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A bill to be entitled

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An act relating to health insurance; amending s. 624.443,

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F.S.; authorizing the Office of Insurance Regulation to

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waive the requirement that each multiple-employer welfare

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arrangement maintain its principal place of business in

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this state if the arrangement meets certain specified

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conditions and has a minimum specified fund balance at the

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time of licensure; amending s. 627.638, F.S.; authorizing

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the payment of health insurance policy benefits directly

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to a licensed ambulance provider; requiring that an

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insurer make payments directly to the preferred provider

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for the delivery of health care services; creating s.

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627.64731, F.S.; providing requirements for the rent,

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lease, or granting of access to the health care services

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of a preferred provider or exclusive provider under a

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health care contract; amending s. 627.662, F.S.; applying

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the requirements for the rent, lease, or granting of

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access to the health care services of a preferred provider

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or exclusive provider under a health care contract to

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group health insurance, blanket health insurance, and

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franchise health insurance policies; amending s. 641.31;

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providing that a health maintenance contract may not

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prohibit and a claims form must provide an option for

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direct payment to specified providers; authorizing a

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health maintenance organization to require a provider to

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make available a written attestation of assignment of

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benefits; authorizing the attestation to be submitted to

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the health maintenance organization in electronic form;

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amending s. 641.3155, F.S.; decreasing the amount of time

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in which a health maintenance organization may make a

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claim for overpayment against a provider; amending s.

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627.6131, F.S.; reducing the period for a health insurer

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to submit a claim to a provider for overpayment; amending

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s. 627.6471, F.S.; requiring that a nonpreferred provider,

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upon request of the insured, provide to the insured the

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estimated range of charges for the services requested;

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specifying that the provider in not liable if the final

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charge exceeds the initial estimate; providing

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applicability; providing an effective date.

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Be It Enacted by the Legislature of the State of Florida:

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     Section 1.  Section 624.443, Florida Statutes, is amended to

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read:

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     624.443  Place of business; maintenance of records.--Each

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arrangement shall have and maintain its principal place of

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business in this state and shall therein make available to the

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office complete records of its assets, transactions, and affairs

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in accordance with such methods and systems as are customary for,

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or suitable to, the kind or kinds of business transacted. The

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office may waive this requirement if an arrangement has been

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operating in another state for at least 25 years, has been

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licensed in such state for at least 10 years, and has a minimum

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fund balance of $25 million at the time of licensure.

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     Section 2.  Section 627.638, Florida Statutes, is amended to

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read:

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     627.638  Direct payment for hospital, medical services.--

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     (1)  Any health insurance policy insuring against loss or

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expense due to hospital confinement or to medical and related

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services may provide for payment of benefits directly to any

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recognized hospital, licensed ambulance provider, doctor, or

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other person who provided the services, in accordance with the

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provisions of the policy. To comply with this section, the words

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"or to the hospital, licensed ambulance provider, doctor, or

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person rendering services covered by this policy," or similar

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words appropriate to the terms of the policy, shall be added to

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applicable provisions of the policy.

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     (2)  Whenever, in any health insurance claim form, an

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insured specifically authorizes payment of benefits directly to

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any recognized hospital, licensed ambulance provider, physician,

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or dentist, the insurer shall make such payment to the designated

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provider of such services, unless otherwise provided in the

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insurance contract. The insurance contract may not prohibit, and

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claims forms must provide an option for, the payment of benefits

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directly to a licensed hospital, licensed ambulance provider,

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physician, or dentist for care provided pursuant to s. 395.1041

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or part III of chapter 401. The insurer may require written

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attestation of assignment of benefits. Payment to the provider

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from the insurer may not be more than the amount that the insurer

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would otherwise have paid without the assignment.

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     (3) Any insurer who has contracted with a preferred

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provider, as defined in s. 627.6471(1)(b), for the delivery of

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health care services to its insureds shall make payments directly

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to the preferred provider for such services.

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     Section 3.  Section 627.64731, Florida Statutes, is created

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to read:

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     627.64731 Leasing, renting, or granting access to a

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preferred provider or exclusive provider.--

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     (1) An insurer or administrator may not lease, rent, or

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otherwise grant access to the health care services of a preferred

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provider or an exclusive provider under a health care contract

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unless expressly authorized by the health care contract. At the

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time a health care contract is entered into with a preferred

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provider or exclusive provider, the insurer shall, to the extent

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possible, identify in the contract any third party to which the

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insurer or administrator has granted access to the health care

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services of the preferred provider or exclusive provider. A third

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party that is granted access must comply with all the applicable

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terms of the health care contract.

