HB 243

1	A bill to be entitled
2	An act relating to health care management; amending s.
3	627.6044, F.S.; prohibiting certain insurers from engaging
4	in actions that encourage insureds not to make payments
5	before medical service is rendered; amending s. 627.6131,
6	F.S.; providing additional circumstances in which a health
7	insurer may not retroactively deny a claim; amending s.
8	627.6141, F.S.; requiring a claimant whose claim is denied
9	for failure to obtain an authorization under certain
10	circumstances to be provided an opportunity for an appeal;
11	requiring that the insurer reverse a denial under certain
12	circumstances; requiring the insurer to submit a written
13	justification for a determination that a service was not
14	medically necessary; amending ss. 627.6474 and 641.315,
15	F.S.; prohibiting a health insurer or health maintenance
16	organization from modifying a policy or procedure that
17	would affect underlying contract terms without having a
18	written mutual agreement; amending s. 641.3155, F.S.;
19	providing additional circumstances in which a health
20	maintenance organization may not retroactively deny a
21	claim; amending s. 641.3156, F.S.; requiring a health
22	maintenance organization to conduct a retrospective review
23	of the medical necessity of a service under certain
24	circumstances; requiring the health maintenance
25	organization to submit a written justification for a
26	determination that a service was not medically necessary
27	and provide a process for appealing the determination;
28	amending s. 641.54, F.S.; prohibiting a health maintenance
29	organization from engaging in certain actions that
30	encourage subscribers not to make payments before medical
31	service is rendered; creating a study group to evaluate
32	increases in a patient's financial responsibility for
33	hospital services; providing for membership; requiring the
34	Office of Insurance Regulation, the Agency for Health Care
35	Administration, and the organizations appointing members
36	to the study group to provide organizational support;
37	providing for the duties of the study group; providing for
38	per diem and travel expenses for members; requiring the
39	study group to present a final report to the Legislature;
40	providing an effective date.
41
42	Be It Enacted by the Legislature of the State of Florida:
43
44	Section 1.  Subsection (3) is added to section 627.6044,
45	Florida Statutes, to read:
46	627.6044  Use of a specific methodology for payment of
47	claims.--
48	(3)  An insurer issuing a policy that provides for payment
49	of claims based on a specific methodology may not take any
50	action, such as providing a printed statement to an insured,
51	that encourages the insured to refuse to pay a copayment,
52	coinsurance, a portion of a deductible, or any other form of
53	patient financial responsibility before a medical service is
54	rendered or prior to receipt of an insurer's explanation of
55	benefits.
56	Section 2.  Subsection (11) of section 627.6131, Florida
57	Statutes, is amended to read:
58	627.6131  Payment of claims.--
59	(11)  A health insurer may not retroactively deny a claim
60	because of insured ineligibility:
61	(a)  More than 1 year after the date of payment of the
62	claim;
63	(b)  If the health insurer verified the eligibility of an
64	insured at the time of treatment and provided an authorization
65	number; or
66	(c)  If, at the time of service, the health insurer
67	provided the insured with a magnetic or smart identification as
68	provided in s. 627.642 that identified the insured as eligible
69	to receive services.
70	Section 3.  Section 627.6141, Florida Statutes, is amended
71	to read:
72	627.6141  Denial of claims.--Each claimant, or provider
73	acting for a claimant, who has had a claim denied as not
74	medically necessary or for failing to obtain authorization or
75	obtaining only partial authorization due to an unintentional act
76	or error or omission must be provided an opportunity for an
77	appeal to the insurer's licensed physician who is responsible
78	for the medical necessity reviews under the plan or is a member
79	of the plan's peer review group. If the insurer determines upon
80	review that the service was medically necessary, the insurer
81	must reverse the denial and pay the claim. If the insurer
82	determines that the service was not medically necessary, the
83	insurer shall submit to the provider specific written clinical
84	justification for the determination. The appeal may be by
85	telephone, and the insurer's licensed physician must respond
86	within a reasonable time, not to exceed 15 business days.
87	Section 4.  Section 627.6474, Florida Statutes, is amended
88	to read:
89	627.6474  Provider contracts.--
90	(1)  A health insurer shall not require a contracted health
91	care practitioner as defined in s. 456.001(4) to accept the
92	terms of other health care practitioner contracts with the
93	insurer or any other insurer, or health maintenance
94	organization, under common management and control with the
95	insurer, including Medicare and Medicaid practitioner contracts
96	and those authorized by s. 627.6471, s. 627.6472, or s. 641.315,
97	except for a practitioner in a group practice as defined in s.
98	456.053 who must accept the terms of a contract negotiated for
99	the practitioner by the group, as a condition of continuation or
100	renewal of the contract. Any contract provision that violates
101	this section is void. A violation of this section is not subject
102	to the criminal penalty specified in s. 624.15.
103	(2)  A health insurer may not modify, amend, or change any
104	policy, procedure, or equivalent document adopted by reference
105	in a contract in effect with a provider that would affect,
106	directly or indirectly, the underlying contract terms without a
107	mutual written agreement between the provider and the insurer.
108	Written notice of any proposed change must be provided by the
109	health insurer to the provider at least 45 days prior to the
110	date the proposed change is implemented.
