| 1 | Representative Galvano offered the following: |
| 2 |
|
| 3 | Substitute Amendment for Amendment (439835) (with title |
| 4 | amendment) |
| 5 | Remove line(s) 52-214 and insert: |
| 6 | Section 2. Section 627.638, Florida Statutes, is amended |
| 7 | to read: |
| 8 | 627.638 Direct payment for hospital, medical services.-- |
| 9 | (1) Any health insurance policy insuring against loss or |
| 10 | expense due to hospital confinement or to medical and related |
| 11 | services may provide for payment of benefits directly to any |
| 12 | recognized hospital, licensed ambulance provider, doctor, or |
| 13 | other person who provided the services, in accordance with the |
| 14 | provisions of the policy. To comply with this section, the words |
| 15 | "or to the hospital, licensed ambulance provider, doctor, or |
| 16 | person rendering services covered by this policy," or similar |
| 17 | words appropriate to the terms of the policy, shall be added to |
| 18 | applicable provisions of the policy. |
| 19 | (2) Whenever, in any health insurance claim form, an |
| 20 | insured specifically authorizes payment of benefits directly to |
| 21 | any recognized hospital, licensed ambulance provider, physician, |
| 22 | or dentist, the insurer shall make such payment to the |
| 23 | designated provider of such services, unless otherwise provided |
| 24 | in the insurance contract. The insurance contract may not |
| 25 | prohibit, and claims forms must provide an option for, the |
| 26 | payment of benefits directly to a licensed hospital, licensed |
| 27 | ambulance provider, physician, or dentist for care provided |
| 28 | pursuant to s. 395.1041 or part III of chapter 401. The insurer |
| 29 | may require written attestation of assignment of benefits. |
| 30 | Payment to the provider from the insurer may not be more than |
| 31 | the amount that the insurer would otherwise have paid without |
| 32 | the assignment. |
| 33 | (3) Any insurer who has contracted with a preferred |
| 34 | provider, as defined in s. 627.6471(1)(b), for the delivery of |
| 35 | health care services to its insureds shall make payments |
| 36 | directly to the preferred provider for such services. |
| 37 | Section 3. Section 627.64731, Florida Statutes, is created |
| 38 | to read: |
| 39 | 627.64731 Leasing, renting, or granting access to a |
| 40 | participating provider.-- |
| 41 | (1) As used in this section: |
| 42 | (a) "Contracting entity" means any person or entity that |
| 43 | is engaged in the act of contracting with participating |
| 44 | providers and has a direct contract with a participating |
| 45 | provider for the delivery of health care services or the selling |
| 46 | or assigning of physicians or physician panels to other health |
| 47 | care entities. |
| 48 | (b) "Participating provider" means a physician licensed |
| 49 | under chapter 458, chapter 459, chapter 460, chapter 461, or |
| 50 | chapter 466 or a physician group practice that has a health care |
| 51 | contract with a contracting entity and is entitled to |
| 52 | reimbursement for health care services rendered to an enrollee |
| 53 | under the health care contract and includes both preferred |
| 54 | providers as defined in s. 627.6471 and exclusive providers as |
| 55 | defined in s. 627.6472. |
| 56 | (2) A contracting entity may not sell, lease, rent, or |
| 57 | otherwise grant access to the health care services of a |
| 58 | participating provider under a health care contract unless |
| 59 | expressly authorized by the health care contract. The health |
| 60 | care contract must specifically provide that it applies to |
| 61 | network rental arrangements and state that one purpose of the |
| 62 | contract is selling, renting, or giving the contracting entity's |
| 63 | rights to the services of the participating provider, including |
| 64 | other preferred provider organizations. At the time a health |
| 65 | care contract is entered into with a participating provider, the |
| 66 | contracting entity shall, to the extent possible, identify any |
| 67 | third party to which the contracting entity has granted access |
| 68 | to the health care services of the participating provider. The |
| 69 | contracting entity may only sell, lease, rent, or otherwise |
| 70 | grant access to the participating provider's services to a third |
| 71 | party that is: |
| 72 | (a) A payor or a third-party administrator or other entity |
| 73 | responsible for administering claims on behalf of the payor; |
