CODING: Words stricken are deletions; words underlined are additions.House Bill 0453c1
Florida House of Representatives - 1997 CS/HBs 453, 573,
689 & 781
By the Committee on Health Care Services and
Representatives Mackey, Heyman, Murman, Frankel, Argenziano,
Wasserman Schultz, Peaden, Fasano, Culp, Brown, Sanderson,
Jacobs, Fischer, Dennis, Dawson-White, Diaz de la Portilla,
(Additional Sponsors on Last Printed Page)
1 A bill to be entitled
2 An act relating to mastectomies; amending ss.
3 627.6417, 627.651, 627.6515, 627.6612, and
4 627.6699, F.S.; requiring certain health
5 insurance policies to provide certain coverage
6 for hospital stays for mastectomies; requiring
7 such coverage to provide postsurgical care;
8 requiring coverage for reconstructive breast
9 surgery for certain purposes; amending s.
10 641.31, F.S.; requiring certain health
11 maintenance contracts to provide certain
12 coverage for hospital stays for mastectomies;
13 requiring such contracts to provide
14 postsurgical care; requiring coverage for
15 reconstructive surgery for certain purposes;
16 creating ss. 627.64175, 627.6614, and
17 641.30198, F.S.; providing requirements and
18 prohibitions for insurers and health
19 maintenance organizations relating to breast
20 cancer coverage; providing a description of
21 state interest; providing an effective date.
22
23 Be It Enacted by the Legislature of the State of Florida:
24
25 Section 1. Section 627.6417, Florida Statutes, is
26 amended to read:
27 627.6417 Optional Coverage for surgical procedures and
28 devices incident to mastectomy.--
29 (1) A health insurance policy that is issued, amended,
30 delivered, or renewed in this state that provides coverage on
31 an expense-incurred basis shall provide hospital, medical, or
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1 surgical coverage for mastectomies to the same extent that
2 such coverage is provided for illness or disease under the
3 policy, and may not limit inpatient hospital coverage for
4 mastectomies to any time period that is less than that
5 determined by the treating surgical, gynecological, or
6 oncological care provider to be medically necessary, in
7 accordance with prevailing medical standards and consistent
8 with the guidelines for surgical, gynecological, and
9 oncological care.
10 (2) Any health insurance policy that provides coverage
11 for mastectomies under subsection (1) must also provide
12 coverage for outpatient postsurgical mastectomy followup care.
13 Such care must be comparable to inpatient hospital
14 postsurgical care and must include assessment of the patient's
15 condition in keeping with prevailing medical standards by a
16 licensed health care professional qualified to provide
17 postsurgical mastectomy care, and may be provided at the
18 hospital, outpatient center, treating physician's office, or
19 in the patient's home. This subsection does not apply to a
20 hospital and surgical policy that primarily provides coverage
21 only for hospital inpatient expenses except that outpatient
22 postsurgical care must be covered to the same extent that the
23 policy would have covered inpatient postsurgical care.
24 (3)(1) Any An accident or health insurance policy
25 issued, amended, delivered, or renewed in this state that
26 provides coverage for mastectomies under subsection (1) must
27 also provide make available to the policyholder, as part of
28 the application, coverage for the initial prosthetic devices
29 device and reconstructive surgery incident to the mastectomy.
30 Breast reconstructive surgery means surgery to reestablish
31 symmetry between the two breasts and includes augmentation
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1 mammoplasty, reduction mammoplasty, and mastoplexy. Such
2 surgery shall be in a manner chosen by the treating physician,
3 consistent with prevailing medical standards, and in
4 consultation with the patient if the patient chooses such
5 surgery. The insurer may charge an appropriate additional
6 premium for the coverage required by this subsection. The
7 coverage for prosthetic devices and reconstructive surgery
8 shall be is subject to any the deductible and coinsurance
9 conditions applied to the mastectomy, and all other terms and
10 conditions applicable to the policy other benefits. If a
11 mastectomy is performed and there is no evidence of
12 malignancy, the coverage may be limited to the provision of
13 the initial prosthetic device and reconstructive surgery
14 within 2 years after the date of the mastectomy.
15 (4)(2) As used in this section, the term "mastectomy"
16 means the removal of all or part of the breast for medically
17 necessary reasons as determined by a licensed physician. The
18 term includes prophylactic mastectomies and lymph node
19 dissections that are determined to be medically necessary.
