Amendment
Bill No. CS/CS/HB 405

Amendment No. 892785

CHAMBER ACTION
Senate		House
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1	Representative Galvano offered the following:
2
3	Substitute Amendment for Amendment (718453) (with title
4	amendment)
5	Remove lines 52-155 and insert:
6	Section 1.  Subsections (18) and (19) are added to section
7	627.6131, Florida Statutes, to read:
8	627.6131  Payment of claims.--
9	(18)  Notwithstanding the 30-month period provided in
10	subsection (6), all claims for overpayment submitted to a
11	provider licensed under chapter 458, chapter 459, chapter 460,
12	chapter 461, or chapter 466 must be submitted to the provider
13	within 12 months after the health insurer's payment of the
14	claim. A claim for overpayment shall not be permitted beyond 12
15	months after the health insurer's payment of a claim, except
16	that claims for overpayment may be sought beyond that time from
17	providers convicted of fraud pursuant to s. 817.234.
18	(19)  Notwithstanding any other provision of this section,
19	all claims for underpayment from a provider licensed under
20	chapter 458, chapter 459, chapter 460, chapter 461, or chapter
21	466 must be submitted to the insurer within 12 months after the
22	health insurer's payment of the claim. A claim for underpayment
23	shall not be permitted beyond 12 months after the health
24	insurer's payment of a claim.
25	Section 2.  Section 627.638, Florida Statutes, is amended
26	to read:
27	627.638  Direct payment for hospital, medical services.--
28	(1)  Any health insurance policy insuring against loss or
29	expense due to hospital confinement or to medical and related
30	services may provide for payment of benefits directly to any
31	recognized hospital, licensed ambulance provider, doctor, or
32	other person who provided the services, in accordance with the
33	provisions of the policy. To comply with this section, the words
34	"or to the hospital, licensed ambulance provider, doctor, or
35	person rendering services covered by this policy," or similar
36	words appropriate to the terms of the policy, shall be added to
37	applicable provisions of the policy.
38	(2)  Whenever, in any health insurance claim form, an
39	insured specifically authorizes payment of benefits directly to
40	any recognized hospital, licensed ambulance provider, physician,
41	or dentist, the insurer shall make such payment to the
42	designated provider of such services, unless otherwise provided
43	in the insurance contract. The insurance contract may not
44	prohibit, and claims forms must provide an option for, the
45	payment of benefits directly to a licensed hospital, licensed
46	ambulance provider, physician, or dentist for care provided
47	pursuant to s. 395.1041 or part III of chapter 401. The insurer
48	may require written attestation of assignment of benefits.
49	Payment to the provider from the insurer may not be more than
50	the amount that the insurer would otherwise have paid without
51	the assignment.
52	(3)  Any insurer that has contracted with a preferred
53	provider as defined in s. 627.6471 for the delivery of health
54	care services to its insureds shall make payments directly to
55	the preferred provider for such services.
56	Section 3.  Section 627.64731, Florida Statutes, is created
57	to read:
58	627.64731  Leasing, renting, or granting access to a
59	participating provider.--
60	(1)  As used in this section, the term:
61	(a)  "Contracting entity" means any person or entity that
62	is engaged in the act of contracting with participating
63	providers and has a direct contract with a participating
64	provider for the delivery of health care services or the selling
65	or assigning of physicians or physician panels to other health
66	care entities.
67	(b)  "Participating provider" means a physician licensed
68	under chapter 458, chapter 459, chapter 460, chapter 461, or
69	chapter 466 or a physician group practice that has a health care
70	contract with a contracting entity and is entitled to
71	reimbursement for health care services rendered to an enrollee
72	under the health care contract and includes both preferred
73	providers as defined in s. 627.6471 and exclusive providers as
74	defined in s. 627.6472.
