CODING: Words stricken are deletions; words underlined are additions.House Bill 0781
Florida House of Representatives - 1997 HB 781
By Representative Peaden
1 A bill to be entitled
2 An act relating to mastectomies; amending ss.
3 627.6417, 627.6612, 627.6699, and 641.31, F.S.;
4 requiring health insurance policies and
5 contracts to provide coverage for mastectomies;
6 prohibiting such policies and contracts from
7 imposing certain limitations on coverage for
8 hospital stays under certain circumstances;
9 creating ss. 627.64175, 627.6614, and
10 641.30198, F.S.; providing requirements and
11 prohibitions for insurers and health
12 maintenance organizations relating to breast
13 cancer coverage; amending ss. 627.651 and
14 627.6515, F.S.; conforming application
15 provisions to include certain cross references;
16 providing an effective date.
17
18 Be It Enacted by the Legislature of the State of Florida:
19
20 Section 1. Section 627.6417, Florida Statutes, is
21 amended to read:
22 627.6417 Optional Coverage for mastectomy and surgical
23 procedures and devices incident to mastectomy.--
24 (1) A health insurance policy that covers a resident
25 of this state and that is issued, amended, delivered, or
26 renewed in this state by an insurer that provides, on an
27 expense-incurred basis, hospital, medical, or surgical expense
28 insurance, or any combination of such coverages, shall provide
29 coverage for mastectomies, including hospital, medical, or
30 surgical care to the same extent that hospital, medical, or
31 surgical coverage is provided for illness or disease under the
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1 policy. The coverage, other than coverage for complications,
2 shall include inpatient hospital coverage for at least 48
3 hours following the date of surgery.
4 (2) The insured shall have the option to be discharged
5 earlier than the time period established in subsection (1).
6 In such case, the coverage must include at least one home
7 health care visit, which shall be in addition to, rather than
8 in lieu of, any home health care coverage available under the
9 policy and which may be requested by the insured within 72
10 hours after discharge from the hospital and shall be provided
11 within 24 hours after such request. The home health care
12 coverage shall be pursuant to the policy and subject to the
13 provisions of this subsection and not subject to deductibles,
14 coinsurance, or copayments.
15 (3)(1) A An accident or health insurance policy
16 issued, amended, delivered, or renewed in this state that
17 provides coverage for mastectomies must also include make
18 available to the policyholder, as part of the application,
19 coverage for the initial prosthetic device and reconstructive
20 surgery incident to the mastectomy. The insurer may charge an
21 appropriate additional premium for the coverage required by
22 this subsection. The coverage for prosthetic devices and
23 reconstructive surgery is subject to the deductible and
24 coinsurance conditions applied to the mastectomy, and all
25 other terms and conditions applicable to other benefits. If a
26 mastectomy is performed and there is no evidence of
27 malignancy, the coverage may be limited to the provision of
28 the initial prosthetic device and reconstructive surgery
29 within 2 years after the date of the mastectomy.
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1 (4)(2) As used in this section, the term "mastectomy"
2 means the removal of all or part of the breast for medically
3 necessary reasons as determined by a licensed physician.
4 (5)(3) This section does not apply to disability
5 income, specified disease other than cancer, or hospital
6 indemnity policies.
7 Section 2. Section 627.64175, Florida Statutes, is
8 created to read:
9 627.64175 Requirements with respect to breast
10 cancer.--
11 (1) An insurer may not refuse to cover an applicant
12 for health insurance due to breast cancer if the applicant has
13 remained free from breast cancer for at least 5 years prior to
14 the applicant's request for health insurance coverage.
15 (2) An insurer may not exclude coverage under a health
16 insurance policy for breast cancer if the applicant has
17 remained free from breast cancer for at least 5 years prior to
18 the applicant's request for health insurance coverage.
19 (3) Routine followup care to determine whether a
20 breast cancer has recurred in a person who has been previously
21 determined to be free of breast cancer shall not be considered
22 as medical advice, diagnosis, care, or treatment for purposes
23 of determining preexisting conditions unless evidence of
24 breast cancer is found during or as a result of the followup
25 care.
