| 1 | Representative Gardiner offered the following: |
| 2 |
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| 3 | Amendment to Amendment (171333) (with title amendment) |
| 4 | Remove lines 610-807 and insert: |
| 5 | Section 12. Section 624.916, Florida Statutes, is created |
| 6 | to read: |
| 7 | 624.916 Developmental disabilities compact.-- |
| 8 | (1) The Office of Insurance Regulation shall convene a |
| 9 | workgroup by August 31, 2008, for the purpose of negotiating a |
| 10 | compact that includes a binding agreement among the participants |
| 11 | relating to insurance and access to services for persons with |
| 12 | developmental disabilities as defined in s. 393.063, with the |
| 13 | addition of autism spectrum disorder. The workgroup shall |
| 14 | consist of the following: |
| 15 | (a) Representatives of all health insurers licensed under |
| 16 | this chapter. |
| 17 | (b) Representatives of all health maintenance |
| 18 | organizations licensed under part I of chapter 641. |
| 19 | (c) Representatives of employers with self-insured health |
| 20 | benefit plans. |
| 21 | (d) Two designees of the Governor, one of whom must be a |
| 22 | consumer advocate. |
| 23 | (e) A designee of the President of the Senate. |
| 24 | (f) A designee of the Speaker of the House of |
| 25 | Representatives. |
| 26 | (2) The Office of Insurance Regulation shall convene a |
| 27 | consumer advisory workgroup for the purpose of providing a forum |
| 28 | for comment on the compact negotiated in subsection (1). The |
| 29 | office shall convene the workgroup prior to finalization of the |
| 30 | compact. |
| 31 | (3) The agreement shall include the following components: |
| 32 | (a) A requirement that each signatory to the agreement |
| 33 | increase coverage for behavior analysis and behavior assistant |
| 34 | services as defined in s. 409.815(2)(r) and speech therapy, |
| 35 | physical therapy, and occupational therapy when necessary due to |
| 36 | the presence of a developmental disability as defined in s. |
| 37 | 393.063 or autism spectrum disorder. |
| 38 | (b) Procedures for clear and specific notice to |
| 39 | policyholders identifying the amount, scope, and conditions |
| 40 | under which coverage is provided for behavior analysis and |
| 41 | behavior assistant services as defined in s. 409.815(2)(r) and |
| 42 | speech therapy, physical therapy, and occupational therapy when |
| 43 | necessary due to the presence of a developmental disability as |
| 44 | defined in s. 393.063 or autism spectrum disorder. |
| 45 | (c) Penalties for documented cases of denial of claims for |
| 46 | medically necessary services due to the presence of a |
| 47 | developmental disability as defined in s. 393.063 or autism |
| 48 | spectrum disorder. |
| 49 | (d) Proposals for new product lines that may be offered in |
| 50 | conjunction with traditional health insurance and provide a more |
| 51 | appropriate means of spreading risk, financing costs, and |
| 52 | accessing favorable prices. |
| 53 | (4) Upon completion of the negotiations for the compact, |
| 54 | the office shall report the results to the Governor, the |
| 55 | President of the Senate, and the Speaker of the House of |
| 56 | Representatives. |
| 57 | (5) Beginning February 15, 2009, and continuing annually |
| 58 | thereafter, the Office of Insurance Regulation shall provide a |
| 59 | report to the Governor, the President of the Senate, and the |
| 60 | Speaker of the House of Representatives regarding the |
| 61 | implementation of the agreement negotiated under this section. |
| 62 | The report shall include: |
| 63 | (a) The signatories to the agreement. |
| 64 | (b) An analysis of the coverage provided under the |
| 65 | agreement in comparison to the coverage required under ss. |
| 66 | 627.6686 and 641.31098. |
| 67 | (c) An analysis of the compliance with the agreement by |
| 68 | the signatories, including documented cases of claims denied in |
| 69 | violation of the agreement. |
| 70 | (6) The Office of Insurance Regulation shall continue to |
| 71 | monitor participation, compliance, and effectiveness of the |
| 72 | agreement and report its findings at least annually. |
| 73 | Section 13. Section 627.6686, Florida Statutes, is created |
| 74 | to read: |
