Florida Senate - 2016                        COMMITTEE AMENDMENT
       Bill No. SB 1442
                              LEGISLATIVE ACTION                        
                    Senate             .             House              
                  Comm: RCS            .                                
                  02/01/2016           .                                

       The Committee on Health Policy (Garcia) 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, 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.
  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
  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
  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.
  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.