Florida Senate - 2016                        COMMITTEE AMENDMENT
       Bill No. CS for SB 1442
                              LEGISLATIVE ACTION                        
                    Senate             .             House              
                  Comm: RCS            .                                
                  02/16/2016           .                                

       The Committee on Banking and Insurance (Detert) recommended the
    1         Senate Amendment (with title amendment)
    3         Delete everything after the enacting clause
    4  and insert:
    5         Section 1. Paragraph (d) is added to subsection (5) of
    6  section 395.003, Florida Statutes, to read:
    7         395.003 Licensure; denial, suspension, and revocation.—
    8         (5)
    9         (d)A hospital, an ambulatory surgical center, a specialty
   10  hospital, or an urgent care center shall comply with ss.
   11  627.64194 and 641.513 as a condition of licensure.
   12         Section 2. Subsection (13) is added to section 395.301,
   13  Florida Statutes, to read:
   14         395.301 Itemized patient bill; form and content prescribed
   15  by the agency; patient admission status notification.—
   16         (13)A hospital shall post on its website:
   17         (a)The names and hyperlinks for direct access to the
   18  websites of all health insurers and health maintenance
   19  organizations for which the hospital contracts as a network
   20  provider or participating provider.
   21         (b)A statement that:
   22         1.Services provided in the hospital by health care
   23  practitioners may not be included in the hospital’s charges;
   24         2.Health care practitioners who provide services in the
   25  hospital may or may not participate in the same health insurance
   26  plans as the hospital; and
   27         3.Prospective patients should contact the health care
   28  practitioner arranging for the services to determine the health
   29  care plans in which the health care practitioner participates.
   30         (c)As applicable, the names, mailing addresses, and
   31  telephone numbers of the health care practitioners and practice
   32  groups that the hospital has contracted with to provide services
   33  in the hospital and instructions on how to contact these health
   34  care practitioners and practice groups to determine the health
   35  insurers and health maintenance organizations for which the
   36  hospital contracts as a network provider or participating
   37  provider.
   38         Section 3. Paragraph (h) is added to subsection (2) of
   39  section 408.7057, Florida Statutes, and subsection (4) of that
   40  section is amended, to read:
   41         408.7057 Statewide provider and health plan claim dispute
   42  resolution program.—
   43         (2)
   44         (h)Either the contracted or noncontracted provider or the
   45  health plan may make an offer to settle the claim dispute when
   46  it submits a request for a claim dispute and supporting
   47  documentation. The offer to settle the claim dispute must state
   48  its total amount, and the party to whom it is directed has 15
   49  days to accept the offer once it is received. If the party
   50  receiving the offer does not accept the offer and the final
   51  order amount is more than 90 percent or less than 110 percent of
   52  the offer amount, the party receiving the offer must pay the
   53  final order amount to the offering party and is deemed a
   54  nonprevailing party for purposes of this section. The amount of
   55  an offer made by a contracted or noncontracted provider to
   56  settle an alleged underpayment by the health plan must be
   57  greater than 110 percent of the reimbursement amount the
   58  provider received. The amount of an offer made by a health plan
   59  to settle an alleged overpayment to the provider must be less
   60  than 90 percent of the alleged overpayment amount by the health
   61  plan. Both parties may agree to settle the disputed claim at any
   62  time, for any amount, regardless of whether an offer to settle
   63  was made or rejected.
   64         (4) Within 30 days after receipt of the recommendation of
   65  the resolution organization, the agency shall adopt the
   66  recommendation as a final order. The final order is subject to
   67  judicial review pursuant to s. 120.68.
   68         Section 4. Paragraph (oo) is added to subsection (1) of
   69  section 456.072, Florida Statutes, to read:
   70         456.072 Grounds for discipline; penalties; enforcement.—
   71         (1) The following acts shall constitute grounds for which
   72  the disciplinary actions specified in subsection (2) may be
   73  taken:
   74         (oo)Willfully failing to comply with s. 627.64194 or s.
   75  641.513 with such frequency as to indicate a general business
   76  practice.
   77         Section 5. Paragraph (tt) is added to subsection (1) of
   78  section 458.331, Florida Statutes, to read:
   79         458.331 Grounds for disciplinary action; action by the
   80  board and department.—
   81         (1) The following acts constitute grounds for denial of a
   82  license or disciplinary action, as specified in s. 456.072(2):
   83         (tt)Willfully failing to comply with s. 627.64194 or s.
   84  641.513 with such frequency as to indicate a general business
   85  practice.
   86         Section 6. Paragraph (vv) is added to subsection (1) of
   87  section 459.015, Florida Statutes, to read:
   88         459.015 Grounds for disciplinary action; action by the
   89  board and department.—
   90         (1) The following acts constitute grounds for denial of a
   91  license or disciplinary action, as specified in s. 456.072(2):
   92         (vv)Willfully failing to comply with s. 627.64194 or s.