| 75 | 627.6686 Coverage for individuals with developmental |
| 76 | disabilities required; exception.-- |
| 77 | (1) As used in this section, the term: |
| 78 | (a) "Developmental disability" has the same meaning as |
| 79 | provided in s. 393.063, with the addition of autism spectrum |
| 80 | disorder. |
| 81 | (b) "Eligible individual" means an individual under 18 |
| 82 | years of age or an individual 18 years of age or older who is in |
| 83 | high school who has been diagnosed as having a developmental |
| 84 | disability at 8 years of age or younger. |
| 85 | (c) "Health insurance plan" means a group health insurance |
| 86 | policy or group health benefit plan offered by an insurer which |
| 87 | includes the state group insurance program provided under s. |
| 88 | 110.123. The term does not include any health insurance plan |
| 89 | offered in the individual market, any health insurance plan that |
| 90 | is individually underwritten, or any health insurance plan |
| 91 | provided to a small employer. |
| 92 | (d) "Insurer" means an insurer providing health insurance |
| 93 | coverage, which is licensed to engage in the business of |
| 94 | insurance in this state and is subject to insurance regulation. |
| 95 | (2) A health insurance plan issued or renewed on or after |
| 96 | July 1, 2009, shall provide coverage to an eligible individual |
| 97 | for: |
| 98 | (a) Well-baby and well-child screening for diagnosing the |
| 99 | presence of a developmental disability. |
| 100 | (b) Treatment of a developmental disability through speech |
| 101 | therapy, occupational therapy, physical therapy, and behavior |
| 102 | analysis services. Behavior analysis services shall be provided |
| 103 | by an individual certified pursuant to s. 393.17 or an |
| 104 | individual licensed under chapter 490 or chapter 491. |
| 105 | (3) The coverage required pursuant to subsection (2) is |
| 106 | subject to the following requirements: |
| 107 | (a) Coverage shall be limited to treatment that is |
| 108 | prescribed by the insured's treating physician in accordance |
| 109 | with a treatment plan. |
| 110 | (b) Coverage for the services described in subsection (2) |
| 111 | shall be limited to $36,000 annually and may not exceed $108,000 |
| 112 | in total lifetime benefits. |
| 113 | (c) Coverage may not be denied on the basis that provided |
| 114 | services are habilitative in nature. |
| 115 | (d) Coverage may be subject to other general exclusions |
| 116 | and limitations of the insurer's policy or plan, including, but |
| 117 | not limited to, coordination of benefits, participating provider |
| 118 | requirements, restrictions on services provided by family or |
| 119 | household members, and utilization review of health care |
| 120 | services, including the review of medical necessity, case |
| 121 | management, and other managed care provisions. |
| 122 | (4) The coverage required pursuant to subsection (2) may |
| 123 | not be subject to dollar limits, deductibles, or coinsurance |
| 124 | provisions that are less favorable to an insured than the dollar |
| 125 | limits, deductibles, or coinsurance provisions that apply to |
| 126 | physical illnesses that are generally covered under the health |
| 127 | insurance plan, except as otherwise provided in subsection (3). |
| 128 | (5) An insurer may not deny or refuse to issue coverage |
| 129 | for medically necessary services, refuse to contract with, or |
| 130 | refuse to renew or reissue or otherwise terminate or restrict |
| 131 | coverage for an individual because the individual is diagnosed |
| 132 | as having a developmental disability. |
| 133 | (6) The treatment plan required pursuant to subsection (3) |
| 134 | shall include all elements necessary for the health insurance |
| 135 | plan to appropriately pay claims. These elements include, but |
| 136 | are not limited to, a diagnosis, the proposed treatment by type, |
| 137 | the frequency and duration of treatment, the anticipated |
| 138 | outcomes stated as goals, the frequency with which the treatment |
| 139 | plan will be updated, and the signature of the treating |
| 140 | physician. |
| 141 | (7) Beginning January 1, 2011, the maximum benefit under |
| 142 | paragraph (3)(b) shall be adjusted annually on January 1 of each |
