Florida Senate - 2016 SENATOR AMENDMENT
Bill No. CS for CS for CS for SB 1442
Ì418906;Î418906
LEGISLATIVE ACTION
Senate . House
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Floor: 1/RS/2R .
03/02/2016 11:14 AM .
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Senator Negron moved the following:
1 Senate Amendment (with title amendment)
2
3 Delete lines 180 - 310
4 and insert:
5 Section 8. Subsection (11) of section 627.6131, Florida
6 Statutes, is amended to read:
7 627.6131 Payment of claims.—
8 (11) A health insurer may not retroactively deny a claim
9 because of insured ineligibility:
10 (a) At any time, if the health insurer verified the
11 eligibility of an insured at the time of treatment and provided
12 an authorization number. If the insured is delinquent by more
13 than 30 days, the health insurer is not obligated to approve the
14 procedure.
15 (b) More than 1 year after the date of payment of the
16 claim.
17 Section 9. Section 627.64194, Florida Statutes, is created
18 to read:
19 627.64194 Coverage requirements for services provided by
20 nonparticipating providers; payment collection limitations.—
21 (1) As used in this section, the term:
22 (a) “Emergency services” means emergency services and care,
23 as defined in s. 641.47(8), which are provided in a facility.
24 (b) “Facility” means a licensed facility as defined in s.
25 395.002(16) and an urgent care center as defined in s.
26 395.002(30).
27 (c) “Insured” means a person who is covered under an
28 individual or group health insurance policy delivered or issued
29 for delivery in this state by an insurer authorized to transact
30 business in this state.
31 (d) “Nonemergency services” means the services and care
32 that are not emergency services.
33 (e) “Nonparticipating provider” means a provider who is not
34 a preferred provider as defined in s. 627.6471 or a provider who
35 is not an exclusive provider as defined in s. 627.6472. For
36 purposes of covered emergency services under this section, a
37 facility licensed under chapter 395 or an urgent care center
38 defined in s. 395.002(30) is a nonparticipating provider if the
39 facility has not contracted with an insurer to provide emergency
40 services to its insureds at a specified rate.
41 (f) “Participating provider” means, for purposes of this
42 section, a preferred provider as defined in s. 627.6471 or an
43 exclusive provider as defined in s. 627.6472.
44 (2) An insurer is solely liable for payment of fees to a
45 nonparticipating provider of covered emergency services provided
46 to an insured in accordance with the coverage terms of the
47 health insurance policy, and such insured is not liable for
48 payment of fees for covered services to a nonparticipating
49 provider of emergency services, other than applicable
50 copayments, coinsurance, and deductibles. An insurer must
51 provide coverage for emergency services that:
52 (a) May not require prior authorization.
53 (b) Must be provided regardless of whether the services are
54 furnished by a participating provider or a nonparticipating
55 provider.
56 (c) May impose a coinsurance amount, copayment, or
57 limitation of benefits requirement for a nonparticipating
58 provider only if the same requirement applies to a participating
59 provider.
60
61 The provisions of s. 627.638 apply to this subsection.
62 (3) An insurer is solely liable for payment of fees to a
63 nonparticipating provider of covered nonemergency services
64 provided to an insured in accordance with the coverage terms of
65 the health insurance policy, and such insured is not liable for
66 payment of fees to a nonparticipating provider, other than
67 applicable copayments, coinsurance, and deductibles, for covered
68 nonemergency services that are:
69 (a) Provided in a facility that has a contract for the
70 nonemergency services with the insurer which the facility would
71 be otherwise obligated to provide under contract with the
72 insurer; and
73 (b) Provided when the insured does not have the ability and
74 opportunity to choose a participating provider at the facility
75 who is available to treat the insured.
76
77 The provisions of s. 627.638 apply to this subsection.
78 (4) An insurer must reimburse a nonparticipating provider
79 of services under subsections (2) and (3) as specified in s.
80 641.513(5), reduced only by insured cost share responsibilities
81 as specified in the health insurance policy, within the
82 applicable timeframe provided in s. 627.6131.
83 (5) A nonparticipating provider of emergency services as
84 provided in subsection (2) or a nonparticipating provider of
85 nonemergency services as provided in subsection (3) may not be
86 reimbursed an amount greater than the amount provided in
87 subsection (4) and may not collect or attempt to collect from
88 the insured, directly or indirectly, any excess amount, other
89 than copayments, coinsurance, and deductibles. This section does
90 not prohibit a nonparticipating provider from collecting or
91 attempting to collect from the insured an amount due for the
92 provision of noncovered services.
93 (6) Any dispute with regard to the reimbursement to the
94 nonparticipating provider of emergency or nonemergency services
95 as provided in subsection (4) shall be resolved in a court of
96 competent jurisdiction or through the voluntary dispute
97 resolution process in s. 408.7057.