26 Section 3. Subsection (4) of section 627.651, Florida
27 Statutes, is amended to read:
28 627.651 Group contracts and plans of self-insurance
29 must meet group requirements.--
30 (4) This section does not apply to any plan which is
31 established or maintained by an individual employer in
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1 accordance with the Employee Retirement Income Security Act of
2 1974, Pub. L. No. 93-406, or to a multiple-employer welfare
3 arrangement as defined in s. 624.437(1), except that a
4 multiple-employer welfare arrangement shall comply with ss.
5 627.419, 627.657, 627.6575, 627.6576, 627.6578, 627.6579,
6 627.6612, 627.6614, 627.6615, 627.6616, and 627.662(6). This
7 subsection does not allow an authorized insurer to issue a
8 group health insurance policy or certificate which does not
9 comply with this part.
10 Section 4. Paragraph (c) of subsection (2) of section
11 627.6515, Florida Statutes, 1996 Supplement, is amended to
12 read:
13 627.6515 Out-of-state groups.--
14 (2) This part does not apply to a group health
15 insurance policy issued or delivered outside this state under
16 which a resident of this state is provided coverage if:
17 (c) The policy provides the benefits specified in ss.
18 627.419, 627.6574, 627.6575, 627.6579, 627.6612, 627.6613,
19 627.6614, 627.667, 627.6675, and 627.6691.
20 Section 5. Section 627.6612, Florida Statutes, is
21 amended to read:
22 627.6612 Optional Coverage for mastectomy and surgical
23 procedures and devices incident to mastectomy.--
24 (1) A group, blanket, or franchise health insurance
25 policy that covers a resident of this state and that is
26 issued, amended, delivered, or renewed in this state that
27 provides, on an expense-incurred basis, coverage for hospital,
28 medical, or surgical expenses, or any combination of such
29 expenses, shall provide coverage for mastectomies, including
30 hospital, medical, or surgical care to the same extent that
31 hospital, medical, or surgical coverage is provided for
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1 illness or disease under the policy. The coverage, other than
2 coverage for complications, shall include inpatient hospital
3 coverage for at least 48 hours following the date of surgery.
4 (2) The certificateholder shall have the option to be
5 discharged earlier than the time period established in
6 subsection (1). In such case, the coverage must include at
7 least one home health care visit, which shall be in addition
8 to, rather than in lieu of, any home health care coverage
9 available under the policy and which may be requested by the
10 insured within 72 hours after discharge from the hospital and
11 shall be provided within 24 hours after such request. The home
12 health care coverage shall be pursuant to the policy and
13 subject to the provisions of this subsection and not subject
14 to deductibles, coinsurance, or copayments.
15 (3)(1) A group, blanket, or franchise accident or
16 health insurance policy issued, amended, delivered, or renewed
17 in this state that provides coverage for mastectomies must
18 also include make available to the policyholder coverage for
19 the initial prosthetic device and reconstructive surgery
20 incident to the mastectomy. The insurer may charge an
21 appropriate additional premium for the coverage required by
22 this subsection. The coverage for prosthetic devices and
23 reconstructive surgery is subject to the deductible and
24 coinsurance conditions applied to the mastectomy, and all
25 other terms and conditions applicable to other benefits. If a
26 mastectomy is performed and there is no evidence of
27 malignancy, the coverage may be limited to the provision of
28 the initial prosthetic device and reconstructive surgery to
29 within 2 years after the date of the mastectomy.
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1 (4)(2) As used in this section, the term "mastectomy"
2 means the removal of all or part of the breast for medically
3 necessary reasons as determined by a licensed physician.
4 Section 6. Section 627.6614, Florida Statutes, is
5 created to read:
6 627.6614 Requirements with respect to breast cancer.--
7 (1) When an insurer is permitted to underwrite and
8 selectively insure, the insurer:
9 (a) May not refuse to cover nor charge an unfairly
10 discriminatory rate for an individual member applicant within
11 a group which is applying for group, blanket, or franchise
12 health insurance due to breast cancer if the individual member
13 applicant has remained free from breast cancer for at least 5
14 years prior to the individual member applicant's request for
15 health insurance coverage.