| 74 | (b) A preferred provider organization or preferred |
| 75 | provider network that receives access to the participating |
| 76 | provider's services pursuant to an arrangement with the |
| 77 | preferred provider organization or preferred provider network in |
| 78 | a contract with the participating provider is required to comply |
| 79 | with all of the terms, conditions, and affirmative obligations |
| 80 | to which the originally contracted primary participating |
| 81 | provider network is bound under its contract with the |
| 82 | participating provider, including, but not limited to, |
| 83 | obligations concerning patient steerage and the timeliness and |
| 84 | manner of reimbursement; or |
| 85 | (c) An entity that is engaged in the business of providing |
| 86 | electronic claims transport between the contracting entity and |
| 87 | the payor or third-party administrator and complies with all of |
| 88 | the applicable terms, conditions, and affirmative obligations of |
| 89 | the contracting entity's contract with the participating |
| 90 | provider, including, but not limited to, obligations concerning |
| 91 | patient steerage and the timeliness and manner of reimbursement. |
| 92 | (3) Upon a request by a participating provider, a |
| 93 | contracting entity must provide the identity of any third party |
| 94 | that has been granted access to the health care services of the |
| 95 | participating provider. |
| 96 | (4) A contracting entity that leases, rents, or otherwise |
| 97 | grants access to the health care services of a participating |
| 98 | provider must maintain an Internet website or a toll-free |
| 99 | telephone number through which the provider may obtain a |
| 100 | listing, updated at least every 90 days, of the third parties |
| 101 | that have been granted access to the provider's health care |
| 102 | services. |
| 103 | (5) A contracting entity that leases, rents, or otherwise |
| 104 | grants access to a participating provider's health care services |
| 105 | must ensure that an explanation of benefits or remittance advice |
| 106 | furnished to the participating provider that delivers health |
| 107 | care services under the health care contract identifies the |
| 108 | contractual source of any applicable discount. |
| 109 | (6) Subject to applicable continuity of care laws, the |
| 110 | right of a third party to exercise the rights and |
| 111 | responsibilities of a contracting entity under a health care |
| 112 | contract terminates on the day after the termination of the |
| 113 | participating provider's contract with the contracting entity. |
| 114 | (7) The provisions of this section do not apply if the |
| 115 | third party that is granted access to a participating provider's |
| 116 | health care services under a health care contract is: |
| 117 | (a) An employer or other entity providing coverage for |
| 118 | health care services to the employer's employees or the entity's |
| 119 | members and the employer or entity has a contract with the |
| 120 | contracting entity or the contracting entity's affiliate for the |
| 121 | administration or processing of claims for payment or services |
| 122 | provided under the health care contract; |
| 123 | (b) An entity providing administrative services to, or |
| 124 | receiving administrative services from, the contracting entity |
| 125 | or the contracting entity's affiliate or subsidiary; or |
| 126 | (c) An affiliate or a subsidiary of a contracting entity |
| 127 | or other entity if operating under the same brand licensee |
| 128 | program as the contracting entity. |
| 129 | (8) A health care contract may provide for arbitration of |
| 130 | disputes arising under this section. |
| 131 | (9) A contracting entity shall ensure that all third |
| 132 | parties to which the contracting entity has sold, rented, |
| 133 | assigned, or otherwise given access to the participating |
| 134 | provider's discounted rate comply with the physician contract, |
| 135 | including all requirements to encourage access to the |
| 136 | participating provider, and pay the provider pursuant to the |
| 137 | rates of payment and methodology set forth in that contract, |
| 138 | unless otherwise agreed to by a participating provider. |
| 139 | (10) A contracting entity is deemed in compliance with |
| 140 | this section when the insured's identification card provides, |
| 141 | written or electronically, information that identifies the |
