets the criteria set forth in this section.
13 2. For purposes of this subsection, the terms
14 "standard health benefit plan" and "basic health benefit plan"
15 mean policies or contracts that a small employer carrier
16 offers to eligible small employers that contain:
17 a. An exclusion for services that are not medically
18 necessary or that are not covered preventive health services;
19 and
20 b. A procedure for preauthorization by the small
21 employer carrier, or its designees.
22 3. A small employer carrier may include the following
23 managed care provisions in the policy or contract to control
24 costs:
25 a. A preferred provider arrangement or exclusive
26 provider organization or any combination thereof, in which a
27 small employer carrier enters into a written agreement with
28 the provider to provide services at specified levels of
29 reimbursement or to provide reimbursement to specified
30 providers. Any such written agreement between a provider and a
31 small employer carrier must contain a provision under which
3
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Florida Senate - 1998 CS for SB 228
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1 the parties agree that the insured individual or covered
2 member has no obligation to make payment for any medical
3 service rendered by the provider which is determined not to be
4 medically necessary. A carrier may use preferred provider
5 arrangements or exclusive provider arrangements to the same
6 extent as allowed in group products that are not issued to
7 small employers.
8 b. A procedure for utilization review by the small
9 employer carrier or its designees.
10
11 This subparagraph does not prohibit a small employer carrier
12 from including in its policy or contract additional managed
13 care and cost containment provisions, subject to the approval
14 of the department, which have potential for controlling costs
15 in a manner that does not result in inequitable treatment of
16 insureds or subscribers. The carrier may use such provisions
17 to the same extent as authorized for group products that are
18 not issued to small employers.
19 4. The standard health benefit plan shall include:
20 a. Coverage for inpatient hospitalization;
21 b. Coverage for outpatient services;
22 c. Coverage for newborn children pursuant to s.
23 627.6575;
24 d. Coverage for child care supervision services
25 pursuant to s. 627.6579;
26 e. Coverage for adopted children upon placement in the
27 residence pursuant to s. 627.6578;
28 f. Coverage for mammograms pursuant to s. 627.6613;
29 g. Coverage for handicapped children pursuant to s.
30 627.6615;
31
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1 h. Emergency or urgent care out of the geographic
2 service area; and
3 i. Coverage for services provided by a hospice
4 licensed under s. 400.602 in cases where such coverage would
5 be the most appropriate and the most cost-effective method for
6 treating a covered illness.
7 5. The standard health benefit plan and the basic
8 health benefit plan may include a schedule of benefit
9 limitations for specified services and procedures. If the
10 committee develops such a schedule of benefits limitation for
11 the standard health benefit plan or the basic health benefit
12 plan, a small employer carrier offering the plan must offer
13 the employer an option for increasing the benefit schedule
14 amounts by 4 percent annually.
15 6. The basic health benefit plan shall include all of
16 the benefits specified in subparagraph 4.; however, the basic
17 health benefit plan shall place additional restrictions on the
18 benefits and utilization and may also impose additional cost
19 containment measures.
20 7. Sections 627.419(2), (3), and (4), 627.6574,
21 627.6612, 627.66121, 627.66122, 627.6616, 627.6618, and
22 627.668, and 627.66911 apply to the standard health benefit
23 plan and to the basic health benefit plan. However,
24 notwithstanding said provisions, the plans may specify limits
25 on the number of authorized treatments, if such limits are
26 reasonable and do not discriminate against any type of
27 provider.
28 8. Each small employer carrier that provides for
29 inpatient and outpatient services by allopathic hospitals may
30 provide as an option of the insured similar inpatient and
31 outpatient services by hospitals accredited by the American
5
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Florida Senate - 1998 CS for SB 228
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1 Osteopathic Association when such services are available and
2 the osteopathic hospital agrees to provide the service.
3 Section 5. Subsection (34) is added to section 641.31,
4 Florida Statutes, to read:
5 641.31 Health maintenance contracts.--
6 (34) A health maintenance contract that covers a child
7 under the age of 18 must provide coverage for treatment of
8 cleft lip and cleft palate for the child. The coverage must
9 include medical, dental, speech therapy, audiology, and
10 nutrition services only if such services are prescribed by the
11 primary care physician or physician to whom the child is
12 referred and such physician certifies that such services are
13 medically necessary and consequent to treatment of the cleft
14 lip or cleft palate. The coverage required by this section is
15 subject to terms and conditions applicable to other benefits.
16 Section 6. Pursuant to Section 18, Article VII of the
17 State Constitution, the Legislature determines that this act
18 fulfills an important state interest.
19 Section 7. This act shall take effect October 1, 1998,
20 and shall apply to policies and contracts issued or renewed on
21 or after that date.
22
23 STATEMENT OF SUBSTANTIAL CHANGES CONTAINED IN
COMMITTEE SUBSTITUTE FOR
24 Senate Bill 228
25
26 Deletes guarantee issue requirement for insurer and HMO
coverage of cranio-facial anomalies and mandates insurer and
27 HMO coverage of medical, dental, speech therapy, audiology,
and nutrition services for treatment of children under age 18
28 with cleft lip and cleft palate, if certain conditions are
met.
29
Amends ss. 627.6515, 627.6699, 641.31, F.S., and creates ss.
30 627.64193 and 627.66911, F.S., to clearly state applicability
of coverage requirements.
31
6