Florida Senate - 2016 COMMITTEE AMENDMENT
Bill No. SB 1442
Ì976590?Î976590
LEGISLATIVE ACTION
Senate . House
Comm: RCS .
02/01/2016 .
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The Committee on Health Policy (Garcia) recommended the
following:
1 Senate Amendment (with title amendment)
2
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, ambulatory surgical center, specialty
10 hospital, or urgent care center shall comply with the provisions
11 of ss. 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 a 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 with the same health
26 insurance plans as the hospital;
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 instruction 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 a participating
37 provider.
38 Section 3. Paragraph (oo) is added to subsection (1) of
39 section 456.072, Florida Statutes, to read:
40 456.072 Grounds for discipline; penalties; enforcement.—
41 (1) The following acts shall constitute grounds for which
42 the disciplinary actions specified in subsection (2) may be
43 taken:
44 (oo) Failing to comply with the provisions of s. 627.64194
45 or s. 641.513 with such frequency as to constitute a general
46 business practice.
47 Section 4. Section 627.64194, Florida Statutes, is created
48 to read:
49 627.64194 Coverage requirements for services provided by
50 nonparticipating providers.—
51 (1) As used in this section, the term:
52 (a) “Emergency services” means the services and care to
53 treat an emergency medical condition, as defined in s. 641.47.
54 For purposes of this section, the term includes emergency
55 transportation and ambulance services, to the extent permitted
56 by applicable state and federal law.
57 (b) “Facility” means a licensed facility as defined in s.
58 395.002(16) or an urgent care center as defined in s.
59 395.002(30).
60 (c) “Nonemergency services” means the services and care to
61 treat a condition other than an emergency medical condition, as
62 defined in s. 395.002(8).
63 (d) “Nonparticipating provider” means a provider who is not
64 a “preferred provider” as defined in s. 627.6471, an “exclusive
65 provider” as defined in s. 627.6472, or a facility licensed
66 under chapter 395. A provider that is employed by a facility
67 licensed under chapter 395, and that is not a “preferred
68 provider” as defined in s. 627.6471 or an “exclusive provider”
69 as defined in s. 627.6472, is a nonparticipating provider.
70 (e) “Participating provider” means a “preferred provider”
71 as defined in s. 627.6471 or an “exclusive provider” as defined
72 in s. 627.6472, but not a facility licensed under chapter 395.
73 (f) “Insured” means a person who is covered under an
74 individual or group health insurance policy delivered or issued
75 for delivery in this state by an insurer authorized to transact
76 business in the state.
77 (2) An insurer is solely liable for payment of fees to a
78 nonparticipating provider of emergency services provided to an
79 insured in accordance with the terms of the health insurance
80 policy. Such insured is not liable for payment of fees to a
81 nonparticipating provider of emergency services other than
82 applicable copayments and deductibles. An insurer must provide
83 coverage for emergency services that:
84 (a) May not require prior authorization.
85 (b) Must be provided regardless of whether the service is
86 furnished by a participating or nonparticipating provider.
87 (c) May impose a coinsurance amount, copayment, or
88 limitation of benefits requirement for a nonparticipating
89 provider only if the same requirement applies to a participating
90 provider.
91 (3) An insurer is solely liable for payment of fees to a
92 nonparticipating provider of nonemergency services provided to
93 an insured in accordance with the terms of the health insurance
94 policy. Such insured is not liable for payment of fees to a
95 nonparticipating provider, other than applicable copayments and
96 deductibles, for nonemergency services:
97 (a) That are provided in a facility that has a contract for
98 the nonemergency services with the insurer which the facility
99 would be otherwise obligated to provide under contract with the
100 insurer; and
101 (b) Where the insured has no ability and opportunity to
102 choose a participating provider at the facility.
103
104 If the insured makes an informed affirmative decision to choose
105 a nonparticipating provider instead of a participating provider
106 who is available at the facility to treat the insured, the
107 provisions of this subsection do not apply.
108 (4) An insurer must reimburse a nonparticipating provider
109 for services under subsections (2) and (3) as specified in s.
110 641.513(5) within the applicable timeframe provided by s.
111 627.6131.