| 142 | preferred provider network or networks to be utilized to |
| 143 | reimburse the provider for covered services. |
| 144 | (11) This section shall not apply to a contract between a |
| 145 | contracting entity and a discount medical plan organization |
| 146 | licensed or exempt under part II of chapter 636. |
| 147 | Section 4. Present subsections (11), (12), and (13) of |
| 148 | section 627.662, Florida Statutes, are renumbered as subsections |
| 149 | (12), (13), and (14), respectively, and a new subsection (11) is |
| 150 | added to that section, to read: |
| 151 | 627.662 Other provisions applicable.--The following |
| 152 | provisions apply to group health insurance, blanket health |
| 153 | insurance, and franchise health insurance: |
| 154 | (11) Section 627.64731, relating to leasing, renting, or |
| 155 | granting access to a preferred provider or exclusive provider. |
| 156 | Section 5. Paragraph (v) of subsection (3) of section |
| 157 | 627.6699, Florida Statutes, is amended to read: |
| 158 | 627.6699 Employee Health Care Access Act.-- |
| 159 | (3) DEFINITIONS.--As used in this section, the term: |
| 160 | (v) "Small employer" means, in connection with a health |
| 161 | benefit plan with respect to a calendar year and a plan year, |
| 162 | any person, sole proprietor, self-employed individual, |
| 163 | independent contractor, firm, corporation, partnership, or |
| 164 | association that is actively engaged in business, has its |
| 165 | principal place of business in this state, employed an average |
| 166 | of at least 1 but not more than 50 eligible employees on |
| 167 | business days during the preceding calendar year the majority of |
| 168 | whom were employed in this state, and employs at least 1 |
| 169 | employee on the first day of the plan year, and is not formed |
| 170 | primarily for purposes of purchasing insurance. In determining |
| 171 | the number of eligible employees, companies that are an |
| 172 | affiliated group as defined in s. 1504(a) of the Internal |
| 173 | Revenue Code of 1986, as amended, shall be considered a single |
| 174 | employer. For purposes of this section, a sole proprietor, an |
| 175 | independent contractor, or a self-employed individual is |
| 176 | considered a small employer only if all of the conditions and |
| 177 | criteria established in this section are met. |
| 178 | Section 6. Subsection (41) is added to section 641.31, |
| 179 | Florida Statutes, to read: |
| 180 | 641.31 Health maintenance contracts.-- |
| 181 | (41) Whenever, in any health maintenance organization |
| 182 | claim form, a subscriber specifically authorizes payment of |
| 183 | benefits directly to any hospital, ambulance provider, |
| 184 | physician, or dentist, the health maintenance organization shall |
| 185 | make such payment to the designated provider of such services, |
| 186 | provided any benefits are due to the subscriber under the terms |
| 187 | of the agreement between the subscriber and the health |
| 188 | maintenance organization. The health maintenance organization |
| 189 | contract may not prohibit, and claims forms must provide an |
| 190 | option for, the payment of benefits directly to a licensed |
| 191 | hospital, ambulance provider, physician, or dentist for covered |
| 192 | services provided, for services provided pursuant to s. |
| 193 | 395.1041, and for ambulance transport and treatment provided |
| 194 | pursuant to part III of chapter 401. The attestation of |
| 195 | assignment of benefits may be in written or electronic form. |
| 196 | Payment to the provider from the health maintenance organization |
| 197 | may not be more than the amount that the insurer would otherwise |
| 198 | have paid without the assignment. Nothing in this subsection |
| 199 | affects the applicability of ss. 641.3154 and 641.513 with |
| 200 | respect to services provided and payment for such services |
| 201 | provided pursuant to this subsection. |
| 202 | Section 7. Subsections (18) and (19) are added to section |
| 203 | 627.6131, Florida Statutes, to read: |
| 204 | 627.6131 Payment of claims.-- |
| 205 | (18) Notwithstanding the 30-month period provided in |
| 206 | subsection (6), all claims for overpayment submitted to a |
| 207 | provider licensed under chapter 458, chapter 459, chapter 460, |
| 208 | chapter 461, or chapter 466 must be submitted to the provider |
| 209 | within 12 months after the health insurer's payment of the |
