1

A bill to be entitled

2

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

3

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

4

waive the requirement that each multiple-employer welfare

5

arrangement maintain its principal place of business in

6

this state if the arrangement meets certain specified

7

conditions and has a minimum specified fund balance at the

8

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

9

the payment of health insurance policy benefits directly

10

to a licensed ambulance provider; requiring that an

11

insurer make payments directly to the preferred provider

12

for the delivery of health care services; amending s.

13

627.6131, F.S.; requiring claims for overpayment and

14

underpayment be submitted to the provider within a certain

15

timeframe; providing exceptions; creating s. 627.64731,

16

F.S.; providing definitions; providing requirements,

17

limitations, and procedures for leasing, renting, or

18

granting access to participating providers by third

19

parties; providing exceptions; providing for arbitration;

20

providing for application; amending s. 627.662, F.S.;

21

expanding the list of sections applicable to certain types

22

of insurance; amending s. 627.6699, F.S.; revising the

23

definition of the term "small employer" with regard to the

24

Employee Health Care Access Act; amending s. 641.31, F.S.;

25

requiring health maintenance organizations to pay benefits

26

directly to certain providers under certain circumstances;

27

prohibiting health maintenance contracts from prohibiting

28

and requiring claims forms to provide the option for

29

payment of benefits directly to certain providers;

30

amending s. 641.3155, F.S.; providing time limitations for

31

and prohibitions against submitting certain claims for

32

overpayment and claims for underpayment; providing for

33

applicability; providing an effective date.

34

35

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

36

37

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

38

read:

39

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

40

arrangement shall have and maintain its principal place of

41

business in this state and shall therein make available to the

42

office complete records of its assets, transactions, and affairs

43

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

44

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

45

office may waive this requirement if an arrangement has been

46

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

47

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

48

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

49

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

50

read:

51

     627.638  Direct payment for hospital, medical services.--

52

     (1)  Any health insurance policy insuring against loss or

53

expense due to hospital confinement or to medical and related

54

services may provide for payment of benefits directly to any

55

recognized hospital, licensed ambulance provider, doctor, or

56

other person who provided the services, in accordance with the

57

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

58

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

59

person rendering services covered by this policy," or similar

60

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

61

applicable provisions of the policy.

62

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

63

insured specifically authorizes payment of benefits directly to

64

any recognized hospital, licensed ambulance provider, physician,

65

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

66

provider of such services, unless otherwise provided in the

67

insurance contract. The insurance contract may not prohibit, and

68

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

69

directly to a licensed hospital, licensed ambulance provider,

70

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

71

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

72

attestation of assignment of benefits. Payment to the provider

73

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

74

would otherwise have paid without the assignment.

75

     (3) Any insurer who has contracted with a preferred

76

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

77

health care services to its insureds shall make payments directly

78

to the preferred provider for such services.

79

     Section 3.  Subsections (18) and (19) are added to section

80

627.6131, Florida Statutes, to read:

81

     627.6131  Payment of claims.--

82

     (18) Notwithstanding the 30-month period provided in

83

subsection (6), all claims for overpayment submitted to a

84

provider licensed under chapter 458, chapter 459, chapter 460,

85

chapter 461, or chapter 466 must be submitted to the provider

86

within 12 months after the health insurer's payment of the claim.

87

A claim for overpayment may not be permitted beyond 12 months

88

after the health insurer's payment of a claim, except that claims

89

for overpayment may be sought beyond that time from providers

90

convicted of fraud pursuant to s. 817.234.

91

     (19) Notwithstanding any other provision of this section,

92

all claims for underpayment from a provider licensed under

93

chapter 458, chapter 459, chapter 460, chapter 461, or chapter

94

466 must be submitted to the insurer within 12 months after the

95

health insurer's payment of the claim. A claim for underpayment

96

may not be permitted beyond 12 months after the health insurer's

97

payment of a claim.

98

     Section 4.  Section 627.64731, Florida Statutes, is created

99

to read:

100

     627.64731 Leasing, renting, or granting access to a

101

participating provider.--

102

     (1) As used in this section, the term:

103

     (a) "Contracting entity" means any person or entity that is

104

engaged in the act of contracting with participating providers

105

and has a direct contract with a participating provider for the

106

delivery of health care services or the selling or assigning of

107

physicians or physician panels to other health care entities.