| 143 | calendar year to reflect any change from the previous year in |
| 144 | the medical component of the then current Consumer Price Index |
| 145 | for all urban consumers, published by the Bureau of Labor |
| 146 | Statistics of the United States Department of Labor. |
| 147 | (8) This section may not be construed as limiting benefits |
| 148 | and coverage otherwise available to an insured under a health |
| 149 | insurance plan. |
| 150 | (9) The Office of Insurance Regulation may not enforce |
| 151 | this section against an insurer that is a signatory no later |
| 152 | than July 1, 2009, to the developmental disabilities compact |
| 153 | established under s. 624.916. The Office of Insurance Regulation |
| 154 | shall enforce this section against an insurer that is a |
| 155 | signatory to the compact established under s. 624.916 if the |
| 156 | insurer has not complied with the terms of the compact for all |
| 157 | health insurance plans by July 1, 2010. |
| 158 | Section 14. Section 641.31098, Florida Statutes, is |
| 159 | created to read: |
| 160 | 641.31098 Coverage for individuals with developmental |
| 161 | disabilities.-- |
| 162 | (1) As used in this section, the term: |
| 163 | (a) "Developmental disability" has the same meaning as |
| 164 | provided in s. 393.063, with the addition of autism spectrum |
| 165 | disorder. |
| 166 | (b) "Eligible individual" means an individual under 18 |
| 167 | years of age or an individual 18 years of age or older who is in |
| 168 | high school who has been diagnosed as having a developmental |
| 169 | disability at 8 years of age or younger. |
| 170 | (c) "Health maintenance contract" means a group health |
| 171 | maintenance contract offered by a health maintenance |
| 172 | organization. This term does not include a health maintenance |
| 173 | contract offered in the individual market, a health maintenance |
| 174 | contract that is individually underwritten, or a health |
| 175 | maintenance contract provided to a small employer. |
| 176 | (2) A health maintenance contract issued or renewed on or |
| 177 | after July 1, 2009, shall provide coverage to an eligible |
| 178 | individual for: |
| 179 | (a) Well-baby and well-child screening for diagnosing the |
| 180 | presence of a developmental disability. |
| 181 | (b) Treatment of a developmental disability through speech |
| 182 | therapy, occupational therapy, physical therapy, and behavior |
| 183 | analysis services. Behavior analysis services shall be provided |
| 184 | by an individual certified pursuant to s. 393.17 or an |
| 185 | individual licensed under chapter 490 or chapter 491. |
| 186 | (3) The coverage required pursuant to subsection (2) is |
| 187 | subject to the following requirements: |
| 188 | (a) Coverage shall be limited to treatment that is |
| 189 | prescribed by the subscriber's treating physician in accordance |
| 190 | with a treatment plan. |
| 191 | (b) Coverage for the services described in subsection (2) |
| 192 | shall be limited to $36,000 annually and may not exceed $108,000 |
| 193 | in total benefits. |
| 194 | (c) Coverage may not be denied on the basis that provided |
| 195 | services are habilitative in nature. |
| 196 | (d) Coverage may be subject to general exclusions and |
| 197 | limitations of the subscriber's contract, including, but not |
| 198 | limited to, coordination of benefits, participating provider |
| 199 | requirements, and utilization review of health care services, |
| 200 | including the review of medical necessity, case management, and |
| 201 | other managed care provisions. |
| 202 | (4) The coverage required pursuant to subsection (2) may |
| 203 | not be subject to dollar limits, deductibles, or coinsurance |
| 204 | provisions that are less favorable to a subscriber than the |
| 205 | dollar limits, deductibles, or coinsurance provisions that apply |
| 206 | to physical illnesses that are generally covered under the |
| 207 | subscriber's contract, except as otherwise provided in |
| 208 | subsection (3). |
| 209 | (5) A health maintenance organization may not deny or |
| 210 | refuse to issue coverage for medically necessary services, |
| 211 | refuse to contract with, or refuse to renew or reissue or |
| 212 | otherwise terminate or restrict coverage for an individual |