| 210 | claim. A claim for overpayment shall not be permitted beyond 12 |
| 211 | months after the health insurer's payment of a claim, except |
| 212 | claims for overpayment may be sought beyond that time from |
| 213 | providers convicted of fraud pursuant to s. 817.234. |
| 214 | (19) Notwithstanding any other provision of this section, |
| 215 | all claims for underpayment from a provider licensed under |
| 216 | chapter 458, chapter 459, chapter 460, chapter 461, or chapter |
| 217 | 466 must be submitted to the insurer within 12 months after the |
| 218 | health insurer's payment of the claim. A claim for underpayment |
| 219 | shall not be permitted beyond 12 months after the health |
| 220 | insurer's payment of a claim. |
| 221 | Section 8. Subsections (16) and (17) are added to section |
| 222 | 641.3155, Florida Statutes, to read: |
| 223 | 641.3155 Prompt payment of claims.-- |
| 224 | (16) Notwithstanding the 30-month period provided in |
| 225 | subsection (5), all claims for overpayment submitted to a |
| 226 | provider licensed under chapter 458, chapter 459, chapter 460, |
| 227 | chapter 461, or chapter 466 must be submitted to the provider |
| 228 | within 12 months after the health maintenance organization's |
| 229 | payment of the claim. A claim for overpayment shall not be |
| 230 | permitted beyond 12 months after the health maintenance |
| 231 | organization's payment of a claim, except claims for overpayment |
| 232 | may be sought beyond that time from providers convicted of fraud |
| 233 | pursuant to s. 817.234. |
| 234 | (17) Notwithstanding any other provision of this section, |
| 235 | all claims for underpayment from a provider licensed under |
| 236 | chapter 458, chapter 459, chapter 460, chapter 461, or chapter |
| 237 | 466 must be submitted to the health maintenance organization |
| 238 | within 12 months after the health maintenance organization's |
| 239 | payment of the claim. A claim for underpayment shall not be |
| 240 | permitted beyond 12 months after the health maintenance |
| 241 | organization's payment of a claim. |
| 242 | Section 9. This act shall take effect November 1, 2008, |
| 243 | and applies to contracts entered into, issued, or renewed on or |
| 244 | after that date, and the amendments made by this act to sections |
| 245 | 627.6131 and 641.3155, Florida Statutes, apply to claims |
| 246 | payments made on or after November 1, 2008. |
| 247 |
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| 248 |
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| 249 | ----------------------------------------------------- |
| 250 | T I T L E A M E N D M E N T |
| 251 | Remove line(s) 7-36 and insert: |
| 252 | circumstances; amending s. 627.638, F.S.; authorizing the |
| 253 | payment of health insurance policy benefits directly to a |
| 254 | licensed ambulance provider; requiring that an insurer make |
| 255 | payments directly to the preferred provider for the delivery of |
| 256 | health care services; creating s. 627.64731, F.S.; providing |
| 257 | definitions; providing requirements, limitations, and procedures |
| 258 | for leasing, renting, or granting access to participating |
| 259 | providers by third parties; providing exceptions; providing for |
| 260 | arbitration; prohibiting third party access to certain services |
| 261 | under certain circumstances; providing exceptions; providing |
| 262 | application; amending s. 627.662, F.S.; applying the |
| 263 | requirements for the rent, lease, or granting of access to the |
| 264 | health care services of a preferred provider or exclusive |
| 265 | provider under a health care contract to group health insurance, |
| 266 | blanket health insurance, and franchise health insurance |
| 267 | policies; amending s. 627.6699, F.S.; revising the definition of |
| 268 | the term "small employer"; amending s. 641.31; requiring health |
| 269 | maintenance organizations to pay benefits directly to certain |
| 270 | providers under certain circumstances; prohibiting health |
| 271 | maintenance contracts from prohibiting and requiring claims form |
| 272 | to provide the option for payment of benefits directly to |
| 273 | certain providers; amending ss. 627.6131 and 641.3155, F.S.; |
| 274 | providing requirements for and prohibitions against filing |
| 275 | claims for overpayments and claims for underpayments with |
| 276 | insurers and health maintenance organizations; providing |
| 277 | applicability; providing an effective date. |