108

     (b) "Participating provider" means a physician licensed

109

under chapter 458, chapter 459, chapter 460, chapter 461, or

110

chapter 466, or a physician group practice that has a health care

111

contract with a contracting entity and is entitled to

112

reimbursement for health care services rendered to an enrollee

113

under the health care contract and includes both preferred

114

providers as defined in s. 627.6471 and exclusive providers as

115

defined in s. 627.6472.

116

     (2) A contracting entity may not sell, lease, rent, or

117

otherwise grant access to the health care services of a

118

participating provider under a health care contract unless

119

expressly authorized by the health care contract. The health care

120

contract must specifically provide that it applies to network

121

rental arrangements and state that one purpose of the contract is

122

selling, renting, or giving the contracting entity rights to the

123

services of the participating provider, including other preferred

124

provider organizations. At the time a health care contract is

125

entered into with a participating provider, the contracting

126

entity shall, to the extent possible, identify any third party to

127

which the contracting entity has granted access to the health

128

care services of the participating provider. The contracting

129

entity may sell, lease, rent, or otherwise grant access to the

130

participating provider's services only to a third party that is:

131

     (a) A payer or a third-party administrator or other entity

132

responsible for administering claims on behalf of the payer;

133

     (b) A preferred provider organization or preferred provider

134

network that receives access to the participating provider's

135

services pursuant to an arrangement with the preferred provider

136

organization or preferred provider network in a contract with the

137

participating provider and that is required to comply with all of

138

the terms, conditions, and affirmative obligations to which the

139

originally contracted primary participating provider network is

140

bound under its contract with the participating provider,

141

including, but not limited to, obligations concerning patient

142

steerage and the timeliness and manner of reimbursement; or

143

     (c) An entity that is engaged in the business of providing

144

electronic claims transport between the contracting entity and

145

the payer or third-party administrator and that complies with all

146

of the applicable terms, conditions, and affirmative obligations

147

of the contracting entity's contract with the participating

148

provider including, but not limited to, obligations concerning

149

patient steerage and the timeliness and manner of reimbursement.

150

     (3) Upon a request by a participating provider, a

151

contracting entity must provide the identity of any third party

152

that has been granted access to the health care services of the

153

participating provider.

154

     (4) A contracting entity that leases, rents, or otherwise

155

grants access to the health care services of a participating

156

provider must maintain an Internet website or a toll-free

157

telephone number through which the provider may obtain a listing,

158

updated at least every 90 days, of the third parties that have

159

been granted access to the provider's health care services.

160

     (5) A contracting entity that leases, rents, or otherwise

161

grants access to a participating provider's health care services

162

must ensure that an explanation of benefits or remittance advice

163

furnished to the participating provider that delivers health care

164

services under the health care contract identifies the

165

contractual source of any applicable discount.

166

     (6) Subject to applicable continuity-of-care laws, the

167

right of a third party to exercise the rights and

168

responsibilities of a contracting entity under a health care

169

contract terminates on the day following the termination of the

170

participating provider's contract with the contracting entity.

171

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

172

third party that is granted access to a participating provider's

173

health care services under a health care contract is:

174

     (a) An employer or other entity providing coverage for

175

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

176

members and the employer or entity has a contract with the

177

contracting entity or the contracting entity's affiliate for the

178

administration or processing of claims for payment or services

179

provided under the health care contract;

180

     (b) An entity providing administrative services to, or

181

receiving administrative services from, the contracting entity or

182

the contracting entity's affiliate or subsidiary; or

183

     (c) An affiliate or a subsidiary of a contracting entity,

184

or other entity if operating under the same brand licensee

185

program as the contracting entity.

186

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

187

disputes arising under this section.

188

     (9) A contracting entity shall ensure that all third

189

parties to which the contracting entity has sold, rented,

190

assigned, or otherwise given access to the participating

191

provider's discounted rate comply with the physician contract,

192

including all requirements to encourage access to the

193

participating provider, and pay the provider pursuant to the

194

rates of payment and methodology set forth in that contract,

195

unless otherwise agreed to by a participating provider.

196

     (10) A contracting entity is deemed in compliance with this

197

section when the insured's identification card provides

198

information, written or electronically, which identifies the

199

preferred provider network or networks to be used to reimburse

200

the provider for covered services.