   93  641.513 with such frequency as to indicate a general business
   94  practice.
   95         Section 7. Paragraph (gg) is added to subsection (1) of
   96  section 626.9541, Florida Statutes, to read:
   97         626.9541 Unfair methods of competition and unfair or
   98  deceptive acts or practices defined.—
  100  ACTS.—The following are defined as unfair methods of competition
  101  and unfair or deceptive acts or practices:
  102         (gg)Out-of-network reimbursement.—Willfully failing to
  103  comply with s. 627.64194 with such frequency as to indicate a
  104  general business practice.
  105         Section 8. Section 627.64194, Florida Statutes, is created
  106  to read:
  107         627.64194Coverage requirements for services provided by
  108  nonparticipating providers; payment collection limitations.—
  109         (1)As used in this section, the term:
  110         (a)“Emergency services” means the services and care to
  111  treat an emergency medical condition as defined in s. 641.47(8).
  112         (b)“Facility” means a licensed facility as defined in s.
  113  395.002(16) and an urgent care center as defined in s.
  114  395.002(30).
  115         (c)“Insured” means a person who is covered under an
  116  individual or group health insurance policy delivered or issued
  117  for delivery in this state by an insurer authorized to transact
  118  business in this state.
  119         (d)“Nonemergency services” means the services and care to
  120  treat a condition other than an emergency medical condition.
  121         (e)“Nonparticipating provider” means a provider who is not
  122  a preferred provider as defined in s. 627.6471 or a provider who
  123  is not an exclusive provider as defined in s. 627.6472. For
  124  purposes of covered emergency services under this section, a
  125  facility licensed under chapter 395 or an urgent care center
  126  defined in s. 395.002(30) is a nonparticipating provider if the
  127  facility has not contracted with an insurer to provide emergency
  128  services to its insureds at a specified rate.
  129         (f)“Participating provider” means, for purposes of this
  130  section, a preferred provider as defined in s. 627.6471 or an
  131  exclusive provider as defined in s. 627.6472.
  132         (2)An insurer is solely liable for payment of fees to a
  133  nonparticipating provider of covered emergency services provided
  134  to an insured in accordance with the coverage terms of the
  135  health insurance policy, and such insured is not liable for
  136  payment of fees for covered services to a nonparticipating
  137  provider of emergency services, other than applicable
  138  copayments, coinsurance, and deductibles. An insurer must
  139  provide coverage for emergency services that:
  140         (a)May not require prior authorization.
  141         (b)Must be provided regardless of whether the services are
  142  furnished by a participating provider or a nonparticipating
  143  provider.
  144         (c)May impose a coinsurance amount, copayment, or
  145  limitation of benefits requirement for a nonparticipating
  146  provider only if the same requirement applies to a participating
  147  provider.
  149  The provisions of s. 627.638 apply to this subsection.
  150         (3)An insurer is solely liable for payment of fees to a
  151  nonparticipating provider of covered nonemergency services
  152  provided to an insured in accordance with the coverage terms of
  153  the health insurance policy, and such insured is not liable for
  154  payment of fees to a nonparticipating provider, other than
  155  applicable copayments, coinsurance, and deductibles, for covered
  156  nonemergency services that are:
  157         (a)Provided in a facility that has a contract for the
  158  nonemergency services with the insurer which the facility would
  159  be otherwise obligated to provide under contract with the
  160  insurer; and
  161         (b)Provided when the insured does not have the ability and
  162  opportunity to choose a participating provider at the facility
  163  who is available to treat the insured.
  165  The provisions of s. 627.638 apply to this subsection.
  166         (4)An insurer must reimburse a nonparticipating provider
  167  of services under subsections (2) and (3) as specified in s.
  168  641.513(5), reduced only by insured cost share responsibilities
  169  as specified in the health insurance policy, within the
  170  applicable timeframe provided in s. 627.6131.
  171         (5)A nonparticipating provider of emergency services as
  172  provided in subsection (2) or a nonparticipating provider of
  173  nonemergency services as provided in subsection (3) may not be
  174  reimbursed an amount greater than the amount provided in
  175  subsection (4) and may not collect or attempt to collect from
  176  the insured, directly or indirectly, any excess amount, other
  177  than copayments, coinsurance, and deductibles. This section does
  178  not prohibit a nonparticipating provider from collecting or
  179  attempting to collect from the insured an amount due for the
  180  provision of noncovered services.
  181         (6)Any dispute with regard to the reimbursement to the
  182  nonparticipating provider of emergency or nonemergency services
  183  as provided in subsection (4) shall be resolved in a court of
  184  competent jurisdiction or through the voluntary dispute
  185  resolution process in s. 408.7057.
