Florida Senate - 2016                          SENATOR AMENDMENT
       Bill No. CS for CS for CS for SB 1442
                              LEGISLATIVE ACTION                        
                    Senate             .             House              
                Floor: 1/RS/2R         .                                
             03/02/2016 11:14 AM       .                                

       Senator Negron moved the following:
    1         Senate Amendment (with title amendment)
    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         627.64194Coverage 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.
   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.
   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
  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
  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.
  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.