20 (5) An insurer subject to subsection (1) may not:
21 (a) Deny to an insured continued eligibility to renew
22 coverage under the terms of the policy for the purpose of
23 avoiding the requirements of this section;
24 (b) Provide monetary payments or rebates to an insured
25 patient to accept less than the minimum protections available
26 under this section;
27 (c) Penalize or otherwise reduce or limit the
28 reimbursement of an attending provider solely because the
29 attending provider provided care to an insured patient under
30 this section;
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1 (d) Provide incentives, monetary or otherwise, to an
2 attending provider solely to induce the provider to provide
3 care to an insured in a manner inconsistent with this section;
4 or
5 (e) Subject to the other provisions of this section,
6 restrict benefits for any portion of a period within a
7 hospital length of stay or outpatient care as required by this
8 section in a manner that is less than favorable than the
9 benefits provided for any preceding portion of such stay.
10 (6) This section does not affect any agreement between
11 an insurer and a hospital or other health care provider with
12 respect to reimbursement for health care services provided,
13 rate negotiations with providers, or capitation of providers,
14 and does not prohibit appropriate utilization review or case
15 management by the insurer.
16 (7)(3) This section does not apply to disability
17 income, specified disease other than cancer, or hospital
18 indemnity policies.
19 Section 2. Section 627.64175, Florida Statutes, is
20 created to read:
21 627.64175 Requirements with respect to breast
22 cancer.--
23 (1) An insurer may not refuse to provide coverage for
24 an applicant for health insurance due to breast cancer if the
25 applicant has remained free from breast cancer for at least 5
26 years prior to the applicant's request for health insurance
27 coverage.
28 (2) An insurer may not exclude coverage under a health
29 insurance policy for breast cancer if the applicant has
30 remained free from breast cancer for at least 2 years prior to
31 the applicant's request for health insurance coverage. The
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1 department shall report to the Legislature by October 1, 1999,
2 the cost in terms of premium increases and the number of
3 additional persons covered as a result of this section.
4 (3) Routine followup care to determine whether a
5 breast cancer has recurred in a person who has been previously
6 determined to be free of breast cancer shall not be considered
7 as medical advice, diagnosis, care, or treatment for purposes
8 of determining preexisting conditions unless evidence of
9 breast cancer is found during or as a result of followup care.
10 Section 3. Subsection (4) of section 627.651, Florida
11 Statutes, is amended to read:
12 627.651 Group contracts and plans of self-insurance
13 must meet group requirements.--
14 (4) This section does not apply to any plan which is
15 established or maintained by an individual employer in
16 accordance with the Employee Retirement Income Security Act of
17 1974, Pub. L. No. 93-406, or to a multiple-employer welfare
18 arrangement as defined in s. 624.437(1), except that a
19 multiple-employer welfare arrangement shall comply with ss.
20 627.419, 627.657, 627.6575, 627.6576, 627.6578, 627.6579,
21 627.6612, 627.6614, 627.6615, 627.6616, and 627.662(6). This
22 subsection does not allow an authorized insurer to issue a
23 group health insurance policy or certificate which does not
24 comply with this part.
25 Section 4. Paragraph (c) of subsection (2) of section
26 627.6515, Florida Statutes, 1996 Supplement, is amended to
27 read:
28 627.6515 Out-of-state groups.--
29 (2) This part does not apply to a group health
30 insurance policy issued or delivered outside this state under
31 which a resident of this state is provided coverage if:
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1 (c) The policy provides the benefits specified in ss.
2 627.419, 627.6417, 627.64175, 627.6574, 627.6575, 627.6579,
3 627.6613, 627.667, 627.6675, and 627.6691.
4 Section 5. Section 627.6612, Florida Statutes, is
5 amended to read:
6 627.6612 Optional Coverage for mastectomy and surgical
7 procedures and devices incident to mastectomy.--
8 (1) A group, blanket, or franchise health insurance
9 policy that is issued, amended, delivered, or renewed in this
10 state that provides coverage on an expense-incurred basis
11 shall provide hospital, medical, or surgical coverage for
12 mastectomies to the same extent that hospital, medical, or
13 surgical coverage is provided for illness or disease under the
14 policy, and may not limit inpatient hospital coverage for
15 mastectomies to any time period that is less than that
16 determined by the treating surgical, gynecological, or
17 oncological care provider to be medically necessary, in
18 accordance with prevailing medical standards and consistent
19 with the guidelines for surgical, gynecological, and
20 oncological care.