201

     (11) This section does not apply to a contract between a

202

contracting entity and a discount medical plan organization

203

licensed or exempt under part II of chapter 636.

204

     Section 5.  Subsections (11), (12), and (13) of section

205

627.662, Florida Statutes, are renumbered as subsections (12),

206

(13), and (14), respectively, and a new subsection (11) is added

207

to that section, to read:

208

     627.662  Other provisions applicable.--The following

209

provisions apply to group health insurance, blanket health

210

insurance, and franchise health insurance:

211

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

212

granting access to a participating provider.

213

     Section 6.  Paragraph (v) of subsection (3) of section

214

627.6699, Florida Statutes, is amended to read:

215

     627.6699  Employee Health Care Access Act.--

216

     (3)  DEFINITIONS.--As used in this section, the term:

217

     (v)  "Small employer" means, in connection with a health

218

benefit plan with respect to a calendar year and a plan year, any

219

person, sole proprietor, self-employed individual, independent

220

contractor, firm, corporation, partnership, or association that

221

is actively engaged in business, has its principal place of

222

business in this state, employed an average of at least 1 but not

223

more than 50 eligible employees on business days during the

224

preceding calendar year the majority of whom were employed in

225

this state, and employs at least 1 employee on the first day of

226

the plan year, and is not formed primarily for purposes of

227

purchasing insurance. In determining the number of eligible

228

employees, companies that are an affiliated group as defined in

229

s. 1504(a) of the Internal Revenue Code of 1986, as amended, are

230

considered a single employer. For purposes of this section, a

231

sole proprietor, an independent contractor, or a self-employed

232

individual is considered a small employer only if all of the

233

conditions and criteria established in this section are met.

234

     Section 7.  Subsection (41) is added to section 641.31,

235

Florida Statutes, to read:

236

     641.31  Health maintenance contracts.--

237

     (41) Whenever, in any health maintenance organization claim

238

form, a subscriber specifically authorizes payment of benefits

239

directly to any contracted hospital, ambulance provider,

240

physician, or dentist, the health maintenance organization shall

241

make such payment to the designated provider of such services if

242

any benefits are due to the subscriber under the terms of the

243

agreement between the subscriber and the health maintenance

244

organization. The health maintenance organization contract may

245

not prohibit, and claims forms must provide an option for, the

246

payment of benefits directly to a licensed hospital, ambulance

247

provider, physician, or dentist for covered services provided,

248

for services provided pursuant to s. 395.1041, and for ambulance

249

transport and treatment provided pursuant to part III of chapter

250

401. The attestation of assignment of benefits may be in written

251

or electronic form. Payment to the provider from the health

252

maintenance organization may not be more than the amount that the

253

insurer would otherwise have paid without the assignment. This

254

subsection does not affect the applicability of ss. 641.3154 and

255

641.513 with respect to services provided and payment for such

256

services provided pursuant to the subsection.

257

     Section 8.  Subsections (16) and (17) are added to section

258

641.3155, Florida Statutes, to read:

259

     641.3155  Prompt payment of claims.--

260

     (16) Notwithstanding the 30-month period provided in

261

subsection (5), all claims for overpayment submitted to a

262

provider licensed under chapter 458, chapter 459, chapter 460,

263

chapter 461, or chapter 466 must be submitted to the provider

264

within 12 months after the health maintenance organization's

265

payment of the claim. A claim for overpayment may not be

266

permitted beyond 12 months after the health maintenance

267

organization's payment of a claim, except that claims for

268

overpayment may be sought beyond that time from providers

269

convicted of fraud pursuant to s. 817.234.

270

     (17) Notwithstanding any other provision of this section,

271

all claims for underpayment from a provider licensed under

272

chapter 458, chapter 459, chapter 460, chapter 461, or chapter

273

466 must be submitted to the health maintenance organization

274

within 12 months after the health maintenance organization's

275

payment of the claim. A claim for underpayment may not be

276

permitted beyond 12 months after the health maintenance

277

organization's payment of a claim.

278

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

279

applies to contracts entered into, issued, or renewed on or after

280

that date, and the amendments made by this act to ss. 627.6131

281

and 641.3155, Florida Statutes, apply to claims payments made on

282

or after November 1, 2008.