111	Section 5.  Subsection (11) is added to section 641.315,
112	Florida Statutes, to read:
113	641.315  Provider contracts.--
114	(11)  A health maintenance organization may not modify,
115	amend, or change any policy, procedure, or equivalent document
116	adopted by reference in a contract in effect with a provider
117	that would affect, directly or indirectly, the underlying
118	contract terms without a mutual written agreement between the
119	provider and the organization. Written notice of any proposed
120	change must be provided by the health maintenance organization
121	to the provider at least 45 days prior to the date the proposed
122	change is implemented.
123	Section 6.  Subsection (10) of section 641.3155, Florida
124	Statutes, is amended to read:
125	641.3155  Prompt payment of claims.--
126	(10)  A health maintenance organization may not
127	retroactively deny a claim because of subscriber ineligibility:
128	(a)   More than 1 year after the date of payment of the
129	claim;
130	(b)  If the health maintenance organization verified the
131	eligibility of a subscriber at the time of treatment and
132	provided an authorization number; or
133	(c)  If, at the time of service, the health maintenance
134	organization provided the subscriber with a magnetic or smart
135	identification as provided in s. 627.642 that identified the
136	subscriber as eligible to receive services.
137	Section 7.  Subsection (3) of section 641.3156, Florida
138	Statutes, is renumbered as subsection (4), and a new subsection
139	(3) is added to that section to read:
140	641.3156  Treatment authorization; payment of claims.--
141	(3)  If a hospital-service or referral-service claim is
142	denied because the provider, due to an unintentional act of
143	error or omission, failed to obtain authorization or obtained
144	only partial authorization, the provider may appeal the denial
145	and the health maintenance organization must conduct and
146	complete within 30 days after the submitted appeal a
147	retrospective review of the medical necessity of the service. If
148	the health maintenance organization determines that the service
149	is medically necessary, the health maintenance organization must
150	reverse the denial and pay the claim. If the health maintenance
151	organization determines that the service is not medically
152	necessary, the health maintenance organization shall provide the
153	provider with specific written clinical justification for the
154	determination.
155	Section 8.  Subsection (8) is added to section 641.54,
156	Florida Statutes, to read:
157	641.54  Information disclosure.--
158	(8)  A health maintenance organization may not take any
159	action, such as issuing a printed statement to a subscriber,
160	that encourages a subscriber to refuse to pay a copayment, a
161	coinsurance percentage, a deductible, or any other portion of a
162	patient's financial responsibility before a medical service is
163	rendered or prior to receipt of the health maintenance
164	organization's explanation of benefits.
165	Section 9.  (1)  A 12-person study group is created for the
166	purpose of evaluating increases in patient financial
167	responsibility for hospital services and the resulting impact on
168	the affordability and accessibility of private, employer-
169	sponsored health insurance. A representative of an employer who
170	purchases health insurance for its employees, appointed by the
171	Florida Chamber of Commerce, and an employer who provides health
172	insurance through a self-insured plan, appointed by Associated
173	Industries of Florida, shall act as co-chairs of the study
174	group. The remaining 10 members of the study group shall be
175	appointed as follows:
176	(a)  Two members appointed by the Florida Hospital
177	Association.
178	(b)  Two members appointed by the Florida Chamber of
179	Commerce representing purchasers of health insurance.
180	(c)  Two members appointed by Associated Industries of
181	Florida representing purchasers of health insurance.
182	(d)  One member of the Florida Senate appointed by the
183	President.
184	(e)  One member of the House of Representatives appointed
185	by the Speaker of the House of Representatives.
186	(f)  Two representatives of health insurance plans
187	appointed by the Chief Financial Officer.
188	(2)  Organizational support for the study group shall be
189	provided by the Office of Insurance Regulation, the Agency for
190	Health Care Administration, and the organizations appointing
191	members to the study group.
192	(3)  The study group shall evaluate and develop findings
193	and recommendations regarding the following:
194	(a)  Changes in patient financial responsibility associated
195	with hospital services in the form of copayments, coinsurance,
196	and deductibles over the last several years as data is
197	available.
198	(b)  The effect of patient payment requirements on access
199	to hospital services.
200	(c)  The effect of financial disincentives regarding the
201	inappropriate use of hospital emergency rooms and ways to
202	strengthen such incentives.
203	(d)  The effect of patient payment requirements on the cost
204	of employer-sponsored health insurance.
205	(e)  Methods to ensure that patient financial requirements
206	are met.
207	(f)  Impediments to collections from patients at the point
208	of service.
209	(g)  Methods to improve accurate collections from patients
210	at the point of service.
211	(4)  Members of the study group shall serve without
212	compensation. The organizations appointing members shall pay per
213	diem and travel expenses for their respective members for the
214	meetings of the study group. All meetings shall be held in
215	Tallahassee.
216	(5)  The members of the study group shall be appointed by
217	July 30, 2009, and shall hold their first meeting by September
218	1, 2009. The final report of the study group shall be presented
219	to the President of the Senate and the Speaker of the House of
220	Representatives no later than January 29, 2010.
221	Section 10.  This act shall take effect July 1, 2009.

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