21 (2) Any group, blanket, or franchise health insurance
22 policy that provides coverage for mastectomies under
23 subsection (1) must also provide coverage for outpatient
24 postsurgical mastectomy followup care. Such care must be
25 comparable to inpatient hospital postsurgical care and must
26 include assessment of the patient's condition in keeping with
27 prevailing medical standards by a licensed health care
28 professional qualified to provide postsurgical mastectomy
29 care, and may be provided at the hospital, outpatient center,
30 treating physician's office, or in the patient's home.
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1 (3)(1) Any A group, blanket, or franchise accident or
2 health insurance policy issued, amended, delivered, or renewed
3 in this state that provides coverage for mastectomies under
4 subsection (1) must also provide make available to the
5 policyholder coverage for the initial prosthetic devices
6 device and reconstructive surgery incident to the mastectomy.
7 Breast reconstructive surgery means surgery to reestablish
8 symmetry between the two breasts and includes augmentation
9 mammoplasty, reduction mammoplasty, and mastoplexy. Such
10 surgery shall be in a manner chosen by the treating physician,
11 consistent with prevailing medical standards, and in
12 consultation with the patient if the patient chooses such
13 surgery. The insurer may charge an appropriate additional
14 premium for the coverage required by this subsection. The
15 coverage for prosthetic devices and reconstructive surgery
16 shall be is subject to any the deductible and coinsurance
17 conditions applied to the mastectomy, and all other terms and
18 conditions applicable to the policy other benefits. If a
19 mastectomy is performed and there is no evidence of
20 malignancy, the coverage may be limited to the provision of
21 the initial prosthetic device and reconstructive surgery to
22 within 2 years after the date of the mastectomy.
23 (4)(2) As used in this section, the term "mastectomy"
24 means the removal of all or part of the breast for medically
25 necessary reasons as determined by a licensed physician. The
26 term includes prophylactic mastectomies and lymph node
27 dissections that are determined to be medically necessary.
28 (5) An insurer subject to subsection (1) may not:
29 (a) Deny to an insured eligibility, or continued
30 eligibility, to enroll or to renew coverage under the terms of
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1 the policy for the purpose of avoiding the requirements of
2 this section;
3 (b) Provide monetary payments or rebates to an insured
4 patient to accept less than the minimum protections available
5 under this section;
6 (c) Penalize or otherwise reduce or limit the
7 reimbursement of an attending provider solely because the
8 attending provider provided care to an insured patient under
9 this section;
10 (d) Provide incentives, monetary or otherwise, to an
11 attending provider solely to induce the provider to provide
12 care to an insured in a manner inconsistent with this section;
13 or
14 (e) Subject to the other provisions of this section,
15 restrict benefits for any portion of a period within a
16 hospital length of stay or outpatient care as required by this
17 section in a manner that is less than favorable than the
18 benefits provided for any preceding portion of such stay.
19 (6) This section does not affect any agreement between
20 an insurer and a hospital or other health care provider with
21 respect to reimbursement for health care services provided,
22 rate negotiations with providers, or capitation of providers,
23 and does not prohibit appropriate utilization review or case
24 management by the insurer.
25 Section 6. Section 627.6614, Florida Statutes, is
26 created to read:
27 627.6614 Requirements with respect to breast
28 cancer.--Routine followup care to determine whether a breast
29 cancer has recurred in a person who has been previously
30 determined to be free of breast cancer shall not be considered
31 as medical advice, diagnosis, care, or treatment for purposes
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1 of determining preexisting conditions unless evidence of
2 breast cancer is found during or as a result of followup care.
3 Section 7. Paragraph (b) of subsection (12) of section
4 627.6699, Florida Statutes, 1996 Supplement, is amended to
5 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
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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;
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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, 627.6614, 627.6616, 627.6618, and 627.668 apply to
22 the standard health benefit plan and to the basic health
23 benefit plan. However, notwithstanding said provisions, the
24 plans may specify limits on the number of authorized
25 treatments, if such limits are reasonable and do not
26 discriminate against any type of provider.
27 8. Each small employer carrier that provides for
28 inpatient and outpatient services by allopathic hospitals may
29 provide as an option of the insured similar inpatient and
30 outpatient services by hospitals accredited by the American
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1 Osteopathic Association when such services are available and
2 the osteopathic hospital agrees to provide the service.
