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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; amending s.

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

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underpayment be submitted to the provider within a certain

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timeframe; providing exceptions; creating s. 627.64731,

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F.S.; providing definitions; providing requirements,

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limitations, and procedures for leasing, renting, or

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granting access to participating providers by third

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parties; providing exceptions; providing for arbitration;

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

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expanding the list of sections applicable to certain types

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

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

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

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requiring health maintenance organizations to pay benefits

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directly to certain providers under certain circumstances;

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prohibiting health maintenance contracts from prohibiting

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and requiring claims forms to provide the option for

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payment of benefits directly to certain providers;

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

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and prohibitions against submitting certain claims for

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overpayment and claims for underpayment; providing for

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

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627.6131, Florida Statutes, to read:

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     627.6131  Payment of claims.--

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     (18) Notwithstanding the 30-month period provided in

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

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

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

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

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A claim for overpayment may not be permitted beyond 12 months

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

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for overpayment may be sought beyond that time from providers

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convicted of fraud pursuant to s. 817.234.

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     (19) Notwithstanding any other provision of this section,

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all claims for underpayment from a provider licensed under

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

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

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

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

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payment of a claim.

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     Section 4.  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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participating provider.--

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

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

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engaged in the act of contracting with participating providers

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and has a direct contract with a participating provider for the

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delivery of health care services or the selling or assigning of

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physicians or physician panels to other health care entities.

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     (b) "Participating provider" means a physician licensed

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

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

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contract with a contracting entity and is entitled to

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reimbursement for health care services rendered to an enrollee

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under the health care contract and includes both preferred

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providers as defined in s. 627.6471 and exclusive providers as

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defined in s. 627.6472.

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

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otherwise grant access to the health care services of a

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participating provider under a health care contract unless

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expressly authorized by the health care contract. The health care

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contract must specifically provide that it applies to network

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rental arrangements and state that one purpose of the contract is

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

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services of the participating provider, including other preferred

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provider organizations. At the time a health care contract is

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entered into with a participating provider, the contracting

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

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which the contracting entity has granted access to the health

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care services of the participating provider. The contracting

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

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

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

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responsible for administering claims on behalf of the payer;

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     (b) A preferred provider organization or preferred provider

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network that receives access to the participating provider's

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services pursuant to an arrangement with the preferred provider

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organization or preferred provider network in a contract with the

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participating provider and that is required to comply with all of

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the terms, conditions, and affirmative obligations to which the

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originally contracted primary participating provider network is

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bound under its contract with the participating provider,

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including, but not limited to, obligations concerning patient

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steerage and the timeliness and manner of reimbursement; or

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

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electronic claims transport between the contracting entity and

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

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of the applicable terms, conditions, and affirmative obligations

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of the contracting entity's contract with the participating

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provider including, but not limited to, obligations concerning

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patient steerage and the timeliness and manner of reimbursement.

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

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contracting entity must provide the identity of any third party

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

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participating provider.

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

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grants access to the health care services of a participating

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provider must maintain an Internet website or a toll-free

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telephone number through which the provider may obtain a listing,

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

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

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

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grants access to a participating provider's health care services

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must ensure that an explanation of benefits or remittance advice

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furnished to the participating provider that delivers health care

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services under the health care contract identifies the

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contractual source of any applicable discount.

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

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right of a third party to exercise the rights and

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responsibilities of a contracting entity under a health care

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contract terminates on the day following the termination of the

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participating provider's contract with the contracting entity.

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

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

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health care services under a health care 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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contracting entity or the contracting entity's affiliate for the

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administration or processing of claims for payment or services

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provided under the health care contract;

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     (b) An entity providing administrative services to, or

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receiving administrative services from, the contracting entity or

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the contracting entity's affiliate or subsidiary; or

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

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or other entity if operating under the same brand licensee

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program as the contracting entity.

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

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disputes arising under this section.

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     (9) A contracting entity shall ensure that all third

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parties to which the contracting entity has sold, rented,

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assigned, or otherwise given access to the participating

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provider's discounted rate comply with the physician contract,

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including all requirements to encourage access to the

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participating provider, and pay the provider pursuant to the

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rates of payment and methodology set forth in that contract,

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unless otherwise agreed to by a participating provider.

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

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section when the insured's identification card provides

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information, written or electronically, which identifies the

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preferred provider network or networks to be used to reimburse

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the provider for covered services.

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

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contracting entity and a discount medical plan organization

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licensed or exempt under part II of chapter 636.

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

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

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

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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 participating provider.

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

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627.6699, Florida Statutes, is amended to read:

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     627.6699  Employee Health Care Access Act.--

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

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

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

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person, sole proprietor, self-employed individual, independent

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contractor, firm, corporation, partnership, or association that

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is actively engaged in business, has its principal place of

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

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more than 50 eligible employees on business days during the

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preceding calendar year the majority of whom were employed in

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

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

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purchasing insurance. In determining the number of eligible

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employees, companies that are an affiliated group as defined in

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

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

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

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individual is considered a small employer only if all of the

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conditions and criteria established in this section are met.

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     Section 7.  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) Whenever, in any health maintenance organization claim

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form, a subscriber specifically authorizes payment of benefits

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directly to any contracted hospital, ambulance provider,

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physician, or dentist, the health maintenance organization shall

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make such payment to the designated provider of such services if

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

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agreement between the subscriber and the health maintenance

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organization. The health maintenance organization contract may

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not 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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provider, physician, or dentist for covered services provided,

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

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transport and treatment provided pursuant to part III of chapter

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

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or electronic form. Payment to the provider from the health

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maintenance organization may not be more than the amount that the

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insurer would otherwise have paid without the assignment. This

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subsection does not affect the applicability of ss. 641.3154 and

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641.513 with respect to services provided and payment for such

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services provided pursuant to the subsection.

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

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641.3155, Florida Statutes, to read:

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     641.3155  Prompt payment of claims.--

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     (16) Notwithstanding the 30-month period provided in

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

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

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

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within 12 months after the health maintenance organization's

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

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permitted beyond 12 months after the health maintenance

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

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overpayment may be sought beyond that time from providers

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convicted of fraud pursuant to s. 817.234.

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     (17) Notwithstanding any other provision of this section,

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all claims for underpayment from a provider licensed under

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

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466 must be submitted to the health maintenance organization

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within 12 months after the health maintenance organization's

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

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permitted beyond 12 months after the health maintenance

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organization's payment of a claim.

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

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

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

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

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or after November 1, 2008.