CODING: Words stricken are deletions; words underlined are additions.House Bill 0573
Florida House of Representatives - 1997 HB 573
By Representatives Murman, Frankel, Argenziano, Brown,
Heyman, Sanderson, Jacobs, Fischer, Dennis, Dawson-White, Diaz
de la Portilla, Kosmas, Silver, Lippman, Futch, Chestnut,
Merchant, Brennan, Wasserman Schultz and Horan
1 A bill to be entitled
2 An act relating to reconstructive breast
3 surgery; amending ss. 627.6417, 627.6612, and
4 627.6699, F.S.; requiring certain insurance
5 policies to provide coverage for reconstructive
6 breast surgery for certain purposes; providing
7 an effective date.
8
9 Be It Enacted by the Legislature of the State of Florida:
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11 Section 1. Subsection (1) of section 627.6417, Florida
12 Statutes, is amended to read:
13 627.6417 Optional coverage for surgical procedures and
14 devices incident to mastectomy.--
15 (1) An accident or health insurance policy issued,
16 amended, delivered, or renewed in this state that provides
17 coverage for mastectomies shall provide must make available to
18 the policyholder, as part of the application, coverage for the
19 initial prosthetic devices device and reconstructive surgery
20 on the breast which was the subject of the mastectomy, and for
21 any reconstructive surgery on the other breast in the manner
22 chosen by the patient and her physician if the patient elects
23 such surgery, to restore and achieve symmetry for the patient
24 incident to the mastectomy. The insurer may charge an
25 appropriate additional premium for the coverage required by
26 this subsection. The coverage for prosthetic devices and
27 reconstructive surgery is subject to the deductible and
28 coinsurance conditions applied to the mastectomy, and all
29 other terms and conditions applicable to other benefits. If a
30 mastectomy is performed and there is no evidence of
31 malignancy, the coverage may be limited to the provision of
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Florida House of Representatives - 1997 HB 573
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1 the initial prosthetic devices device and reconstructive
2 surgery within 2 years after the date of the mastectomy.
3 Section 2. Subsection (1) of section 627.6612, Florida
4 Statutes, is amended to read:
5 627.6612 Optional coverage for surgical procedures and
6 devices incident to mastectomy.--
7 (1) A group, blanket, or franchise accident or health
8 insurance policy issued, amended, delivered, or renewed in
9 this state that provides coverage for mastectomies shall
10 include must make available to the policyholder coverage for
11 the initial prosthetic devices device and reconstructive
12 surgery on the breast which was the subject of the mastectomy,
13 and for any reconstructive surgery on the other breast in the
14 manner chosen by the patient and her physician if the patient
15 elects such surgery, to restore and achieve symmetry for the
16 patient incident to the mastectomy. The insurer may charge an
17 appropriate additional premium for the coverage required by
18 this subsection. The coverage for prosthetic devices and
19 reconstructive surgery is subject to the deductible and
20 coinsurance conditions applied to the mastectomy, and all
21 other terms and conditions applicable to other benefits. If a
22 mastectomy is performed and there is no evidence of
23 malignancy, the coverage may be limited to the provision of
24 the initial prosthetic devices device and reconstructive
25 surgery to within 2 years after the date of the mastectomy.
26 Section 3. Paragraph (b) of subsection (12) of section
27 627.6699, Florida Statutes, 1996 Supplement, is amended to
28 read:
29 627.6699 Employee Health Care Access Act.--
30 (12) STANDARD, BASIC, AND LIMITED HEALTH BENEFIT
31 PLANS.--
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Florida House of Representatives - 1997 HB 573
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1 (b)1. Each small employer carrier issuing new health
2 benefit plans shall offer to any small employer, upon request,
3 a standard health benefit plan and a basic health benefit plan
4 that meets the criteria set forth in this section.
5 2. For purposes of this subsection, the terms
6 "standard health benefit plan" and "basic health benefit plan"
7 mean policies or contracts that a small employer carrier
8 offers to eligible small employers that contain:
9 a. An exclusion for services that are not medically
10 necessary or that are not covered preventive health services;
11 and
12 b. A procedure for preauthorization by the small
13 employer carrier, or its designees.
14 3. A small employer carrier may include the following
15 managed care provisions in the policy or contract to control
16 costs:
17 a. A preferred provider arrangement or exclusive
18 provider organization or any combination thereof, in which a
19 small employer carrier enters into a written agreement with
20 the provider to provide services at specified levels of
21 reimbursement or to provide reimbursement to specified
22 providers. Any such written agreement between a provider and a
23 small employer carrier must contain a provision under which
24 the parties agree that the insured individual or covered
25 member has no obligation to make payment for any medical
26 service rendered by the provider which is determined not to be
27 medically necessary. A carrier may use preferred provider
28 arrangements or exclusive provider arrangements to the same
29 extent as allowed in group products that are not issued to
30 small employers.
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1 b. A procedure for utilization review by the small
2 employer carrier or its designees.
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4 This subparagraph does not prohibit a small employer carrier
5 from including in its policy or contract additional managed
6 care and cost containment provisions, subject to the approval
7 of the department, which have potential for controlling costs
8 in a manner that does not result in inequitable treatment of
9 insureds or subscribers. The carrier may use such provisions
10 to the same extent as authorized for group products that are
11 not issued to small employers.
12 4. The standard health benefit plan shall include:
13 a. Coverage for inpatient hospitalization;
14 b. Coverage for outpatient services;
15 c. Coverage for newborn children pursuant to s.
16 627.6575;
17 d. Coverage for child care supervision services
18 pursuant to s. 627.6579;
19 e. Coverage for adopted children upon placement in the
20 residence pursuant to s. 627.6578;
21 f. Coverage for reconstructive breast surgery pursuant
22 to s. 627.6612.
23 g.f. Coverage for mammograms pursuant to s. 627.6613;
24 h.g. Coverage for handicapped children pursuant to s.
25 627.6615;
26 i.h. Emergency or urgent care out of the geographic
27 service area; and
28 j.i. Coverage for services provided by a hospice
29 licensed under s. 400.602 in cases where such coverage would
30 be the most appropriate and the most cost-effective method for
31 treating a covered illness.
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1 5. The standard health benefit plan and the basic
2 health benefit plan may include a schedule of benefit
3 limitations for specified services and procedures. If the
4 committee develops such a schedule of benefits limitation for
5 the standard health benefit plan or the basic health benefit
6 plan, a small employer carrier offering the plan must offer
7 the employer an option for increasing the benefit schedule
8 amounts by 4 percent annually.
9 6. The basic health benefit plan shall include all of
10 the benefits specified in subparagraph 4.; however, the basic
11 health benefit plan shall place additional restrictions on the
12 benefits and utilization and may also impose additional cost
13 containment measures.
14 7. Sections 627.419(2), (3), and (4), 627.6574,
15 627.6616, 627.6618, and 627.668 apply to the standard health
16 benefit plan and to the basic health benefit plan. However,
17 notwithstanding said provisions, the plans may specify limits
18 on the number of authorized treatments, if such limits are
19 reasonable and do not discriminate against any type of
20 provider.
21 8. Each small employer carrier that provides for
22 inpatient and outpatient services by allopathic hospitals may
23 provide as an option of the insured similar inpatient and
24 outpatient services by hospitals accredited by the American
25 Osteopathic Association when such services are available and
26 the osteopathic hospital agrees to provide the service.
27 Section 4. This act shall take effect October 1, 1997.
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2 HOUSE SUMMARY
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Requires insurance which provides coverage for
4 mastectomies to provide coverage for reconstructive
breast surgery after a mastectomy. See bill for details.
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