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(2) An insurer or administrator must notify a preferred

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provider or exclusive provider, in writing, within 5 business

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days of the identity of any third party that has been granted

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access to the health care services of the provider by the insurer

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or administrator. The provider may opt out of participating in a

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third party's health care plan by providing written notice to the

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insurer or administrator within 30 days after receiving notice

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pursuant to this subsection.

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(3) An insurer or administrator that leases, rents, or

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otherwise grants access to the health care services of a

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preferred provider or exclusive provider must maintain an

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Internet website or a toll-free telephone number through which

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the provider may obtain a listing, updated at least biannually,

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of the third parties that have been granted access to the

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provider's health care services.

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(4) An insurer or administrator that leases, rents, or

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otherwise grants access to a provider's health care services must

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ensure that an explanation of benefits or remittance advice

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furnished to the preferred provider or exclusive provider that

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delivers health care services under the health care contract

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identifies the contractual source of any applicable discount.

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(5) The right of a third party to exercise the rights and

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responsibilities of an insurer or administrator under a health

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care contract terminates on the date that the preferred

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provider's or exclusive provider's contract with the insurer or

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administrator is terminated.

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(6) The provisions of this section do not apply if the

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third party that is granted access to a preferred provider's or

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exclusive provider's health care services under a health care

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contract is:

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(a) An employer or other entity providing coverage for

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health care services to the employer's employees or the entity's

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members and the employer or entity has a contract with the

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insurer or administrator or the insurer's or administrator's

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affiliate for the administration or processing of claims for

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payment or services provided under the health care contract;

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(b) An affiliate or a subsidiary of the insurer or

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administrator; or

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(c) An entity providing administrative services to, or

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receiving administrative services from, the insurer or

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administrator or the insurer's or administrators' affiliate or

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subsidiary.

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     (7) A health care contract may provide for arbitration of

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disputes arising under this section.

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     Section 4.  Present subsections (11), (12), and (13) of

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section 627.662, Florida Statutes, are renumbered as subsections

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(12), (13), and (14), respectively, and new subsection (11) is

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added to that section, to read:

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     627.662  Other provisions applicable.--The following

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provisions apply to group health insurance, blanket health

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insurance, and franchise health insurance:

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     (11) Section 627.64731, relating to leasing, renting, or

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granting access to a preferred provider or exclusive provider.

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     Section 5.  Subsection (41) is added to section 641.31,

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Florida Statutes, to read:

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     641.31  Health maintenance contracts.--

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     (41) A health maintenance organization contract may not

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prohibit, and claims forms must provide an option for, the

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payment of benefits directly to a licensed hospital, ambulance

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transport and treatment provider pursuant to part III of chapter

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401, physician, or dentist for covered services provided pursuant

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to s. 395.1041. The health maintenance organization may require a

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provider to retain and make available upon request a written

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attestation of assignment of benefits. The attestation of

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assignment of benefits may be submitted to the health maintenance

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organization in electronic form.

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     Section 6.  Subsection (5) of section 641.3155, Florida

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Statutes, is amended to read:

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     641.3155  Prompt payment of claims.--

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     (5)  If a health maintenance organization determines that it

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has made an overpayment to a provider for services rendered to a

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subscriber, the health maintenance organization must make a claim

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for such overpayment to the provider's designated location. A

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health maintenance organization that makes a claim for

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overpayment to a provider under this section shall give the

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provider a written or electronic statement specifying the basis

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for the retroactive denial or payment adjustment. The health

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maintenance organization must identify the claim or claims, or

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overpayment claim portion thereof, for which a claim for

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overpayment is submitted.

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     (a)  If an overpayment determination is the result of

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retroactive review or audit of coverage decisions or payment

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levels not related to fraud, a health maintenance organization

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shall adhere to the following procedures:

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     1.  All claims for overpayment must be submitted to a

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provider within 12 30 months after the health maintenance

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organization's payment of the claim. A provider must pay, deny,

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or contest the health maintenance organization's claim for

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overpayment within 40 days after the receipt of the claim. All

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contested claims for overpayment must be paid or denied within

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120 days after receipt of the claim. Failure to pay or deny

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overpayment and claim within 140 days after receipt creates an

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uncontestable obligation to pay the claim.

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     2.  A provider that denies or contests a health maintenance

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organization's claim for overpayment or any portion of a claim

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shall notify the organization, in writing, within 35 days after

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the provider receives the claim that the claim for overpayment is

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contested or denied. The notice that the claim for overpayment is

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denied or contested must identify the contested portion of the

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claim and the specific reason for contesting or denying the claim

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and, if contested, must include a request for additional

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information. If the organization submits additional information,

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the organization must, within 35 days after receipt of the

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request, mail or electronically transfer the information to the

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provider. The provider shall pay or deny the claim for

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overpayment within 45 days after receipt of the information. The

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notice is considered made on the date the notice is mailed or

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electronically transferred by the provider.