16 (b) May not exclude coverage under the group, blanket,
17 or franchise health insurance policy for breast cancer if the
18 individual member applicant has remained free from breast
19 cancer for at least 5 years prior to the individual member
20 applicant's request for health insurance coverage.
21 (2) Routine followup care to determine whether a
22 breast cancer has recurred in a person who has been previously
23 determined to be free of breast cancer shall not be considered
24 as medical advice, diagnosis, care, or treatment for purposes
25 of determining preexisting conditions unless evidence of
26 breast cancer is found during or as a result of the followup
27 care.
28 Section 7. Subsection (29) is added to section 641.31,
29 Florida Statutes, 1996 Supplement, to read:
30 641.31 Health maintenance contracts.--
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1 (29)(a) Every health maintenance contract issued,
2 amended, delivered, or renewed in this state shall provide
3 coverage for mastectomies, including hospital, medical, and
4 surgical care to the same extent that hospital, medical, and
5 surgical coverage is provided for illness or disease under the
6 contract. The coverage, other than coverage for
7 complications, shall include inpatient hospital coverage for
8 at least 48 hours following the date of the surgery.
9 (b) The subscriber shall have the option to be
10 discharged earlier than the time period established in
11 paragraph (a). In such case, the coverage must include at
12 least one home care visit, which shall be in addition to,
13 rather than in lieu of, any home health care coverage
14 available under the contract and which may be requested by the
15 insured within 72 hours after discharge from the hospital and
16 shall be provided within 24 hours after such request. The
17 home health care coverage shall be pursuant to the contract
18 and subject to the provisions of this subsection, and not
19 subject to copayments.
20 (c) Every health maintenance contract must also
21 provide coverage for the initial prosthetic device and
22 reconstructive surgery incident to the mastectomy. The
23 coverage for prosthetic devices and reconstructive surgery is
24 subject to the deductible and copayment provisions applicable
25 to the contract, and is also subject to all other terms and
26 conditions applicable to other benefits.
27 (d) As used in this subsection, the term "mastectomy"
28 means the removal of all or part of the breast for medically
29 necessary reasons as determined by a licensed physician.
30 Section 8. Section 641.30198, Florida Statutes, is
31 created to read:
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1 641.30198 Requirements with respect to breast
2 cancer.--
3 (1) A health maintenance organization may not refuse
4 to cover nor charge an unfairly discriminatory rate to an
5 applicant for health coverage due to breast cancer if the
6 applicant has remained free from breast cancer for at least 5
7 years prior to the applicant's request for health coverage.
8 (2) A health maintenance organization may not consider
9 the condition as a preexisting condition under a health
10 maintenance contract if the applicant has remained free from
11 breast cancer for at least 5 years prior to the applicant's
12 request for health coverage.
13 (3) Routine followup care to determine whether a
14 breast cancer has recurred in a person who has been previously
15 determined to be free from breast cancer shall not be
16 considered as medical advice, diagnosis, care, or treatment
17 for purposes of determining preexisting conditions unless
18 evidence of breast cancer is found during or as a result of
19 the followup care.
20 Section 9. Paragraph (b) of subsection (12) of section
21 627.6699, Florida Statutes, 1996 Supplement, is amended to
22 read:
23 627.6699 Employee Health Care Access Act.--
24 (12) STANDARD, BASIC, AND LIMITED HEALTH BENEFIT
25 PLANS.--
26 (b)1. Each small employer carrier issuing new health
27 benefit plans shall offer to any small employer, upon request,
28 a standard health benefit plan and a basic health benefit plan
29 that meets the criteria set forth in this section.