3 Section 8. Subsection (29) is added to section 641.31,
4 Florida Statutes, 1996 Supplement, to read:
5 641.31 Health maintenance contracts.--
6 (29)(a) As used in this subsection, the term
7 "mastectomy" means the removal of all or part of the breast
8 for medically necessary reasons as determined by a licensed
9 network or plan physician. The term includes prophylactic
10 mastectomies and lymph node dissections that are determined to
11 be medically necessary.
12 (b) Every health maintenance contract issued, amended,
13 delivered, or renewed in this state shall provide hospital,
14 medical, and surgical coverage for mastectomies to the same
15 extent that such coverage is provided for illness or disease
16 under the contract, and may not limit inpatient hospital
17 coverage for mastectomies to any time period that is less than
18 that determined by the treating surgical, gynecological, or
19 oncological care provider to be medically necessary, in
20 accordance with prevailing medical standards and consistent
21 with the guidelines for surgical, gynecological, and
22 oncological care.
23 (c) Any health maintenance contract that provides
24 coverage for mastectomies under paragraph (b) must also
25 provide outpatient postsurgical mastectomy followup care.
26 Such care must be comparable to inpatient hospital
27 postsurgical care and must include assessment of the patient's
28 condition in keeping with prevailing medical standards by a
29 licensed health care professional qualified to provide
30 postsurgical mastectomy care, and may be provided at the
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1 hospital, outpatient center, treating physician's office, or
2 in the patient's home.
3 (d) Any health maintenance contract that provides
4 coverage for mastectomies under paragraph (b) must also
5 provide coverage for prosthetic devices and reconstructive
6 surgery incident to the mastectomy. Breast reconstructive
7 surgery means surgery to reestablish symmetry between the two
8 breasts and includes augmentation mammoplasty, reduction
9 mammoplasty, and mastoplexy. Such surgery shall be in a
10 manner chosen by the treating physician, consistent with
11 prevailing medical standards, and in consultation with the
12 patient if the patient chooses such surgery. The coverage for
13 prosthetic devices and reconstructive surgery shall be subject
14 to any copayments under the contract.
15 (e) A health maintenance contract subject to this
16 subsection may not:
17 1. Deny to a covered person continued eligibility to
18 renew coverage under the terms of the contract for the purpose
19 of avoiding the requirements of this subsection;
20 2. Provide monetary payments or rebates to a covered
21 patient to accept less than the minimum protections available
22 under this subsection;
23 3. Penalize or otherwise reduce or limit the
24 reimbursement of an attending provider solely because the
25 attending provider provided care to an insured patient under
26 this subsection;
27 4. Provide incentives, monetary or otherwise, to an
28 attending provider solely to induce the provider to provide
29 care to a covered patient in a manner inconsistent with this
30 subsection; or
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1 5. Subject to the other provisions of this subsection,
2 restrict benefits for any portion of a period within a
3 hospital length of stay or outpatient care as required by this
4 subsection in a manner that is less than favorable than the
5 benefits provided for any preceding portion of such stay.
6 (f) This subsection does not affect any agreement
7 between a health maintenance organization and a hospital or
8 other health care provider with respect to reimbursement for
9 health care services provided, rate negotiations with
10 providers, or capitation of providers, and does not prohibit
11 appropriate utilization review or case management by the
12 health maintenance organization.
13 Section 9. Section 641.30198, Florida Statutes, is
14 created to read:
15 641.30198 Requirements with respect to breast
16 cancer.--Routine followup care to determine whether a breast
17 cancer has recurred in a person who has been previously
18 determined to be free of breast cancer shall not be considered
19 as medical advice, diagnosis, care, or treatment for purposes
20 of determining preexisting conditions unless evidence of
21 breast cancer is found during or as a result of followup care.
22 Section 10. The provisions of this act fulfill an
23 important state interest in that they promote the relief and
24 alleviation of health and medical problems that affect
25 residents of this state who have been stricken with breast
26 cancer. The act, in prohibiting limitations on inpatient
27 hospital coverage for mastectomies and requiring more
28 comprehensive insurance coverage for breast cancer treatment,
29 should insure the provision of appropriate and cost-effective
30 medical treatment.
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1 Section 11. This act shall take effect October 1,
2 1997.
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7 ADDITIONAL SPONSORS
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Kosmas, Silver, Lippman, Futch, Chestnut, Merchant, Brennan,
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Horan, Ritter, Flanagan, Burroughs, Dockery, Byrd, Maygarden,
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Casey, Rodriguez-Chomat, Arnall, Goode, Littlefield and Geller
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