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     3.  The health maintenance organization may not reduce

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payment to the provider for other services unless the provider

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agrees to the reduction in writing or fails to respond to the

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health maintenance organization's overpayment claim as required

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by this paragraph.

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     4.  Payment of an overpayment claim is considered made on

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the date the payment was mailed or electronically transferred. An

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overdue payment of a claim bears simple interest at the rate of

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12 percent per year. Interest on an overdue payment for a claim

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for an overpayment payment begins to accrue when the claim should

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have been paid, denied, or contested.

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     (b) A claim for overpayment may shall not be made permitted

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beyond 12 30 months after the health maintenance organization's

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payment of a claim, except that claims for overpayment may be

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sought beyond that time from providers convicted of fraud

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pursuant to s. 817.234.

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     Section 7.  Subsection (6) of section 627.6131, Florida

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Statutes, is amended to read:

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     627.6131  Payment of claims.--

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     (6)  If a health insurer determines that it has made an

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overpayment to a provider for services rendered to an insured,

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the health insurer must make a claim for such overpayment to the

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provider's designated location. A health insurer that makes a

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claim for overpayment to a provider under this section shall give

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the provider a written or electronic statement specifying the

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basis for the retroactive denial or payment adjustment. The

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insurer must identify the claim or claims, or overpayment claim

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portion thereof, for which a claim for overpayment is submitted.

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     (a)  If an overpayment determination is the result of

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retroactive review or audit of coverage decisions or payment

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levels not related to fraud, a health insurer shall adhere to the

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following procedures:

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     1.  All claims for overpayment must be submitted to a

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provider within 12 30 months after the health insurer's payment

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of the claim. A provider must pay, deny, or contest the health

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insurer's claim for overpayment within 40 days after the receipt

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of the claim. All contested claims for overpayment must be paid

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or denied within 120 days after receipt of the claim. Failure to

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pay or deny overpayment and claim within 140 days after receipt

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creates an uncontestable obligation to pay the claim.

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     2.  A provider that denies or contests a health insurer's

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claim for overpayment or any portion of a claim shall notify the

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health insurer, in writing, within 35 days after the provider

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receives the claim that the claim for overpayment is contested or

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denied. The notice that the claim for overpayment is denied or

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contested must identify the contested portion of the claim and

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the specific reason for contesting or denying the claim and, if

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contested, must include a request for additional information. If

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the health insurer submits additional information, the health

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insurer must, within 35 days after receipt of the request, mail

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or electronically transfer the information to the provider. The

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provider shall pay or deny the claim for overpayment within 45

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days after receipt of the information. The notice is considered

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made on the date the notice is mailed or electronically

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transferred by the provider.

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     3.  The health insurer may not reduce payment to the

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provider for other services unless the provider agrees to the

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reduction in writing or fails to respond to the health insurer's

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overpayment claim as required by this paragraph.

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     4.  Payment of an overpayment claim is considered made on

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the date the payment was mailed or electronically transferred. An

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overdue payment of a claim bears simple interest at the rate of

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12 percent per year. Interest on an overdue payment for a claim

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for an overpayment begins to accrue when the claim should have

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been paid, denied, or contested.

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     (b)  A claim for overpayment shall not be permitted beyond

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12 30 months after the health insurer's payment of a claim,

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except that claims for overpayment may be sought beyond that time

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from providers convicted of fraud pursuant to s. 817.234.

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     Section 8.  Subsection (7) is added to section 627.6471,

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Florida Statutes, to read:

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     627.6471  Contracts for reduced rates of payment;

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limitations; coinsurance and deductibles.--

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     (7) For care other than for ambulance transport or

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treatment under to part III of chapter 401 or services provided

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under s. 395.1041, if an insured under this section is requesting

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services from a nonpreferred provider and requests information

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from the insurer or the provider in order to determine patient

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financial responsibility:

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     (a) The nonpreferred provider shall provide the insured

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with an estimated average charge for the service and a statement

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notifying the insured that the final charge may exceed the

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estimated charge.

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     (b) The insurer shall provide the insured and the

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nonpreferred provider with an estimate of the payment to the

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provider and a statement notifying the insured that the final

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charge may exceed the estimated allowable payment amount.

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The nonpreferred provider and the insurer are not liable if the

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total charges of the provider or the insurer's actual payment

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differs from the estimate.

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     Section 9.  This act shall take effect July 1, 2008, and

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shall apply to contracts entered into, issued, or renewed on or

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after that date.