98 Section 10. Subsection (2) of section 627.6471, Florida
99 Statutes, is amended to read:
100 627.6471 Contracts for reduced rates of payment;
101 limitations; coinsurance and deductibles.—
102 (2) Any insurer issuing a policy of health insurance in
103 this state, which insurance includes coverage for the services
104 of a preferred provider, must provide each policyholder and
105 certificateholder with a current list of preferred providers and
106 must make the list available on its website. The list must
107 include, when applicable and reported, a listing by specialty of
108 the names, addresses, and telephone numbers of all participating
109 providers, including facilities, and, in the case of physicians,
110 must also include board certifications, languages spoken, and
111 any affiliations with participating hospitals. Information
112 posted on the insurer’s website must be updated on at least a
113 calendar-month basis with additions or terminations of providers
114 from the insurer’s network or reported changes in physicians’
115 hospital affiliations for public inspection during regular
116 business hours at the principal office of the insurer within the
117 state.
118 Section 11. Effective upon this act becoming a law,
119 subsection (7) is added to section 627.6471, Florida Statutes,
120 to read:
121 627.6471 Contracts for reduced rates of payment;
122 limitations; coinsurance and deductibles.—
123 (7) Any policy issued under this section after January 1,
124 2017, must include the following disclosure: “WARNING: LIMITED
125 BENEFITS WILL BE PAID WHEN NONPARTICIPATING PROVIDERS ARE USED.
126 You should be aware that when you elect to utilize the services
127 of a nonparticipating provider for a covered nonemergency
128 service, benefit payments to the provider are not based upon the
129 amount the provider charges. The basis of the payment will be
130 determined according to your policy’s out-of-network
131 reimbursement benefit. Nonparticipating providers may bill
132 insureds for any difference in the amount. YOU MAY BE REQUIRED
133 TO PAY MORE THAN THE COINSURANCE OR COPAYMENT AMOUNT.
134 Participating providers have agreed to accept discounted
135 payments for services with no additional billing to you other
136 than coinsurance, copayment, and deductible amounts. You may
137 obtain further information about the providers who have
138 contracted with your insurance plan by consulting your insurer’s
139 website or contacting your insurer or agent directly.”
140 Section 12. Subsection (15) is added to section 627.662,
141 Florida Statutes, to read:
142 627.662 Other provisions applicable.—The following
143 provisions apply to group health insurance, blanket health
144 insurance, and franchise health insurance:
145 (15) Section 627.64194, relating to coverage requirements
146 for services provided by nonparticipating providers and payment
147 collection limitations.
148 Section 13. Subsection (10) of section 641.3155, Florida
149 Statutes, is amended to read:
150 641.3155 Prompt payment of claims.—
151 (10) A health maintenance organization may not
152 retroactively deny a claim because of subscriber ineligibility:
153 (a) At any time, if the health maintenance organization
154 verified the eligibility of a subscriber at the time of
155 treatment and provided an authorization number. If the
156 subscriber is delinquent by more than 30 days, the health
157 maintenance organization is not obligated to approve the
158 procedure.
159 (b) More than 1 year after the date of payment of the
160 claim.
161
162 ================= T I T L E A M E N D M E N T ================
163 And the title is amended as follows:
164 Delete lines 2 - 45
165 and insert:
166 An act relating to health care services; amending s.
167 395.003, F.S.; requiring hospitals, ambulatory
168 surgical centers, specialty hospitals, and urgent care
169 centers to comply with certain provisions as a
170 condition of licensure; amending s. 395.301, F.S.;
171 requiring a hospital to post on its website certain
172 information regarding health insurers, health
173 maintenance organizations, health care practitioners,
174 and practice groups that it contracts with, and a
175 specified disclosure statement; amending s. 408.7057,
176 F.S.; providing requirements for settlement offers
177 between certain providers and health plans in a
178 specified dispute resolution program; requiring the
179 Agency for Health Care Administration to include in
180 its rules additional requirements relating to a
181 resolution organization’s process in considering
182 certain claim disputes; requiring a final order to be
183 subject to judicial review; amending ss. 456.072,
184 458.331, and 459.015, F.S.; providing additional acts
185 that constitute grounds for denial of a license or
186 disciplinary action to which penalties apply; amending
187 s. 626.9541, F.S.; specifying an additional unfair
188 method of competition and unfair or deceptive act or
189 practice; amending s. 627.6131, F.S.; prohibiting a
190 health insurer from retroactively denying a claim
191 under specified circumstances; providing an exception;
192 creating s. 627.64194, F.S.; defining terms; providing
193 that an insurer is solely liable for payment of
194 certain fees to a nonparticipating provider; providing
195 limitations and requirements for reimbursements by an
196 insurer to a nonparticipating provider; providing that
197 certain disputes relating to reimbursement of a
198 nonparticipating provider shall be resolved in a court
199 of competent jurisdiction or through a specified
200 voluntary dispute resolution process; amending s.
201 627.6471, F.S.; requiring an insurer that issues a
202 policy including coverage for the services of a
203 preferred provider to post on its website certain
204 information about participating providers and
205 physicians; requiring that specified notice be
206 included in policies issued after a specified date
207 which provide coverage for the services of a preferred
208 provider; amending s. 627.662, F.S.; providing
209 applicability of provisions relating to coverage for
210 services and payment collection limitations to group
211 health insurance, blanket health insurance, and
212 franchise health insurance; amending s. 641.3155,
213 F.S.; prohibiting a health maintenance organization
214 from retroactively denying a claim under specified
215 circumstances; providing an exception; providing
216 effective dates.