30 2. For purposes of this subsection, the terms
31 "standard health benefit plan" and "basic health benefit plan"
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1 mean policies or contracts that a small employer carrier
2 offers to eligible small employers that contain:
3 a. An exclusion for services that are not medically
4 necessary or that are not covered preventive health services;
5 and
6 b. A procedure for preauthorization by the small
7 employer carrier, or its designees.
8 3. A small employer carrier may include the following
9 managed care provisions in the policy or contract to control
10 costs:
11 a. A preferred provider arrangement or exclusive
12 provider organization or any combination thereof, in which a
13 small employer carrier enters into a written agreement with
14 the provider to provide services at specified levels of
15 reimbursement or to provide reimbursement to specified
16 providers. Any such written agreement between a provider and a
17 small employer carrier must contain a provision under which
18 the parties agree that the insured individual or covered
19 member has no obligation to make payment for any medical
20 service rendered by the provider which is determined not to be
21 medically necessary. A carrier may use preferred provider
22 arrangements or exclusive provider arrangements to the same
23 extent as allowed in group products that are not issued to
24 small employers.
25 b. A procedure for utilization review by the small
26 employer carrier or its designees.
27
28 This subparagraph does not prohibit a small employer carrier
29 from including in its policy or contract additional managed
30 care and cost containment provisions, subject to the approval
31 of the department, which have potential for controlling costs
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1 in a manner that does not result in inequitable treatment of
2 insureds or subscribers. The carrier may use such provisions
3 to the same extent as authorized for group products that are
4 not issued to small employers.
5 4. The standard health benefit plan shall include:
6 a. Coverage for inpatient hospitalization;
7 b. Coverage for outpatient services;
8 c. Coverage for newborn children pursuant to s.
9 627.6575;
10 d. Coverage for child care supervision services
11 pursuant to s. 627.6579;
12 e. Coverage for adopted children upon placement in the
13 residence pursuant to s. 627.6578;
14 f. Coverage for a mastectomy and surgical procedures
15 and devices incident to a mastectomy pursuant to s. 627.6612.
16 g.f. Coverage for mammograms pursuant to s. 627.6613;
17 h.g. Coverage for handicapped children pursuant to s.
18 627.6615;
19 i.h. Emergency or urgent care out of the geographic
20 service area; and
21 j.i. Coverage for services provided by a hospice
22 licensed under s. 400.602 in cases where such coverage would
23 be the most appropriate and the most cost-effective method for
24 treating a covered illness.
25 5. The standard health benefit plan and the basic
26 health benefit plan may include a schedule of benefit
27 limitations for specified services and procedures. If the
28 committee develops such a schedule of benefits limitation for
29 the standard health benefit plan or the basic health benefit
30 plan, a small employer carrier offering the plan must offer
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1 the employer an option for increasing the benefit schedule
2 amounts by 4 percent annually.
3 6. The basic health benefit plan shall include all of
4 the benefits specified in subparagraph 4.; however, the basic
5 health benefit plan shall place additional restrictions on the
6 benefits and utilization and may also impose additional cost
7 containment measures.
8 7. Sections 627.419(2), (3), and (4), 627.6574,
9 627.6616, 627.6618, and 627.668 apply to the standard health
10 benefit plan and to the basic health benefit plan. However,
11 notwithstanding said provisions, the plans may specify limits
12 on the number of authorized treatments, if such limits are
13 reasonable and do not discriminate against any type of
14 provider.
15 8. Each small employer carrier that provides for
16 inpatient and outpatient services by allopathic hospitals may
17 provide as an option of the insured similar inpatient and
18 outpatient services by hospitals accredited by the American
19 Osteopathic Association when such services are available and
20 the osteopathic hospital agrees to provide the service.
21 Section 10. This act shall take effect October 1,
22 1997.
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25 HOUSE SUMMARY
26
Requires health insurance policies and health maintenance
27 contracts to provide coverage for mastectomies. Provides
for limited home health care after discharge from a
28 hospital after a mastectomy. Prohibits insurers or
health maintenance organizations from refusing to provide
29 or exclude coverage for breast cancer under specified
conditions. See bill for details.
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