112 (5) A nonparticipating provider of emergency services as
113 provided in subsection (2) or nonemergency services as provided
114 in subsection (3) may not be reimbursed an amount greater than
115 the amount provided in subsection (4) and may not collect or
116 attempt to collect from the patient, directly or indirectly, any
117 excess amount except for copays and deductibles.
118 (6) A dispute with regard to the amount of reimbursement
119 owed to the nonparticipating provider of emergency or
120 nonemergency services as provided in subsection (4) must be
121 resolved in a court of competent jurisdiction or by the
122 voluntary dispute resolution process in s. 408.7057.
123 Section 5. Subsection (2) of section 627.6471, Florida
124 Statutes, is amended, and a new subsection (7) is added to that
125 section, to read:
126 627.6471 Contracts for reduced rates of payment;
127 limitations; coinsurance and deductibles.—
128 (2) Any insurer issuing a policy of health insurance in
129 this state, which insurance includes coverage for the services
130 of a preferred provider, must provide each policyholder and
131 certificateholder with a current list of preferred providers and
132 must make the list available on its website. The list must
133 include, where applicable and reported, a listing by specialty
134 of the names, addresses, and telephone numbers of all
135 participating providers, including facilities; and in the case
136 of physicians, board certifications, languages spoken, and any
137 affiliations with participating hospitals. Information posted to
138 the insurer’s website must be updated on at least a calendar
139 month basis with additions or terminations of providers from the
140 insurer’s network or reported changes in physician’s hospital
141 affiliations must make the list available for public inspection
142 during regular business hours at the principal office of the
143 insurer within the state.
144 (7) Any policy issued after January 1, 2017 under this
145 section must include the following disclosure: “WARNING: LIMITED
146 BENEFITS WILL BE PAID WHEN NONPARTICIPATING PROVIDERS ARE USED.
147 You should be aware that when you elect to utilize the services
148 of a nonparticipating provider for a covered nonemergency
149 service, benefit payments to the provider are not based upon the
150 amount the provider charges. The basis of the payment will be
151 determined according to your policy’s out-of-network
152 reimbursement benefit. Nonparticipating providers may bill
153 insureds for any difference in the amount. YOU MAY BE REQUIRED
154 TO PAY MORE THAN THE COINSURANCE OR COPAYMENT. Participating
155 providers have agreed to accept discounted payments for services
156 with no additional billing to you other than coinsurance and
157 deductible amounts. You may obtain further information about the
158 providers who have contracted with your insurance plan by
159 consulting your insurer’s website or contacting your insurer or
160 agent directly.”
161 Section 6. This act shall take effect October 1, 2016.
162
163 ================= T I T L E A M E N D M E N T ================
164 And the title is amended as follows:
165 Delete everything before the enacting clause
166 and insert:
167 A bill to be entitled
168 An act relating to out-of-network health insurance
169 coverage; amending s. 395.003, F.S.; requiring
170 hospitals, ambulatory surgical centers, specialty
171 hospitals, and urgent care centers to comply with
172 certain provisions as a condition of licensure;
173 amending s. 395.301, F.S.; requiring a hospital to
174 post certain information on its website regarding its
175 contracts with health insurers, health maintenance
176 organizations, and health care practitioners and
177 practice groups and a specified statement to patients
178 and prospective patients; amending s. 456.072, F.S.;
179 adding a ground for discipline of referring health
180 care providers by the Department of Health; creating
181 s. 627.64194, F.S.; defining terms; specifying
182 requirements for coverage provided by an insurer for
183 emergency services; providing that an insurer is
184 solely liable for payment of certain fees to a
185 provider; providing that an insured is not liable for
186 payment of certain fees; providing limitations and
187 requirements for reimbursements by an insurer to a
188 nonparticipating provider; providing applicability;
189 authorizing a nonparticipating provider or insurer to
190 initiate action in a court of competent jurisdiction
191 or through voluntary dispute resolution; amending s.
192 627.6471, F.S.; requiring an insurer that issues a
193 policy including coverage for the services of a
194 preferred provider to post certain information about
195 participating providers on its website; requiring a
196 specified disclosure to be included in policies
197 providing coverage for the services of a preferred
198 provider; providing an effective date.