  186         Section 9. Subsection (2) of section 627.6471, Florida
  187  Statutes, is amended to read:
  188         627.6471 Contracts for reduced rates of payment;
  189  limitations; coinsurance and deductibles.—
  190         (2) Any insurer issuing a policy of health insurance in
  191  this state, which insurance includes coverage for the services
  192  of a preferred provider, must provide each policyholder and
  193  certificateholder with a current list of preferred providers and
  194  must make the list available on its website. The list must
  195  include, when applicable and reported, a listing by specialty of
  196  the names, addresses, and telephone numbers of all participating
  197  providers, including facilities, and, in the case of physicians,
  198  must also include board certifications, languages spoken, and
  199  any affiliations with participating hospitals. Information
  200  posted on the insurer’s website must be updated on at least a
  201  calendar-month basis with additions or terminations of providers
  202  from the insurer’s network or reported changes in physicians’
  203  hospital affiliations for public inspection during regular
  204  business hours at the principal office of the insurer within the
  205  state.
  206         Section 10. Effective upon this act becoming a law,
  207  subsection (7) is added to section 627.6471, Florida Statutes,
  208  to read:
  209         627.6471 Contracts for reduced rates of payment;
  210  limitations; coinsurance and deductibles.—
  211         (7)Any policy issued under this section after January 1,
  212  2017, must include the following disclosure: “WARNING: LIMITED
  214  You should be aware that when you elect to utilize the services
  215  of a nonparticipating provider for a covered nonemergency
  216  service, benefit payments to the provider are not based upon the
  217  amount the provider charges. The basis of the payment will be
  218  determined according to your policy’s out-of-network
  219  reimbursement benefit. Nonparticipating providers may bill
  220  insureds for any difference in the amount. YOU MAY BE REQUIRED
  222  Participating providers have agreed to accept discounted
  223  payments for services with no additional billing to you other
  224  than coinsurance, copayment, and deductible amounts. You may
  225  obtain further information about the providers who have
  226  contracted with your insurance plan by consulting your insurer’s
  227  website or contacting your insurer or agent directly.”
  228         Section 11. Subsection (15) is added to section 627.662,
  229  Florida Statutes, to read:
  230         627.662 Other provisions applicable.—The following
  231  provisions apply to group health insurance, blanket health
  232  insurance, and franchise health insurance:
  233         (15)Section 627.64194, relating to coverage requirements
  234  for services provided by nonparticipating providers and payment
  235  collection limitations.
  236         Section 12. Except as otherwise expressly provided in this
  237  act and except for this section, which shall take effect upon
  238  this act becoming a law, this act shall take effect October 1,
  239  2016.
  241  ================= T I T L E  A M E N D M E N T ================
  242  And the title is amended as follows:
  243         Delete everything before the enacting clause
  244  and insert:
  245                        A bill to be entitled                      
  246         An act relating to out-of-network health insurance
  247         coverage; amending s. 395.003, F.S.; requiring
  248         hospitals, ambulatory surgical centers, specialty
  249         hospitals, and urgent care centers to comply with
  250         certain provisions as a condition of licensure;
  251         amending s. 395.301, F.S.; requiring a hospital to
  252         post on its website certain information regarding its
  253         contracts with health insurers, health maintenance
  254         organizations, and health care practitioners and
  255         practice groups and specified notice to patients and
  256         prospective patients; amending s. 408.7057, F.S.;
  257         providing requirements for settlement offers between
  258         certain providers and health plans in a specified
  259         dispute resolution program; requiring a final order to
  260         be subject to judicial review; amending ss. 456.072,
  261         458.331, and 459.015, F.S.; providing additional acts
  262         that constitute grounds for denial of a license or
  263         disciplinary action, to which penalties apply;
  264         amending s. 626.9541, F.S.; specifying an additional
  265         unfair method of competition and unfair or deceptive
  266         act or practice; creating s. 627.64194, F.S.; defining
  267         terms; providing that an insurer is solely liable for
  268         payment of certain fees to a nonparticipating
  269         provider; providing limitations and requirements for
  270         reimbursements by an insurer to a nonparticipating
  271         provider; providing that certain disputes relating to
  272         reimbursement of a nonparticipating provider shall be
  273         resolved in a court of competent jurisdiction or
  274         through a specified voluntary dispute resolution
  275         process; amending s. 627.6471, F.S.; requiring an
  276         insurer that issues a policy including coverage for
  277         the services of a preferred provider to post on its
  278         website certain information about participating
  279         providers and physicians; requiring that specified
  280         notice be included in policies issued after a
  281         specified date which provide coverage for the services
  282         of a preferred provider; amending s. 627.662, F.S.;
  283         providing applicability of provisions relating to
  284         coverage for services and payment collection
  285         limitations to group health insurance, blanket health
  286         insurance, and franchise health insurance; providing
  287         effective dates.