| 213 | solely because the individual is diagnosed as having a |
| 214 | developmental disability. |
| 215 | (6) The treatment plan required pursuant to subsection (3) |
| 216 | shall include, but is not limited to, a diagnosis, the proposed |
| 217 | treatment by type, the frequency and duration of treatment, the |
| 218 | anticipated outcomes stated as goals, the frequency with which |
| 219 | the treatment plan will be updated, and the signature of the |
| 220 | treating physician. |
| 221 | (7) Beginning January 1, 2011, the maximum benefit under |
| 222 | paragraph (3)(b) shall be adjusted annually on January 1 of each |
| 223 | calendar year to reflect any change from the previous year in |
| 224 | the medical component of the then current Consumer Price Index |
| 225 | for all urban consumers, published by the Bureau of Labor |
| 226 | Statistics of the United States Department of Labor. |
| 227 | (8) The Office of Insurance Regulation may not enforce |
| 228 | this section against a health maintenance organization that is a |
| 229 | signatory no later than July 1, 2009, to the developmental |
| 230 | disabilities compact established under s. 624.916. The Office of |
| 231 | Insurance Regulation shall enforce this section against a health |
| 232 | maintenance organization that is a signatory to the compact |
| 233 | established under s. 624.916 if the health maintenance |
| 234 | organization has not complied with the terms of the compact for |
| 235 | all health maintenance contracts by July 1, 2010. |
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| 241 | ----------------------------------------------------- |
| 242 | T I T L E A M E N D M E N T |
| 243 | Remove lines 891-929 and insert: |
| 244 | Legislature; creating s. 624.916, F.S.; directing the Office of |
| 245 | Insurance Regulation to establish a workgroup to develop and |
| 246 | execute a compact relating to coverage for insured persons with |
| 247 | development disabilities; providing for membership of the |
| 248 | workgroup; requiring the workgroup to convene within a specified |
| 249 | period of time; directing the office to establish a consumer |
| 250 | advisory workgroup and providing purpose thereof; requiring the |
| 251 | compact to contain specified components; requiring reports to |
| 252 | the Governor and the Legislature; creating s. 627.6686, F.S.; |
| 253 | providing health insurance coverage for individuals with |
| 254 | developmental disabilities; providing definitions; providing |
| 255 | coverage for certain screening to diagnose and treat |
| 256 | developmental disabilities; providing limitations on coverage; |
| 257 | providing for eligibility standards for benefits and coverage; |
| 258 | prohibiting insurers from denying coverage under certain |
| 259 | circumstances; specifying required elements of a treatment plan; |
| 260 | providing, beginning January 1, 2011, that the maximum benefit |
| 261 | shall be adjusted annually; clarifying that the section may not |
| 262 | be construed as limiting benefits and coverage otherwise |
| 263 | available to an insured under a health insurance plan; |
| 264 | prohibiting the Office of Insurance Regulation from enforcing |
| 265 | certain provisions against insurers that are signatories to the |
| 266 | developmental disabilities compact by a specified date; creating |
| 267 | s. 641.31098, F.S.; providing coverage under a health |
| 268 | maintenance contract for individuals with developmental |
| 269 | disabilities; providing definitions; providing coverage for |
| 270 | certain screening to diagnose and treat developmental |
| 271 | disabilities; providing limitations on coverage; providing for |
| 272 | eligibility standards for benefits and coverage; prohibiting |
| 273 | health maintenance organizations from denying coverage under |
| 274 | certain circumstances; specifying required elements of a |
| 275 | treatment plan; providing, beginning January 1, 2011, that the |
| 276 | maximum benefit shall be adjusted annually; prohibiting the |
| 277 | Office of Insurance Regulation from enforcing certain provisions |
| 278 | against health maintenance organizations that are signatories to |
| 279 | the developmental disabilities compact by a specified date; |
| 280 | providing an effective date. |