75	(2)  A contracting entity may not sell, lease, rent, or
76	otherwise grant access to the health care services of a
77	participating provider under a health care contract unless
78	expressly authorized by the health care contract. At the time a
79	health care contract is entered into with a participating
80	provider, the contracting entity shall, to the extent possible,
81	identify any third party to which the contracting entity has
82	granted access to the health care services of the participating
83	provider.
84	(3)  Upon a request by a participating provider, a
85	contracting entity must provide the identity of any third party
86	that has been granted access to the health care services of the
87	participating provider.
88	(4)  A contracting entity that leases, rents, or otherwise
89	grants access to the health care services of a participating
90	provider must maintain an Internet website or a toll-free
91	telephone number through which the provider may obtain a
92	listing, updated at least every 90 days, of the third parties
93	that have been granted access to the provider's health care
94	services.
95	(5)  A contracting entity that leases, rents, or otherwise
96	grants access to a participating provider's health care services
97	must ensure that an explanation of benefits or remittance advice
98	furnished to the participating provider that delivers health
99	care services under the health care contract identifies the
100	contractual source of any applicable discount.
101	(6)  Subject to applicable continuity of care laws, the
102	right of a third party to exercise the rights and
103	responsibilities of a contracting entity under a health care
104	contract terminates on the day after the termination of the
105	participating provider's contract with the contracting entity.
106	(7)  The provisions of this section do not apply if the
107	third party that is granted access to a participating provider's
108	health care services under a health care contract is:
109	(a)  An employer or other entity providing coverage for
110	health care services to the employer's employees or the entity's
111	members and the employer or entity has a contract with the
112	contracting entity or the contracting entity's affiliate for the
113	administration or processing of claims for payment or services
114	provided under the health care contract;
115	(b)  An entity providing administrative services to, or
116	receiving administrative services from, the contracting entity
117	or the contracting entity's affiliate or subsidiary; or
118	(c)  An affiliate or a subsidiary of a contracting entity
119	or other entity if operating under the same brand licensee
120	program as the contracting entity.
121	(8)  A health care contract may provide for arbitration of
122	disputes arising under this section.
123	(9)  A contracting entity shall ensure that all third
124	parties to which the contracting entity has sold, rented,
125	assigned, or otherwise given access to the participating
126	provider's discounted rate comply with the physician contract,
127	including all requirements to encourage access to the
128	participating provider, and pay the provider pursuant to the
129	rates of payment and methodology set forth in that contract,
130	unless otherwise agreed to by a participating provider.
131	(10)  Notwithstanding any other provision of this section,
132	no contracting entity shall sell, rent, lease, or give a third
133	party the contracting entity's rights to a participating
134	provider's services pursuant to the contracting entity's health
135	care contract with the participating provider unless one of the
136	following applies:
137	(a)  The third party accessing the participating provider's
138	services under the health care contract is an employer or other
139	entity providing coverage for health care services to its
140	employees or members, and that employer or entity has a contract
141	with the contracting entity or its affiliate for the
142	administration or processing of claims for payment for services
143	provided pursuant to the health care contract with the
144	participating provider.
145	(b)  The third party accessing the participating provider's
146	services under the health care contract is an affiliate or
147	subsidiary of the contracting entity, is an entity operating
148	under the same brand licensee program as the contracting entity,
149	or is providing administrative services to or receiving
150	administrative services from the contracting entity or an
151	affiliate or subsidiary of the contracting entity.
152	(c)  The health care contract specifically provides that it
153	applies to network rental arrangements and states that one
154	purpose of the contract is selling, renting, or giving the
155	contracting entity's rights to the services of the participating
156	provider, including other preferred provider organizations, and
157	the third party accessing the participating provider's services
158	is:
159	1.  A payor or a third-party administrator or other entity
160	responsible for administering claims on behalf of the payor;
161	2.  A preferred provider organization or preferred provider
162	network that receives access to the participating provider's
163	services pursuant to an arrangement with the preferred provider
164	organization or preferred provider network in a contract with
165	the participating provider and is required to comply with all of
166	the terms, conditions, and affirmative obligations to which the
167	originally contracted primary participating provider network is
168	bound under its contract with the participating provider,
169	including, but not limited to, obligations concerning patient
170	steerage and the timeliness and manner of reimbursement; or
171	3.  An entity that is engaged in the business of providing
172	electronic claims transport between the contracting entity and
173	the payor or third-party administrator and complies with all of
174	the applicable terms, conditions, and affirmative obligations of
175	the contracting entity's contract with the participating
176	provider, including, but not limited to, obligations concerning
177	patient steerage and the timeliness and manner of reimbursement.
178	(11)  A contracting entity is deemed in compliance with
179	this section when the insured's identification card provides,
180	written or electronically, information that identifies the
181	preferred provider network or networks to be utilized to
182	reimburse the provider for covered services.
183	(12)  This section shall not apply to a contract between a
184	contracting entity and a discount medical plan organization
185	licensed or exempt under part II of chapter 636.
186	Section 4.  Subsections (11) through (13) of section
187	627.662, Florida Statutes, are renumbered as subsections (12)
188	through (14), respectively, and a new subsection (11) is added
189	to that section to read:
190	627.662  Other provisions applicable.--The following
191	provisions apply to group health insurance, blanket health
192	insurance, and franchise health insurance:
193	(11)  Section 627.64731, relating to leasing, renting, or
194	granting access to a participating provider.
195	Section 5.  Subsection (41) is added to section 641.31,
196	Florida Statutes, to read:
197	641.31  Health maintenance contracts.--
198	(41)  Whenever, in any health maintenance organization
199	claim form, a subscriber specifically authorizes payment of
200	benefits directly to any contracted hospital, ambulance
201	provider, physician, dentist, or other person who provided
202	services, the health maintenance organization shall make such
203	payment to the designated provider of such services, provided
204	any benefits are due to the subscriber under the terms of the
205	agreement between the subscriber and the health maintenance
206	organization. The health maintenance organization contract may
207	not prohibit, and claims forms must provide an option for, the
208	payment of benefits directly to a licensed hospital, ambulance
209	provider, physician, or dentist for covered services provided,
210	for services provided pursuant to s. 395.1041, and for ambulance
211	transport and treatment provided pursuant to part III of chapter
212	401. The attestation of assignment of benefits may be in written
213	or electronic form. Payment to the provider from the health
214	maintenance organization may not be more than the amount that
215	the insurer would otherwise have paid without the assignment.
216	Nothing in this subsection affects the applicability of ss.
217	641.3154 and 641.513 with respect to services provided and
218	payment for such services provided pursuant to this subsection.
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224	T I T L E  A M E N D M E N T
225	Remove lines 7-33 and insert:
226	circumstances; amending s. 627.6131, F.S.; providing
227	requirements for and prohibitions against certain claims for
228	overpayment and claims for underpayment; amending s. 627.638,
229	F.S.; revising provisions providing for direct payment to
230	certain providers for certain services to include licensed
231	ambulance providers; requiring certain insurers to make payments
232	directly to contracted preferred providers for certain services;
233	creating s. 627.64731, F.S.; providing definitions; providing
234	requirements, limitations, and procedures for leasing, renting,
235	or granting access to participating providers by third parties;
236	providing exceptions; providing for arbitration; prohibiting
237	third party access to certain services under certain
238	circumstances; providing exceptions; providing application;
239	amending s. 627.662, F.S.; expanding the list of applicable
240	sections to certain types of insurance; amending s. 641.31,
241	F.S.; requiring health maintenance organizations to pay benefits
242	directly to certain providers under certain circumstances;
243	prohibiting health maintenance contracts from prohibiting and
244	requiring claims form to provide the option for payment of
245	benefits directly to certain providers; amending s.

CODING: Words stricken are deletions; words underlined are additions.